Vertigo and dizziness: causes, diagnosis and treatment

Vertigo and dizziness are two of the most common reasons for medical consultation, and yet many people endure them for months without knowing exactly what is happening to them or which specialist to see. If you have noticed that the world is spinning around you, that you lose your balance for no apparent reason, or that you have episodes of unsteadiness that prevent you from leading a normal life, this article will help you understand what is happening and what treatment options exist.

The important thing from the outset: “vertigo” is not a diagnosis, it is a symptom. Behind it there can be a dozen different conditions that are investigated and treated very differently, which is why the first step is not to seek a remedy for vertigo, but to find out which condition you have.

What is vertigo and how does it differ from dizziness?

Although in everyday language we use “vertigo” and “dizziness” almost synonymously, from a medical point of view they are different things, and that difference matters greatly for diagnosis.

Vertigo is an illusory sensation of movement: the person perceives that they themselves or their environment are spinning, swaying or moving, when in reality there is no actual movement. It tends to be more intense, more sudden, and is often accompanied by nausea, sweating or nystagmus (involuntary eye movements).

Dizziness, on the other hand, is a more non-specific feeling of lightheadedness, disorientation or a “faint” sensation in the head. It does not necessarily involve a perception of spinning and can have very diverse causes: low blood pressure, anaemia, anxiety, dehydration, or inner ear problems, among others.

Unsteadiness is the difficulty in maintaining balance when walking or standing, and can appear on its own or alongside either of the previous two.

All three can have a vestibular origin, and all three can not. Distinguishing between them is not a matter of vocabulary: it is what guides the investigation in one direction or another.

The role of the inner ear in balance

Many people do not know that the balance organ is not in the brain or the legs, but in the inner ear. The vestibular system, made up of three semicircular canals and two structures called the utricle and saccule, detects head movements and sends this information to the brain so it can coordinate posture and gaze at all times.

When something goes wrong in this system, whether due to an infection, a displacement of calcium crystals within the canals, or inflammation of the vestibular nerve, the brain receives conflicting signals and the result is the sensation of vertigo or unsteadiness.

Most common causes of vertigo and dizziness

There are dozens of possible causes, but in clinical practice most cases of true vertigo originate in the inner ear or the vestibular nerve. These are the most common.

Benign paroxysmal positional vertigo (BPPV)

It is by far the most common cause of vertigo, accounting for between 20 and 30% of all cases. It occurs when otoliths, small calcium carbonate crystals that are normally located in the utricle, move into one of the semicircular canals. When the head moves, these crystals displace the fluid in the canal abnormally, generating a false signal of movement.

The characteristic symptom is a brief but intense episode of vertigo, lasting between 20 and 60 seconds, which appears when changing head position: getting out of bed, turning over in bed, looking up, or bending down. It is bothersome, but as its name indicates, it is benign and can be treated very effectively using specific repositioning manoeuvres. We explain this in more detail in ear crystal vertigo.

Vestibular neuritis

This is an inflammation of the vestibular nerve, usually of viral origin, which produces a very intense and prolonged episode of vertigo (it can last for days), with severe nausea and loss of balance. Unlike BPPV, it is not linked to position changes and does not improve by staying still.

Patients often describe it as one of the most terrifying episodes of their life: they cannot get out of bed, any movement makes it worse, and the nausea is incapacitating. With appropriate treatment, which includes medication in the acute phase followed by vestibular rehabilitation, recovery is complete in most cases.

Labyrinthitis

Similar to neuritis, but also involving the cochlea (the part of the ear that processes sound), so auditory symptoms are added to the spinning sensation: hearing loss, ringing or tinnitus. It can be viral or bacterial in origin, with the bacterial form being more severe and less common.

Ménière's disease

It is a chronic inner ear disorder characterised by recurrent episodes of intense vertigo (lasting between 20 minutes and several hours), fluctuating hearing loss, tinnitus, and a feeling of fullness or pressure in the ear. The exact cause is not fully understood, although it is linked to an abnormal accumulation of fluid in the labyrinth (endolymphatic hydrops).

It is a condition that requires long-term follow-up and a stepped treatment approach, from dietary changes and medication to more specific procedures in refractory cases. It has its own page: Ménière's disease.

Vestibular migraine

This is a cause of vertigo that has historically been underdiagnosed. People suffering from it experience episodes of vertigo, sometimes without a headache, related to migraine. They can last from minutes to days and are usually accompanied by sensitivity to light or noise. Diagnosis requires a detailed medical history and the exclusion of other causes.

Red flags: when dizziness may be urgent

Most cases of vertigo have benign causes and do not represent a medical emergency. However, there are symptoms accompanying dizziness or vertigo that require immediate attention in A&E:

• Sudden, severe headache, different from any previous pain.
• Difficulty speaking, swallowing or seeing clearly.
• Weakness or numbness in arms or legs.
• Loss of consciousness or confusion.
• Sudden hearing loss in one ear.
• Vertigo following head or neck trauma.

These signs may indicate a central (neurological or vascular) problem that requires urgent assessment. In their absence, vertigo can be investigated on a scheduled basis by an otoneurology specialist.

How vertigo is investigated

A good diagnosis is not made with a single question and a couple of manoeuvres. It requires examining the vestibular system systematically using the appropriate tools. At the Vestibular Unit at Rincón Salud, the assessment includes:

• Detailed medical history. The type of symptom, its duration, triggering or relieving factors, associated symptoms, and medical history form the foundation of any vestibular diagnosis.
• Otoneurological examination. We assess balance, gait, and above all eye movements, looking for signs that can help us understand which part of the vestibular system may be involved. We evaluate, among other aspects, the presence and characteristics of nystagmus, oculomotor control, static and dynamic balance, and the patient's response to different stimuli.
  
• Positional vertigo assessment. When symptoms appear upon lying down, turning in bed, looking up, or performing certain head movements, we carry out specific positional manoeuvres, such as Dix-Hallpike or McClure. Not all positional vertigo is BPPV, which is why it is important to carefully analyse the nystagmus that appears during these manoeuvres before prescribing a treatment.
• Videonystagmography (VNG). Using goggles with infrared cameras, we can observe and record eye movements without visual fixation masking them. This allows for a more precise study of spontaneous, positional, or induced nystagmus and enables the analysis of different aspects of vestibular and oculomotor function.
• Video Head Impulse Test (vHIT). This test allows us to examine the vestibulo-ocular reflex during rapid head movements and individually evaluate the function of all six semicircular canals. It provides particularly useful information on high-frequency vestibular system function.
• Rotary chair test. This allows us to analyse the vestibular response to controlled rotational movements and evaluate the vestibulo-ocular reflex at frequencies different from those assessed by other tests. We can also observe how nystagmus is modified with visual fixation.
• Vibration-induced nystagmus (VIN). Applying a vibratory stimulus allows us to explore the vestibular response at very high frequencies and can provide complementary information when there is an asymmetry between the two vestibular systems.
• Vestibular Evoked Myogenic Potentials (VEMPs). These allow us to study inner ear structures and vestibular pathways that are not directly assessed by other tests, particularly function related to the otolith organs and their connections.
• Audiometry and tympanometry. Necessary when associated hearing impairment is suspected, such as in Ménière's disease or labyrinthitis.

You can see what each test involves in balance testing.

The ultimate goal is to integrate what the patient describes, what we find during the examination, and the test results to arrive at the most precise diagnosis possible and, from there, decide on the most appropriate treatment or rehabilitation.

Vertigo treatment

The treatment of vertigo, dizziness or unsteadiness depends on the underlying cause. There is no single treatment for “vertigo”.

BPPV, loss of vestibular function, Ménière's disease, vestibular migraine, or persistent dizziness require different approaches. That is why, before starting treatment, the first step is to establish as accurate a diagnosis as possible.

Repositioning manoeuvres

These are the treatment of choice for benign paroxysmal positional vertigo (BPPV).

The goal is to return displaced inner ear particles to a location where they no longer trigger vertigo. Different manoeuvres exist — such as the Epley manoeuvre, among others — and the choice depends on the semicircular canal affected and the type of BPPV.

For this reason, before performing a manoeuvre, it is important to correctly identify the affected canal and ear through positional testing and observation of nystagmus.

Vestibular rehabilitation

Vestibular rehabilitation is an essential component of treating many balance disorders, especially when there is a loss of vestibular function, difficulty regaining balance, or symptoms that persist with movement.

It does not simply consist of performing a standard set of exercises. The programme must be tailored to the patient's symptoms, examination findings, and specific difficulties.

It may include gaze stabilisation exercises, movement habituation, balance, gait training, progressive exposure to visual stimuli, and the gradual resumption of activities that the patient has been avoiding.

In our unit, we work in coordination with physiotherapists specialising in vestibular rehabilitation, monitoring progress and adapting the treatment when necessary.

Pharmacological treatment

Medication can serve very different purposes depending on the diagnosis.

During acute episodes, medications may be used to temporarily control symptoms such as severe vertigo, nausea, or vomiting. Vestibular suppressants, when indicated, should generally be used for short periods, as prolonged use can hinder vestibular compensation mechanisms.

In other disorders, pharmacological treatment has a preventive or modulating purpose.

The decision to start pharmacological treatment must be individualised, explaining to the patient why it is being prescribed, the expected benefit, and potential side effects.

Follow-up and treatment adjustment

Follow-up consultations allow us to evaluate the response to treatment, identify factors that may be hampering recovery, and modify the plan when necessary.

When to seek medical advice?

If you experience recurrent or persistent vertigo, dizziness, or unsteadiness, especially if it limits your daily activities, it is worth investigating what is causing it.

Even when tests have already been carried out previously, a comprehensive otoneurological evaluation can help integrate symptoms, examination findings, and test results to decide on the next steps.

The goal is not only to reduce dizziness, but to understand its cause and help you progressively regain your routine and quality of life.

Our motto: “understanding what is happening is part of the treatment”.