Dizziness and Vertigo

Overview
Types of Dizziness
Common Causes
Mechanisms
Evaluation
Management
When to Seek Medical Care
Connections
References & Research
Featured Videos

Overview

Dizziness is one of the most over-used symptom words in medicine. The same complaint can mean true vertigo (illusion of motion), presyncope (about to faint), disequilibrium (unsteady gait), or a non-specific lightheadedness. The first task in any dizziness workup is to figure out which of these the patient means, because the differential diagnosis — and the urgency — differ enormously. Most acute dizziness is benign (BPPV, vestibular neuritis, vestibular migraine), but a small fraction signals posterior-circulation stroke and requires urgent imaging.

Types of Dizziness

Vertigo — the illusion of self- or environmental motion (spinning, tilting). Suggests vestibular system pathology.
Presyncope — the sense of being about to faint, often with greying vision and sweating. See Lightheadedness on Standing.
Disequilibrium — unsteadiness on standing or walking, without spinning or near-fainting. Often multifactorial in older adults (sensory + neurologic + musculoskeletal).
Non-specific lightheadedness — a vague sense of being "off," often anxiety-driven; chronic subjective dizziness / persistent postural-perceptual dizziness (PPPD) is the formal diagnosis.

Common Causes

Benign paroxysmal positional vertigo (BPPV) — brief intense vertigo with head position changes; the most common cause of vertigo. Caused by dislodged otoconia in the semicircular canals; treated with the Epley maneuver.
Vestibular neuritis and labyrinthitis — sudden continuous vertigo lasting days, often after a viral illness; with hearing loss in labyrinthitis.
Meniere's disease — episodic vertigo (minutes to hours), tinnitus, fluctuating low-frequency hearing loss, ear fullness.
Vestibular migraine — vertigo with migraine features; often without classic headache.
Posterior-circulation stroke or TIA — sudden vertigo with neurologic deficits; the dangerous mimicker of vestibular neuritis. The HINTS exam helps separate them.
Multiple sclerosis — sub-acute vertigo with other neurologic features in young adults.
Cerebellar disease — tumor, hemorrhage, demyelination, degeneration.
Acoustic neuroma (vestibular schwannoma) — gradual unilateral hearing loss, tinnitus, mild imbalance.
Persistent postural-perceptual dizziness (PPPD) — chronic non-spinning dizziness, often after an acute vestibular event; worse with motion and visually busy environments.
Medications — aminoglycosides (vestibulotoxic), antihypertensives, sedatives, anticonvulsants.
Cervicogenic dizziness — from cervical spine dysfunction; controversial but recognized.
Anxiety and panic — common cause of chronic non-specific dizziness; often coexists with other vestibular disorders.

Mechanisms

Peripheral vestibular dysfunction — semicircular canals (BPPV), vestibular nerve (neuritis), or end-organ (Meniere's). Tends to cause severe acute vertigo with horizontal nystagmus.
Central vestibular dysfunction — brainstem or cerebellum (stroke, demyelination, tumor). Often less spinning and more disequilibrium, plus cranial-nerve or cerebellar signs.
Migraine pathways — vestibular migraine involves cortical spreading depression and trigeminovascular activation in vestibular pathways.
Sensory mismatch — competing visual, vestibular, and proprioceptive inputs produce dizziness in motion sickness, virtual environments, and PPPD.
Endolymphatic hydrops — pressure increase in the inner ear underlies Meniere's symptoms.

Evaluation

Categorize — vertigo, presyncope, disequilibrium, or non-specific.
Timing and triggers (TiTrATE) — episodic vs continuous; positional vs spontaneous. This drives the differential more than the descriptor.
HINTS exam — head impulse, nystagmus, test of skew. In acute vestibular syndrome, a normal head impulse, direction-changing nystagmus, or skew deviation suggests stroke and warrants MRI.
Dix-Hallpike maneuver — positional test for posterior-canal BPPV.
Audiometry — for suspected Meniere's, acoustic neuroma, labyrinthitis.
Vestibular testing (VNG, VEMP, video head-impulse test) — for chronic or atypical cases.
MRI brain with attention to brainstem and cerebellum — for central signs, atypical features, or first attack with unilateral hearing loss.
Bloodwork — CBC, electrolytes, glucose, TSH; targeted infectious or autoimmune testing if indicated.
Cardiovascular evaluation — if presyncope is the dominant feature; orthostatic vitals, ECG.

Management

BPPV — canalith repositioning maneuvers (Epley, Semont); home maneuvers for recurrence; usually no medication needed.
Vestibular neuritis — short course of vestibular suppressants (meclizine, dimenhydrinate) for 2–3 days, then early vestibular rehabilitation.
Meniere's disease — low-salt diet, diuretics, betahistine (in some countries), intratympanic corticosteroids or gentamicin, surgery for refractory cases.
Vestibular migraine — migraine prevention and acute treatment; trigger avoidance.
PPPD — SSRIs / SNRIs, vestibular rehabilitation, cognitive-behavioral therapy.
Vestibular rehabilitation therapy — habituation, gaze stabilization, and balance training; effective in most chronic vestibular disorders.
Treat central causes — stroke pathway for posterior-circulation stroke; immunomodulation for MS; surgery or radiation for tumors.
Avoid prolonged vestibular suppressants — they delay central compensation in chronic disease.

When to Seek Medical Care

Sudden vertigo with weakness, numbness, double vision, dysarthria, dysphagia, or imbalance preventing standing — call 911 for possible posterior-circulation stroke.
Severe headache with new vertigo, especially "worst headache of life."
New unilateral hearing loss with vertigo.
Vertigo after head trauma.
Recurrent or persistent vertigo affecting daily function.
Vertigo with chest pain, palpitations, or near-fainting (consider cardiac).
Progressive disequilibrium with cognitive change.

Connections

References & Research

Historical Background

Robert Bárány earned the 1914 Nobel Prize for caloric testing and the physiology of the vestibular system. The 1980 Epley maneuver transformed BPPV from a chronic burden into a 5-minute office cure. The HINTS exam (Kattah, 2009) gave clinicians a bedside tool with sensitivity exceeding early MRI for posterior-circulation stroke. Vestibular migraine was formally codified in 2012 by the Bárány Society and the International Headache Society.