Vertigo: Types, Diagnosis and Treatment

How the balance system works

The inner ear contains three semicircular canals, which detect head rotation, and two otolith organs (utricle and saccule), which detect gravity and straight-line movement. Signals travel along the vestibular nerve to the brainstem and cerebellum, where they are combined with information from the eyes and from joints and muscles. Vertigo results when one side sends abnormal signals, or when the brain cannot process them correctly.

Peripheral vs central vertigo

Peripheral causes

Benign paroxysmal positional vertigo

BPPV is the most common vestibular disorder. Detached otoconia (calcium carbonate crystals) move into a semicircular canal, most often the posterior canal. Brief vertigo occurs with head position changes. Lifetime prevalence is around 2 to 3% and it is more common in older adults, women, after head injury and with low vitamin D.

Vestibular neuritis and labyrinthitis

Viral inflammation of the vestibular nerve (vestibular neuritis) causes acute continuous vertigo over days. When hearing is involved, it is labyrinthitis. Recovery happens through central compensation over weeks.

Ménière's disease

Ménière's disease is linked to excess fluid (endolymphatic hydrops) in the inner ear. Diagnosis requires two or more spontaneous attacks lasting 20 minutes to 12 hours, low-to-mid frequency hearing loss on testing, and fluctuating ear symptoms.

Other peripheral causes

• perilymph fistula after barotrauma or surgery
• superior canal dehiscence
• vestibulotoxic drugs, such as gentamicin
• acoustic neuroma (vestibular schwannoma), usually causing hearing loss more than vertigo
• herpes zoster oticus (Ramsay Hunt syndrome)

Central causes

Posterior circulation stroke and TIA

Strokes in the vertebrobasilar territory can cause vertigo, sometimes as the only symptom. Studies of patients with acute continuous vertigo show the bedside HINTS exam, done by trained clinicians, is more sensitive than early CT for detecting stroke. MRI is the imaging test of choice. See stroke.

Vestibular migraine

Vestibular migraine is now recognized as one of the most common causes of recurrent vertigo. Diagnosis requires a migraine history, recurrent vestibular episodes of 5 minutes to 72 hours, and migraine features with at least half the episodes.

Multiple sclerosis

Demyelinating plaques in the brainstem can cause vertigo, often with other neurological symptoms. See multiple sclerosis.

Other central causes

Cerebellar tumors, Chiari malformation, and some medication or alcohol toxicity.

Diagnosis

History

The key questions concern timing and triggers:

• Triggered episodic vertigo (seconds, with head movement): BPPV
• Spontaneous episodic vertigo (minutes to hours): Ménière's, vestibular migraine, TIA
• Acute continuous vertigo (days): vestibular neuritis, labyrinthitis, stroke
• Chronic dizziness (months): persistent postural-perceptual dizziness (PPPD), uncompensated vestibular loss, bilateral vestibular loss

Bedside tests

• Dix-Hallpike maneuver: diagnoses posterior canal BPPV
• Supine roll test: diagnoses horizontal canal BPPV
• HINTS exam: Head Impulse, Nystagmus pattern and Test of Skew, used in acute continuous vertigo to separate vestibular neuritis from stroke
• Gait and coordination testing

Further tests

• Audiometry: hearing loss patterns
• Videonystagmography (VNG), caloric testing, video head impulse test (vHIT), VEMPs: measure vestibular function on each side
• MRI of the brain and internal auditory canals: for suspected central cause, acoustic neuroma or asymmetrical hearing loss

Treatment

Canalith repositioning for BPPV

The Epley and Semont maneuvers move crystals back into the utricle. AAO-HNS guidance recommends them as first-line treatment, with success rates of about 80% after one to three maneuvers. Post-maneuver restrictions are generally not needed. Recurrence is common, about 15% per year.

Vestibular suppressants

Antihistamines such as meclizine, antiemetics and benzodiazepines can ease severe acute vertigo, but should be limited to a few days. Prolonged use delays central compensation.

Vestibular rehabilitation therapy

Exercises that include gaze stabilization, habituation and balance training help the brain adapt. It is effective for vestibular neuritis, uncompensated vestibular loss, and chronic dizziness.

Cause-specific treatment

• Vestibular neuritis: early corticosteroids may aid recovery of nerve function, though evidence for long-term benefit is mixed
• Ménière's disease: salt restriction, diuretics, betahistine in some countries, intratympanic steroids or gentamicin, and surgery in refractory cases
• Vestibular migraine: lifestyle and trigger management, migraine preventives
• Stroke: acute stroke treatment and secondary prevention
• PPPD: vestibular rehabilitation, CBT and SSRIs

Complications

• falls and injuries, particularly in older adults
• anxiety and avoidance behavior
• chronic dizziness (PPPD) after an acute vestibular event
• dehydration from vomiting

Outlook

The outlook for peripheral vertigo is generally good. BPPV usually resolves with treatment, though it can recur. Most people recover from vestibular neuritis within weeks to months, especially with rehabilitation. Ménière's disease is chronic, but attacks can be controlled for most. Central vertigo outcomes depend on the cause.

For a practical guide to vertigo symptoms and when to seek help, see vertigo symptoms.

Frequently asked questions

What is the difference between peripheral and central vertigo?

Peripheral vertigo comes from the inner ear or vestibular nerve and is the most common type, usually with severe nausea and sometimes hearing changes. Central vertigo comes from the brain, often with other neurological signs such as double vision, slurred speech or inability to walk.

What is the most common type of vertigo?

Benign paroxysmal positional vertigo (BPPV) is the most common. It causes brief episodes of spinning triggered by head movements such as rolling over in bed, caused by loose crystals in the inner ear.

How is vertigo diagnosed?

Diagnosis relies on the history of timing and triggers plus bedside tests such as the Dix-Hallpike maneuver and the HINTS exam. Hearing tests and vestibular function tests help, and MRI is used when a brain cause is possible.

What is the best treatment for vertigo?

It depends on the cause. BPPV is best treated with repositioning maneuvers. Vestibular neuritis and long-term imbalance improve with vestibular rehabilitation. Ménière's disease and vestibular migraine have specific treatments. Medicines only help briefly in acute attacks.

Can vertigo be cured?

Many causes can. BPPV is usually cured with repositioning maneuvers, though it may recur. Vestibular neuritis typically resolves as the brain compensates. Ménière's disease cannot be cured but can be controlled. Treatment of the underlying cause is key.