Dizziness and vertigo
If the room is spinning around you, that is vertigo, and the cause is usually in the ear. If instead your vision goes dark or you feel unsteady on your feet, the cause more often lies elsewhere. 2 questions point the way: how long the episode lasts and whether your hearing is affected. The most common form can be recognized and treated with simple head movements in the same visit.
Dizziness or vertigo?
The word you use at the doctor's office steers the diagnosis more than you might think, so it is worth separating 3 things that people all call "dizziness"..
Vertigo is a false sense of movement. The room spins around you, or you spin within it. This is the symptom that points to the balance system of the inner ear.
Feeling faint is the "I'm going to fall" sensation, with your vision going dark, usually when you stand up quickly. It points to blood pressure, the heart or medicines
Unsteadiness is difficulty standing or walking steadily, without anything spinning. It points to a neurological assessment, eyesight or the muscles and joints.
Of the 3, only the first belongs clearly to the ENT specialist and it is the first thing clarified at the appointment.
What does the length of an episode tell us?
The duration, together with whether your hearing is affected, points to the cause in most cases.
Seconds, with head movement. You turn over in bed, bend down or look up, and the room spins briefly. Your hearing is not affected. This is benign positional vertigo (BPPV), the most common cause of vertigo and the only one that can be resolved with maneuvers in the doctor's office.
Minutes to hours, with episodes that come back. Along with the vertigo there is hearing loss that comes and goes, ringing in the ear and a feeling of fullness in the ear.This picture fits Ménière's disease.
Days, one severe episode. If hearing is normal, it is vestibular neuritis, an inflammation of the balance nerve. If there is also hearing loss or ringing, it is labyrinthitis.
Episodes with headache, sensitivity to light or sensitivity to sound. Η Vestibular migraine is one of the most common causes of recurring vertigo and one of the slowest to be recognized, because the headache does not always coincide with the dizziness.
One clarification is needed. In everyday language, almost any vertigo is called "labyrinthitis". Medically, however, it is one specific condition, the one that also affects hearing. If your hearing is normal, you most likely do not have labyrinthitis, and that changes both the treatment and the outlook.
When the cause is not in the ear
Dizziness does not always come from the ear, and a thorough assessment takes this into account from the start. Causes outside the ear include a drop in blood pressure, anemia, blood sugar problems, heart rhythm disorders and other heart-related causes, medicines you take, uncorrected eyesight problems, problems in the neck, as well as anxiety and panic attacks.
That is why the examination does not stop at the ear. When the findings point elsewhere, the next step is with a cardiologist, a neurologist or an internal medicine specialist, not repeated ear tests.
When is dizziness an emergency?
Some symptoms are not for an appointment, they need you to go to a hospital immediately.
- Double vision or blurred vision that does not clear
- Difficulty speaking or swallowing
- Weakness or numbness on one side of the body, or a drooping face
- A very severe headache that came on suddenly
- Being unable to stand or walk
- Loss of consciousness
There is also one ear emergency. Vertigo that comes together with sudden hearing loss in one ear needs a hearing test right away, because treatment has the best chances within the first 2 weeks.
What happens at the appointment?
First your history, with the questions you already know: how long it lasts, what triggers it, what comes with it, whether your hearing has changed. If you can, make notes on 2 or 3 episodes before you come, because these details are worth more than any test.
Dix-Hallpike test
You lie back quickly from a sitting position with your head turned, and the doctor watches your eye movements. The flickering eye movements that appear (nystagmus), their direction and how long they last confirm benign positional vertigo and show which of the inner ear's balance canals is involved. The test may briefly bring on the symptom, and that is exactly the point.
Body-roll test
This is a simple, painless test used to investigate positional vertigo, especially when the problem is suspected to come from the horizontal balance canal of the inner ear. You lie on your back and the doctor turns your head to the right and then to the left, watching whether this brings on vertigo or the typical eye movements (nystagmus). In this way, the side and the part of the balance system responsible for the symptoms can be identified.
Ear examination and hearing test
Hearing is the second key to the diagnosis, which is why it is checked in the same visit. It distinguishes vestibular neuritis from labyrinthitis, supports or rules out Ménière's disease and picks up sudden hearing loss that needs immediate treatment.
VEMP: vestibular evoked myogenic potentials
VEMP is a specialized, painless test of the inner ear's balance system. Using special sound signals and small electrodes, it records the response of specific parts of the balance system and the related nerve pathways. The test adds to the assessment of vertigo and unsteadiness and can provide important information in inner ear conditions, when the clinical picture calls for more specialized investigation.
When is imaging needed?
When the picture is typical of benign positional vertigo and there are no other findings, an MRI scan adds no further information and we do not request it. It is needed when there are neurological signs, when the vertigo is one-sided with uneven hearing or when the picture does not match any of the known forms.
Treatment
Repositioning maneuvers
In benign positional vertigo the cause is mechanical: tiny crystals have moved to where they do not belong inside the inner ear. The Epley maneuver is one of the maneuvers that move them back into place, with a series of head movements lasting a few minutes. It is the recommended treatment, and in most cases the symptoms settle immediately or after 1 repetition. A follow-up check takes place within 1 month, to confirm that the problem has been solved.
You do not need to wear a neck collar, sleep sitting up or avoid movement after the maneuver. These restrictions used to be given in the past, but they do not improve the result.
When the cause is different
In vestibular neuritis the brain gradually compensates, and recovery is faster with balance exercises (vestibular rehabilitation), not with rest.
In Ménière's disease, management is long term and includes dietary measures, medication and regular monitoring of hearing.
In vestibular migraine, treatment follows the approach used for migraine, in cooperation with a neurologist.
What about medication?
Medicines that suppress the balance system have a place in the acute phase, when the vertigo and vomiting are unbearable, for a few days. They are not, however, a treatment for benign positional vertigo, and using them for a long time delays the compensation that the brain makes on its own. We mention this because it is the most common mistake in managing dizziness: months of medication for something that could have been solved with a single maneuver.
Frequently asked questions
Some forms settle, but in their own time. Benign positional vertigo can clear up by itself within weeks, while with a maneuver it is usually solved in a single visit. The difference is not only the discomfort, it is also the risk of falling in the meantime, especially in older people.
Not during episodes, and not while you feel unsteady or faint. Because episodes usually start without warning, driving should be avoided until the cause has been established. After successful treatment, returning to driving is discussed at the practice.
No. Position restrictions after a repositioning maneuver do not improve the result. You can move and sleep normally.
It depends on the cause and on which balance canal is involved, something that only an examination can show. The right maneuver on the wrong ear does not help and can make the symptoms worse. Once the diagnosis is made, the doctor gives you exercises to do at home, and these prove very useful.
Stress makes almost every form of dizziness worse and can cause it on its own, in panic attacks. It is not, however, a safe conclusion before physical causes have been ruled out, because the reverse is also true: unexplained vertigo causes anxiety.
Less often than you might think. The neck contributes to a feeling of unsteadiness but rarely causes true vertigo. When the room is spinning, the investigation starts with the ear.
When should you not wait?
Urgent
Dizziness with neurological symptoms
Double vision, slurred speech, weakness on one side, a sudden severe headache or being unable to walk mean going to a hospital immediately.
Urgent
Vertigo with sudden hearing loss
Hearing test right away, treatment ideally within the first 2 weeks.
Medical review: Dr. Ioannis KotrotsosENT Surgeon and Specialist in Phoniatrics and Pediatric Audiology.
Πηγές: Bhattacharyya N et al., Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update), AAO-HNSF, 2017 · Chandrasekhar SS et al., Clinical Practice Guideline: Sudden Hearing Loss (Update), AAO-HNSF, 2019.
The information on this page is for general information only and does not replace a medical examination. For diagnosis and treatment, please consult a doctor.
