Vertigo and dizziness

Vertigo and Dizziness: How to Understand and Treat Them?

Vertigo and dizziness are understood based on their duration, triggers, and accompanying symptoms, and are then treated according to their probable cause. Vertigo causes a false sensation of movement, such as spinning, swaying, or pitching. Dizziness, on the other hand, describes a lightheaded feeling, unsteadiness, or general discomfort. Some causes respond well to physical therapy, while others require a medical evaluation. Our guide to vestibular physical therapy explains the treatment process.

How to Differentiate Between Dizziness and Lightheadedness?

Vertigo gives you the sensation that you are moving or that your surroundings are moving—for example, as if everything is spinning—while dizziness is more of a sensation of lightheadedness, unsteadiness, or discomfort without the false impression of movement. The duration, triggers, and other symptoms then help the healthcare professional identify possible causes.

Internal vertigo makes it feel as though your body is spinning. External vertigo makes it feel as though the room or objects are spinning around you, even though you are standing still.

Dizziness can feel like lightheadedness, disorientation, a sensation of floating, or a feeling of unsteadiness similar to that experienced after drinking alcohol. The description varies from person to person.

These symptoms may originate in the vestibular system in your inner ear. This system acts like an internal gyroscope. It tells your brain the position of your head.¹ When you have a vestibular disorder, the information about movement and position may become less consistent. However, this explanation does not cover all causes of dizziness or lightheadedness.

Both can occur simultaneously in the same person. Sometimes, an episode of intense vertigo gives way to persistent dizziness. Persistent or changing symptoms warrant reevaluation, especially if new signs appear.

The symptoms associated with vertigo and dizziness vary depending on the cause, but the most common include a sensation of spinning or rocking, unsteadiness when walking, nausea and vomiting, difficulty keeping one's gaze steady during movement, and fatigue and anxiety related to these episodes.

What is Benign Paroxysmal Positional Vertigo (BPPV)?

BPPV is a disorder of the inner ear that causes brief episodes of dizziness when the head changes position. Small calcium crystals move within a canal in the inner ear and temporarily disrupt the balance signal². BPPV is the most common vestibular disorder—that is, a disorder of the inner ear’s balance system³. A population-based study estimates that 2.4% of adults experience it at some point in their lives⁴.

When the head moves, these crystals displace the fluid in a canal in the inner ear. The canal then sends a false signal of rotation to the brain, even when the head has stopped moving. This false signal causes intense, but usually brief, vertigo².

What are the Symptoms of BPPV?

VPPB usually causes intense dizziness that lasts less than a minute⁴. Lying down, standing up, rolling over in bed, bending over, or looking up can trigger an episode.

Dizziness may be accompanied by nausea, vomiting, or a loss of balance. Some people therefore avoid any movements that trigger these symptoms. Exercising temporary caution can reduce the risk of falling, but an assessment can help determine how to safely resume normal movements.

What are the Causes of BPPV?

BPPV can occur without a clear cause or following a traumatic event, such as a concussion or a head or neck injury. After a traumatic event, both ears or multiple semicircular canals may be affected more often than in cases of BPPV with no^known cause^{.³, ⁵}

The inner ear contains three semicircular canals that detect head rotations. The posterior canal is affected in approximately 80 to 90 percent of BPPV cases, and the horizontal canal in approximately 5 to 30 percent³. The affected canal determines the symptoms observed and the maneuver used. Multiple canals may be affected at the same time³. In a series of 583 patients, 8% had BPPV involving multiple canals⁶.

How is BPPV diagnosed?

A physical therapist trained in vestibular rehabilitation diagnoses BPPV based on the patient’s symptom history and maneuvers that place the head in specific positions. The therapist then observes the symptoms and involuntary eye movements to determine which canal is likely affected. The therapist also assesses eye movements, balance, and neck function when necessary.

For VPPB that meets the diagnostic criteria and has no inconsistent signs, the guideline does not recommend routine imaging. In other cases, the decision to perform imaging depends on the medical evaluation and associated signs.

What are the Treatments for BPPV?

Treatment for BPPV involves a repositioning maneuver tailored to the affected canal: a series of head positions that guides the crystals out of that canal and back to their usual location in the inner ear. For the posterior canal, the Epley maneuver is more effective at resolving vertigo in the short term compared to a sham maneuver or no^{treatment at all⁷, ²}. The number of sessions varies depending on the canal, the cause, and the response to treatment. A clinical review describes rapid and effective treatment in more than 90% of cases, without specifying a precise number of sessions⁸. BPPV may recur after successful treatment. The same review reports a recurrence rate of 40 to 50% over an average period of five years⁸. A recurrence therefore does not mean that the first maneuver failed³.

While waiting for an evaluation, move more slowly when changing positions and ask for help if you feel like you might fall. Some episodes resolve on their own, but their duration varies. In a population-based study, the median duration was two^{weeks.³, ⁴} However, you do not need to wait for the symptoms to resolve on their own before seeking an evaluation.

Yes, BPPV can resolve on its own without treatment. Once the diagnosis is confirmed, a period of observation with follow-up may be an option. Repositioning maneuvers can also treat it. If symptoms persist or change, a reevaluation is performed to determine whether the BPPV is still present or if there is another cause.

A German study estimated that the cumulative risk of having experienced a BPPV was nearly 10% by age 80. This calculation is based on the ages at which the first episode occurred, as reported retrospectively—that is, after the fact. The study also estimated that 2.4% of adults had already experienced a VPPB at the time of the interview. These two figures represent different measures, and memories of past episodes may be incomplete.⁴

VPPB may resolve on its own within a few days or weeks, but some episodes last longer. Recurrences—that is, new episodes after an improvement—are still possible.³ A review of 30 studies reports recurrences after treatment in 13.7% to 48% of participants followed for less than one year, and in 13.3% to 65% of those followed for at least two years. The study populations and follow-up periods vary across studies.⁹

What is Cervicogenic Lightheadedness?

The term “cervicogenic dizziness” refers to the hypothesis that a problem in the neck causes dizziness. One proposed explanation involves signals from the neck that are out of sync with those from the eyes and the inner ear. This causal link remains^{uncertain.¹⁰, ¹¹}

What are the symptoms of cervicogenic dizziness?

Dizziness associated with the neck can cause a feeling of disorientation, lightheadedness, floating, or unsteadiness. This sensation alone is not sufficient proof that the neck is the cause.

Neck pain or stiffness usually accompanies dizziness that is considered cervicogenic. Headaches or limited neck mobility may also be present.

What are the causes of cervicogenic dizziness?

The exact cause of cervicogenic dizziness remains unclear. One hypothesis suggests that the brain receives less accurate information about the position and movements of the neck.

Neck pain and headaches may accompany dizziness. These symptoms may occur during an episode of neck pain or following a neck sprain—sometimes called whiplash—resulting from a collision.

How is cervicogenic dizziness diagnosed?

The evaluation looks for possible causes of dizziness and any accompanying neck problems; however, it cannot, on its own, confirm that the neck is causing the dizziness. In particular, the physical therapist checks to see if certain neck movements trigger the symptoms and assesses range of motion, strength, and balance.

The physical therapist may also examine eye movement control and the inner ear’s balance system. These assessments help the physical therapist identify other possible causes or multiple factors occurring simultaneously.

There is currently no test or established set of criteria that confirms a cervical origin¹¹. Some publications suggest an approach based on history, physical examination, and the investigation of other^{causes12, 10}. The healthcare professional therefore assesses whether another cause better explains the symptoms, without considering the exclusion of that cause as proof of a cervical origin.

What are the treatments for cervicogenic dizziness?

Treatment depends on the limitations identified during the evaluation. The physical therapist assesses, among other things, neck movement and strength, balance, movement quality, and, if necessary, eye control and the inner ear system.

Based on the results, the physical therapist may recommend joint mobilization and gradual exercises. A systematic review concludes that manual therapy can reduce dizziness, neck symptoms, and balance problems in some people. The evidence is of moderate quality for manual therapy alone and very low when combined with exercises¹³. Home exercises are designed to improve movement, strength, or balance, depending on the difficulties identified during the evaluation.

If the evaluation also identifies a problem with eye control or balance originating in the inner ear, the program may include exercises specifically designed for these functions. Physical therapy for neck pain can complement this program when neck pain accompanies dizziness.

Dizziness may occur after a whiplash injury, which is a sudden movement of the head and neck. There are several possible causes following this type of trauma. An evaluation helps determine the necessary care. Physical therapy for neck pain can treat identified neck problems, but an improvement in dizziness does not confirm a cervical cause.¹¹

What are the warning symptoms that require urgent medical attention?

Call 911 if you suddenly experience dizziness or lightheadedness along with facial drooping, weakness or numbness on one side of the body, sudden difficulty speaking, a sudden change in vision, a sudden and very severe headache, or a sudden inability to stand or walk¹⁴. These signs may indicate a stroke. Also call 911 if a person loses consciousness during physical exertion, does not wake up within a minute, or if the episode is accompanied by chest pain, difficulty breathing, or^{an unusual} heartbeat ^{.¹⁵, ¹⁶}

If you experience sudden hearing loss, with or without dizziness, see a doctor immediately. Sudden hearing loss is also a medical emergency, even if it feels like a blocked ear¹⁷. Loss of consciousness also warrants medical attention, even after a full recovery¹⁵. Dizziness during physical exertion requires prompt medical evaluation¹⁶. Severe or repeated vomiting accompanied by dizziness also requires urgent medical attention¹⁸.

New, sudden, and persistent dizziness requires urgent medical evaluation. Call 911 if it is accompanied by double vision, weakness, sudden numbness, difficulty speaking, a sudden and unusual headache, or a new inability to walk. A disorder of the inner ear should not be assumed without an examination.

If in doubt, seek professional advice. It's always better to get it checked.

Don’t wait until all of these symptoms are present; seek help even if they go away. Do not drive yourself. Sudden hearing loss accompanied by dizziness also requires immediate evaluation in the emergency room.¹⁸ Dizziness accompanied by a severe headache, profuse vomiting, a high fever, or feelings of heat, cold, or chills also requires urgent medical attention, even in the absence of the other symptoms described.¹⁸ If the headache came on suddenly and is very severe, call 911.¹⁴

When to consult a physiotherapist for vertigo or dizziness?

Consult a physical therapist trained in vestibular rehabilitation if you experience brief episodes of dizziness that recur with certain head movements, if your balance remains impaired, or if your symptoms limit your activities. If you notice any of the warning signs described above, seek appropriate medical help first.

You should see a doctor if your dizziness persists, if it interferes with your work or daily activities, if you feel unsteady when walking, or if it occurs after an injury.

If you suspect BPPV, choose a physical therapist who has training in vestibular physical therapy. This training enables the therapist to select the appropriate tests and maneuvers based on which canal may be affected.

You can see a physical therapist directly. The physical therapist will refer you to a doctor or the emergency room if your medical history or physical exam indicates that a medical evaluation is needed immediately.

In Quebec, you can see a physical therapist without a prescription. They can help assess vertigo and treat certain causes that fall within their scope of practice. Your family doctor can perform a general evaluation and rule out medical causes. An otolaryngologist (ENT), a doctor specializing in the ears, nose, and throat, treats complex ear problems or Ménière’s disease. A neurologist is consulted if a neurological cause is suspected.

What are some other causes of dizziness and lightheadedness?

Other causes of dizziness and lightheadedness include inner ear disorders, migraines, certain medications, a drop in blood pressure when standing up, and irregular heart rhythms. Vestibular neuritis is caused by inflammation of the nerve that transmits balance information from the ear to the brain. Labyrinthitis affects the inner ear and can also impair hearing. Ménière’s disease is an inner ear disorder that can involve episodes of vertigo, tinnitus, and hearing loss¹⁸.

Vestibular neuritis is characterized by a sudden decline in vestibular function on one side. The exact cause is not always known.¹⁹ Hearing loss suggests a different diagnosis, which must be evaluated.

Ménière's disease is a disorder of the inner ear that can cause episodes of vertigo, fluctuating hearing loss, ringing in the ears (known as tinnitus), or a sensation of pressure in the ear. The frequency and severity of episodes and symptoms vary. Sudden hearing loss requires immediate medical evaluation.

There is no single confirmed cause of Ménière's disease. An excess of fluid is often observed in the inner ear, but its exact role in the episodes remains unclear²⁰. The prevalence of the condition alone cannot explain a person’s symptoms.

Your doctor or an ENT specialist will provide medical care for Ménière's disease. Dietary changes, such as reducing salt intake, are often recommended, but their effectiveness remains uncertain.²¹ Vestibular physical therapy can help if balance problems persist between attacks; it is not used to treat an acute attack of Ménière’s disease.

For vestibular neuritis, Ménière's disease, and other vestibular disorders, treatment may combine different approaches. During the acute phase, the doctor may prescribe medications for dizziness or nausea, such as anti-vertigo drugs and antiemetics. These are intended to provide temporary relief, without treating the underlying cause.²²

Anxiety and persistent dizziness can also exacerbate each other. Less commonly, a neurological condition—such as a stroke, multiple sclerosis, or a brain tumor—can cause these symptoms. This variety explains why the evaluation takes into account the onset, duration, triggers, and associated signs.

Dizziness originating in the brain can sometimes resemble BPPV. Unusual eye movements, weakness, difficulty speaking, or significant unsteadiness when walking require a medical evaluation.

What is the link between anxiety and vestibular problems?

Anxiety and vestibular symptoms can reinforce each other. Anxiety can increase focus on sensations and lead to avoidance of movement, while unpredictable symptoms can fuel anxiety. A systematic review describes this link in people with persistent dizziness accompanied by anxiety²³.

Stress can affect certain symptoms, but it does not determine their cause. New-onset dizziness or lightheadedness warrants the same evaluation, regardless of whether a person is going through a stressful period.

Constant attention to physical sensations can make every signal from the body seem more threatening. In people with persistent dizziness accompanied by anxiety, vestibular rehabilitation may reduce disability related to dizziness. The reported improvements are small to moderate, and the certainty of the evidence ranges from very low to moderate²³.

Some people are afraid to drive, go to supermarkets, or walk alone. The plan can gradually focus on the activities that matter to them, depending on safety, symptoms, and the observed response.

What conditions are associated with vertigo and dizziness?

Concussions, neck pain, and migraines can be associated with dizziness and lightheadedness. A concussion, in particular, can disrupt balance and eye control. The evaluation determines which functions appear to contribute to the symptoms.

Neck pain may accompany dizziness, especially after a neck injury. A migraine may also be accompanied by vertigo, even without a headache at the same time.

Vestibular migraine may involve episodes of vertigo and other symptoms associated with migraine. The recurrence of episodes alone is not sufficient to establish this diagnosis. Episodes may include vertigo of varying duration, with or without a headache, as well as sensitivity to light or sound and nausea. These features alone are not sufficient to confirm the diagnosis.

A history of migraines and episodes of dizziness may lead a doctor to consider vestibular migraine as one of several possible causes. Treatment depends on an individualized medical evaluation. To learn more about migraines, see our guide on headaches.

In a study of 343 adults who had suffered a mild traumatic brain injury—an injury that disrupts brain function—18.7% still reported an average of at least three symptoms seven months after the injury. The most common symptoms were fatigue and forgetfulness; dizziness was among the less frequently reported symptoms. This result depends on the study population and the definition of persistent symptoms.²⁴

How can you get help for your dizziness or lightheadedness?

You can get help by making an appointment with a physical therapist trained in vestibular rehabilitation, unless the warning signs described above require medical attention first. The physical therapist can assess your symptoms, check your neck, eye, and balance functions, and then propose a plan tailored to the results. The evaluation looks for probable causes and signs that require medical referral, though it does not guarantee that a single cause will be found.

The course of the condition depends on the cause, the duration of symptoms, and any associated problems. Make an appointment if your symptoms are limiting your activities or if you would like to have your balance evaluated.

Sources

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Our physical therapists defined the research strategy, plan, and clinical content of this article. An AI tool assisted with the literature review and text editing to ensure consistency in content and writing style.