Vertigo: Why the Room Is Spinning

What vertigo feels like

Vertigo is different from other types of dizziness:

Vertigo often comes with nausea, vomiting, sweating, unsteadiness and jerky eye movements (nystagmus). See dizziness for the other types.

Common causes of vertigo

Benign paroxysmal positional vertigo (BPPV)

BPPV is the most common cause. Tiny calcium crystals (otoconia) drift into one of the balance canals of the inner ear. When you move your head, they trigger a burst of spinning. Clues:

• brief spins lasting seconds to under a minute
• triggered by lying down, rolling over in bed, getting up, or looking up or bending down
• no hearing loss
• common after age 50, after head injury, or after long bed rest

It is very treatable with repositioning maneuvers.

Vestibular neuritis and labyrinthitis

Vestibular neuritis is inflammation of the balance nerve, usually after a viral infection. It causes sudden, severe, continuous vertigo lasting days, with vomiting and unsteadiness, then gradual improvement over weeks. If hearing is also affected, it is called labyrinthitis.

Vestibular migraine

Vestibular migraine causes episodes of vertigo lasting minutes to days, with or without headache, often with light or sound sensitivity. It is common in people with a history of migraine and is underdiagnosed.

Ménière's disease

Ménière's disease causes attacks of vertigo lasting 20 minutes to 12 hours, with ear fullness, roaring tinnitus and fluctuating hearing loss in one ear. Hearing often worsens over years.

Other causes

• Medicines: anticonvulsants, some blood pressure drugs, sedatives, aminoglycoside antibiotics
• Alcohol
• Motion sickness and mal de débarquement (a rocking sensation after boat travel)
• Head injury: BPPV or inner ear concussion
• Acoustic neuroma: a slow-growing benign tumor, usually causing one-sided hearing loss and tinnitus more than vertigo

Serious causes: stroke and other brain problems

A stroke or bleed in the cerebellum or brainstem can cause vertigo. It is uncommon among all vertigo cases but important not to miss. Warning signs:

• the 5 Ds: dizziness with double vision, dysarthria (slurred speech), dysphagia (trouble swallowing), dysmetria (clumsiness), or numbness
• being unable to walk without help
• a new severe headache or neck pain (possible vertebral artery dissection)
• age over 50 with vascular risk factors

Some strokes cause vertigo alone. Emergency doctors use bedside eye-movement tests (HINTS exam) and MRI to tell these apart from vestibular neuritis.

Timing is the best clue

How vertigo is diagnosed

A doctor will ask what the dizziness feels like, how long episodes last, what triggers them, and about hearing, headache and neurological symptoms. Examination includes:

• watching your eye movements for nystagmus
• Dix-Hallpike test: quickly lying you back with your head turned, which reproduces vertigo and nystagmus in BPPV
• head impulse test and other HINTS components
• balance, walking and coordination tests
• hearing tests

Further tests depend on findings: audiometry, vestibular function tests, and MRI of the brain for suspected stroke or tumor.

Treatment and what helps

BPPV

The Epley maneuver (or Semont maneuver) moves crystals out of the canal. It cures most cases in one to three sessions. A clinician can perform it and teach you to repeat it at home. Medicines are not needed for BPPV.

Acute vertigo attacks

• lie still in a comfortable position with your eyes closed or fixed on one point
• short-term anti-nausea or antihistamine medicines such as meclizine or prochlorperazine, for no more than a few days, because longer use slows the brain's adaptation
• small sips of fluid to avoid dehydration
• a short course of steroids may be used early in vestibular neuritis

Vestibular rehabilitation

Specific head, eye and balance exercises help the brain compensate after inner ear damage. A physical therapist can design a program. It is the main treatment for lingering imbalance.

Cause-specific treatment

• Ménière's disease: low-salt diet, diuretics, and procedures for severe cases
• Vestibular migraine: trigger management and migraine-preventive medicines
• Stroke: emergency treatment and rehabilitation

Safety tips

• get up slowly, sitting on the edge of the bed for a minute first
• use a night light and remove trip hazards
• do not drive, climb ladders or operate machinery during attacks

Frequently asked questions

What causes vertigo?

Most vertigo comes from the inner ear: BPPV (loose crystals), vestibular neuritis or labyrinthitis (inflammation after a virus), Ménière's disease and vestibular migraine. Less often, a stroke, multiple sclerosis or a tumor in the brain is responsible.

Why do I get vertigo when I lie down or roll over in bed?

Brief spinning when lying down, turning over or looking up is the classic pattern of BPPV, caused by tiny crystals moving in the inner ear. It is harmless and usually cured quickly with a repositioning maneuver such as the Epley maneuver.

How do I stop vertigo fast?

Lie still with your eyes fixed on one point, and move slowly. For BPPV, the Epley maneuver can stop episodes once done correctly. Anti-nausea medicines can ease severe attacks for a day or two. See a doctor to identify the cause.

When is vertigo an emergency?

Vertigo is an emergency when it comes with double vision, slurred speech, facial drooping, weakness or numbness, trouble swallowing, a severe headache, or being unable to walk. These may signal a stroke. Call 911 or your local emergency number.

How long does vertigo last?

It depends on the cause. BPPV spins last under a minute each, often recurring for days to weeks. Vestibular neuritis causes continuous vertigo for days, with imbalance for weeks. Ménière's attacks last minutes to hours. See a doctor if vertigo keeps returning.