Vertigo: Why the Room Spins and the Manoeuvre That Often Cures It
Vertigo is not a diagnosis; it is a symptom, and the first useful step is separating it from the other things people call dizziness. Once that is done, the most common cause has a treatment that works in a single visit.
Four different things called “dizzy”
Vertigo: a false sense of movement, usually spinning, of yourself or your surroundings. Points to the inner ear or the brain’s balance pathways.
Presyncope: feeling about to faint, with greying vision. Points to blood pressure, heart rhythm or dehydration.
Disequilibrium: unsteadiness on the feet without spinning. Points to neuropathy, joint problems, vision or Parkinson’s disease.
Light-headedness: vague floating or fuzziness. Often anxiety, hyperventilation or medication.
Describing which of these it is tells a doctor more than any test.
Benign paroxysmal positional vertigo
The commonest cause of true vertigo, and the most satisfying to treat.
Tiny calcium crystals, normally embedded in one part of the inner ear, become dislodged into a semicircular canal. When you move your head, they shift and send a false signal of rotation.
The pattern is distinctive:
- Brief spinning lasting seconds to under a minute, not hours
- Triggered by position change: rolling over in bed, lying down, sitting up, looking up at a shelf, bending forward
- Settles when you keep still
- Often worst on first waking
- No hearing loss, no tinnitus, no neurological symptoms
- Nausea is common
Diagnosis is by the Dix-Hallpike test, in which the head is positioned to provoke a characteristic eye movement.
Treatment is a repositioning manoeuvre, most commonly the Epley manoeuvre, which guides the crystals back out of the canal through a sequence of head positions. It resolves the problem in a large majority of people, often in one session, sometimes needing repetition. It takes a few minutes and uses no medication.
This is worth emphasising because many people are instead given long courses of vestibular sedatives, which suppress symptoms, delay the brain’s natural compensation, and do nothing about the crystals.
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Other causes
Vestibular neuritis / labyrinthitis. Sudden severe vertigo lasting days, with nausea and vomiting, usually after a viral illness. Labyrinthitis also affects hearing; neuritis does not. Treatment is short-term symptom relief, sometimes steroids, and crucially early vestibular rehabilitation exercises rather than prolonged bed rest, which slows recovery.
Ménière’s disease. Episodes lasting 20 minutes to several hours, with fluctuating hearing loss, tinnitus, and a sensation of fullness in one ear. Managed with salt restriction, diuretics, and in resistant cases injections or surgery.
Vestibular migraine. Vertigo lasting minutes to days, often with headache, light sensitivity or a personal or family history of migraine. Commonly missed. Treated as migraine.
Cervicogenic dizziness from neck problems, orthostatic hypotension, medication effects, anxiety, acoustic neuroma causing one-sided hearing loss with imbalance, and perilymph fistula after barotrauma.
When vertigo means stroke
This is the critical distinction. A stroke in the cerebellum or brainstem can present with vertigo alone.
Seek emergency care immediately if vertigo comes with any of:
- Sudden severe headache
- Double vision or visual field loss
- Difficulty speaking or slurred speech
- Weakness or numbness of face, arm or leg
- Difficulty swallowing
- Inability to walk or stand unaided, which is the most useful single sign
- Loss of coordination in the limbs
- New deafness with vertigo
- Loss of consciousness
- Vertigo after head or neck injury
- Vertigo that is continuous and does not change with position in someone with vascular risk factors
A useful rule: inner ear causes usually leave people able to walk, however unpleasantly. Being unable to stand at all shifts suspicion toward the brain.
Practical management during an attack
Sit or lie down immediately to avoid falling. Fix your gaze on a stationary object. Move slowly, especially when getting out of bed. Keep the room dimly lit. Stay hydrated. Avoid driving and heights until the cause is known.
Vestibular sedatives such as betahistine, prochlorperazine and cinnarizine are useful for the first few days of severe symptoms only. Taking them for weeks or months prevents vestibular compensation and prolongs the problem — a very common mistake.
Vestibular rehabilitation, a structured programme of gaze and balance exercises supervised by a physiotherapist, is the treatment with the best long-term evidence for most persistent vestibular problems, and it is markedly under-used.
This is general information. New vertigo, especially with any neurological symptom or inability to walk, needs urgent medical assessment rather than home treatment.