Causes of Vertigo and How It Is Treated

Vertigo is the sensation that you are spinning or the world around you is spinning. The condition may be mild and barely noticeable or so severe that you are unable to keep your balance and feel like you're going to vomit.

Vertigo may be due to problems with the inner ear or parts of the central nervous system. Examples include benign paroxysmal positional vertigo (BPPV) and Ménière’s disease, both of which involve the inner ear, and brain tumors and migraines, which involve the brain. Some causes resolve on their own over time, while others can be managed with medications like antihistamines and steroids.

The article describes the symptoms and various causes of vertigo. It also explains how vertigo is diagnosed and treated.

Vertigo Symptoms

Vertigo differs from dizziness in that dizziness encompasses a variety of sensations ranging from lightheadedness and fainting to unsteadiness and wooziness. Vertigo implies a spinning sensation, either with you at the center of the spinning or the world spinning around you.

In addition to a spinning sensation, vertigo can also cause:

• A feeling of swaying, tilting, or being pulled in one direction
• A loss of balance
• Difficulty standing or walking steadily
• Nausea or vomiting

Depending on the underlying cause, you might also experience symptoms like:

• Ringing in the ear (tinnitus)
• Muffled hearing or ear fullness
• Unusual eye movements (nystagmus)
• Blurred vision
• Difficulty speaking or slurred speech
• Altered consciousness
• Sensitivity to light or sound
• Headache
• Hearing loss
• Ear pain

The spinning episodes can last anywhere from a few seconds to several hours, depending on what is causing your vertigo.

Peripheral Vertigo

There are two types of vertigo, differentiated by the parts of the body in which the symptoms originate. The first and most common type is peripheral vertigo.

Peripheral vertigo occurs when parts of the inner ear malfunction. Central to this is the vestibular system, composed of the semicircular canals and labyrinth of the inner ear and the vestibular nerve which transmit sensory information from the inner ear to the brain.

The function of the vestibular system is to provide a sense of balance and enable proprioception (an awareness of our body's position in space) so that you can navigate and move around. Metaphorically, it functions as a three-dimensional GPS in our brains.

There are a variety of conditions that can affect the inner ear and vestibular system:

Benign Paroxysmal Positional Vertigo

Benign paroxysmal positional vertigo (BPPV) is believed to be caused by calcium debris within the inner ear. It tends to cause spinning episodes that last for seconds rather than minutes.

Typically, a person with BPPV will describe a brief spinning sensation when moving their head in certain ways (such as tilting the head to the sky). Nausea may also be present, but rarely vomiting.

Vestibular Labyrinthitis

Vestibular labyrinthitis, also known as vestibular neuronitis, is caused by inflammation of the vestibulocochlear nerve after an infection, most commonly an upper respiratory infection.

The vestibulocochlear nerve is comprised of the vestibular nerve which regulates balance and the cochlear nerve which regulates hearing.

Inflammation of the vestibulocochlear nerve can cause sudden, severe vertigo accompanied by nausea or vomiting and unsteadiness. The episodes can last for seconds to minutes. Because the cochlear nerve is affected, there may also be hearing loss.

Ménière’s Disease

Ménière’s disease is a condition that causes the abnormal buildup of fluid in the inner ear. The cause of the condition is unknown, but it typically affects one ear initially. Over time, both ears may be impacted.

Ménière’s disease is associated with episodes of severe vertigo that can last for minutes to hours. In addition to nausea, vomiting, and imbalance, there may be one-sided tinnitus, hearing loss, and ear fullness.

Less Common Causes

Several other, less common conditions can cause peripheral vertigo. These include:

• Otosclerosis: This is the abnormal growth of tissue in the middle ear that can move to the inner ear, triggering tinnitus and vertigo.
• Otitis media: This is a middle ear infection that can cause inflammation of the inner ear and change inner ear pressure.
• Labyrinthine concussion: This is the injury of the labyrinth due to a blow to the head.
• Perilymphatic fistula: This is an abnormal opening in the membranes separating the air-filled middle ear from the fluid-filled inner ear. Vertigo is caused by changes in inner ear pressure.
• Ramsay Hunt syndrome: This condition occurs when the herpes zoster virus (shingles) affects the facial nerve. If the vestibular nerve is involved, vertigo can occur.

Central Vertigo

Central vertigo involves the central nervous system, consisting of your brain and spinal cord.

It is less common than peripheral vertigo and mainly involves two parts of the brain called the brainstem (which regulates balance, coordination, and reflexes) and the cerebellum (which is responsible for muscle control, including balance and movement).

Vestibular Migraine

Vestibular migraine refers to vertigo that occurs as a result of a migraine. In addition to vertigo and headache, nausea and sensitivity to light or sound may occur.

Vestibular migraines can develop spontaneously but may also be triggered by stress, sleep problems, hunger, dehydration, and illness.

Stroke

A stroke, especially in the brainstem or cerebellum, can cause vertigo. A brainstem stroke may also cause double vision and slurred speech. A cerebellum stroke can affect walking, speaking, chewing, hearing, and vision.

Vestibular Schwannoma

Vestibular schwannoma, also called acoustic neuroma, is a benign (noncancerous) tumor that develops on the vestibulocochlear nerve. In addition to vertigo, tinnitus and hearing loss may occur.

Because this type of tumor is slow-growing, the vertigo may be subtle, often described as a vague feeling of swaying, tilting, or imbalance.

Multiple Sclerosis

Multiple sclerosis is an autoimmune disease in which a person's immune system attacks the protective coating of nerves in the brain, causing them to misfire. If the autoimmune damage occurs in certain parts of the brainstem or cerebellum, vertigo can regularly occur.

Epileptic Vertigo

Epileptic vertigo refers to vertigo caused by an epileptic seizure. A seizure is the result of abnormal, excessive, and repetitive electrical discharges in brain cells called neurons.

Epileptic vertigo, also known as vestibular epilepsy, affects the temporal lobe, which receives information from the ears, and the parietal association cortex, which aids in spatial recognition from the eyes.

Other Causes

Vertigo is a common feature of certain heart conditions that can suddenly alter or limit the flow of blood to the inner ear or brain. These include:

• Cardiac arrhythmia (irregular heartbeats)
• Atrial fibrillation (irregular, rapid heartbeats)
• Bradycardia (slowed heartbeats)
• Angina (heart-associated chest pain)
• Myocardial infarction (heart attack)
  

Besides heart problems, other possible causes of vertigo include:

• Ototoxic drugs: These include medications like opioid pain relievers, blood pressure medications, and chemotherapy that can injure the organs of the ear.
• Hypotension: This is a drop in blood pressure caused by dehydration, heart dysfunction, blood pressure medications, and other things.
  
• Diabetes: Spikes in blood sugar can cause a sudden drop in blood pressure and the onset of vertigo.
  

How Vertigo Is Diagnosed

The diagnosis of vertigo involves a detailed review of your medical history accompanied by a physical exam. Depending on your healthcare provider's suspicion, imaging studies and lab tests may be ordered.

Medical History

During your appointment, your healthcare provider will ask you several questions to help characterize your vertigo, such as:

• Is your vertigo triggered by a sudden change in head position?
• How long do your vertigo episodes last, or is your vertigo continuous?
• What medications are you taking?
• Have you experienced any form of head trauma?
• Are you experiencing any additional symptoms, such as hearing loss, tinnitus, ear pain, muscle weakness, or slurred speech?

Physical Examination

The physical exam will typically include an evaluation of your ears, heart, eyes, and nervous system. Two of the more common in-office procedures include:

• Dix-Hallpike maneuver: As you sit on the edge of the examining table, the examiner turns your head 30 to 45 degrees and quickly lowers you to your back. The test is positive for peripheral vertigo if your eyes move rapidly from side to side or in circles (called nystagmus).
• Head impulse test: As you stare at the examiner’s nose, the examiner will quickly turn your head 10 to 20 degrees. The test is positive for central vertigo if your eyes move rapidly and repetitively and fail to refocus on the examiner’s nose.

Your blood pressure and pulse will also be taken. Your ears will be examined with an otoscope while the lymph nodes of your neck will be checked for signs of an ear infection.

Lab Tests

Based on the initial findings, certain blood tests and lab procedures may ordered to help pinpoint the possible causes of your vertigo:

• Complete blood count (CBC): This blood test can check for signs of infection and anemia (a condition associated with hypotension).
• Comprehensive metabolic panel (CMP): This blood test can detect electrolyte imbalances associated with dehydration.
• Fasting plasma glucose: This blood test can check for signs of diabetes.
• Electrocardiogram (ECG): This non-invasive test, which measures the electrical activity of your heart, can detect heart rhythm disorders.
• Holter monitor study: This is a form of ECG that is worn on the body to continuously monitor your heart function.

Imaging Tests

The diagnosis of vertigo may require medical imaging studies if the cause of your condition is not readily apparent:

• Computed tomography (CT): This imaging technology composites multiple X-ray images to generate a three-dimensional visualization of internal organs. It is well-suited to detect changes in the inner ear consistent with peripheral vertigo.
• Magnetic resonance imaging (MRI): This is the test of choice if central vertigo is suspected. MRIs utilize powerful magnetic and radio waves to create highly detailed images of soft tissues. It is better able to detect subtle changes in the brain that an X-ray or CT scan might miss.
• Magnetic resonance angiography (MRA): This is a form of MRI used to detect heart abnormalities or dysfunction.

Treating Peripheral and Central Vertigo

The treatment of vertigo depends on the underlying cause. While many diagnoses are benign, some are very serious and require emergent medical attention, most notably a stroke.

For most other diagnoses, lifestyle changes, medications, and/or vestibular rehabilitation remain the mainstay of treatment.

Lifestyle Changes

If you experience vertigo, there are things you can do to reduce your risk of future attacks:

• Keep a migraine diary to identify and avoid potential migraine triggers, such as sleep deprivation or excess stress.
• Avoid things that cause sinus congestion as this can disrupt the fluid balance in your ear.
• If you have Ménière’s disease, limit your salt intake to less than 2,300 milligrams per day. You should also reduce your caffeine and alcohol intake.
• Quit smoking as it irritates the Eustachian tubes which helps normalize pressure in your ears.

During vertigo, to minimize spinning sensations and reduce the risk of vomiting or falling:

• Sit or lie down immediately.
• Avoid moving quickly and try not to change your head position.
• Rest your eyes and stay away from bright lights, including TV and electronics.
• Do not read until symptoms ease.

Medications

Various vertigo-related conditions may be treated with medications. These include:

• Anticholinergics, such as Scopolamine (hyoscine) to ease acute vertigo symptoms
• Anticonvulsants, such as Depakote (valproic acid) for vestibular migraines and epileptic vertigo
• Antihistamines, such as Phenergan (promethazine) to help ease nausea symptoms
• Benzodiazepines, such as Valium (diazepam) to help ease acute vertigo symptoms
• Beta-blockers, such as Lopressor (metoprolol) for vestibular migraine
• Corticosteroids, such as methylprednisolone for vestibular neuritis or dexamethasone for Ménière's disease
• Thiazide diuretics, such as as Thalatone (chlorthalidone) for Ménière's disease

Epley Maneuver

A technique called the Epley maneuver is used to treat people with BPPV. The purpose of the maneuver is to remove the calcium debris from the semicircular canal of the inner ear and return them to the uticle where they belong. Studies suggest that the maneuver is safe and effective for short-term relief of BPPV. Note that your vertigo may get worse during the exercise.

To do the Epley maneuver for your right ear:

1. Sit on the edge of your bed with a pillow placed behind you.
2. Turn your head 45 degrees to the right.
3. Quickly lie back, keeping your head turned with your shoulders on the pillow and your head slightly reclined.
4. Wait 30 seconds.
5. Turn your head 90 degrees to the left, without lifting it.
6. Wait another 30 seconds.
7. Turn your head and body another 90 degrees to the left so that you are lying on your left side.
8. Wait another 30 seconds.
9. Sit up.

To do the Epley maneuver for your left ear:

1. Sit on the edge of your bed with a pillow placed behind you.
2. Turn your head 45 degrees to the left.
3. Quickly lie back, keeping your head turned with your shoulders on the pillow and your head slightly reclined.
4. Wait 30 seconds.
5. Turn your head 90 degrees to the right, without lifting it.
6. Wait another 30 seconds.
7. Turn your head and body another 90 degrees to the right so that you are lying on your right side.
8. Wait another 30 seconds.
9. Sit up.

Vertigo might go away immediately after the maneuver or it may take a few times for it to work. Mild vertigo might continue for a few weeks, but once it stops, you can discontinue the Epley maneuver.

Vestibular Rehabilitation

Vestibular rehabilitation is a type of physical therapy. People with peripheral vertigo may benefit from various head, eye, and balance exercises that aim to ease vertigo symptoms and improve proprioception and balance.

In addition to techniques like the Epley maneuver, the therapist may teach you:

• Habituation exercises: These are exercises that intentionally place you in positions that trigger vertigo, teaching you how to adjust your gaze and balance to minimize symptoms.
• Gaze stability training: These are exercises that help improve vision while the head is moving, reducing dizziness and improving balance.
• Balance retraining: These are exercises that teach you how to change your body position while walking or standing if you suddenly have vertigo.

A general exercise program can also help improve issues like muscle weakness, decreased range of motion of the neck, and other problems that contribute to falls and injury during vertigo.

Complementary and Alternative Therapies

Some people incorporate complementary and alternative therapies into their treatment plans for vertigo. Among those shown to have some benefit are:

• Acupuncture: Some studies suggest that acupuncture may be beneficial in managing vertigo associated with BPPV, vestibular labyrinthitis, and Ménière’s disease.
• Mind-body therapies: These therapies aim to reduce stress that can trigger or worsen vertigo. Options include yoga, mindfulness meditation, breathing exercises, and progressive muscle relaxation (PMR).
• Ginger: Some studies suggest that ginger root extract can help ease motion sickness and may have similar benefits in easing vertigo-associated nausea. Try sipping ginger tea, sucking on ginger candy, or chewing on a sliver of fresh ginger.
  

When to See a Healthcare Provider

Vertigo is an unpleasant symptom that can be debilitating. While most cases of vertigo are benign, due to the many possible causes behind vertigo—some of which are serious—it's important to see a healthcare provider, especially if you develop vertigo for no apparent reason or have recurrent episodes. This is particularly true if you have an underlying heart condition, a history of a stroke, or risk factors for a stroke.

Seek immediate medical care if vertigo is accompanied by any of the following signs or symptoms:

• Severe headache hearing loss or vision changes
  
• Facial drooping
• Weakness in an arm or leg
• Trouble speaking
• Severe chest pain
• Shooting pains in the shoulder or upper back
• Sudden, rapid heartbeats (tachycardia)
• Lightheadedness or fainting
• A feeling of impending doom
  

Summary

Vertigo is a condition in which you experience spinning sensations, often accompanied by nausea and the loss of balance. Peripheral vertigo involves problems with the inner ear and vestibular system, while central vertigo involves problems with the brain.

Vertigo can be diagnosed with a physical exam, a review of your medical history, lab tests, and imaging studies. Some cases resolve on their own, while others need to be managed with lifestyle changes, medications, and vestibular rehabilitation.