Vertigo: Why it Happens, Diagnosis and Treatment

The first time you experience vertigo, it can be an unsettling — even scary — experience. A slight shift of your head and you feel as if you’re wildly spinning, or the world is spinning around you. Patients come into my office completely baffled, worried they may be suffering from a serious brain disease.

Fortunately, in most cases I’m able to diagnose them with the most common cause of this spinning sensation: benign paroxysmal positional vertigo, or BPPV. We call this condition “benign” because even though it can be intense and upsetting — and even debilitating, for some patients — BPPV is not life-threatening. “Paroxysmal” means it comes in sudden, short episodes, so the disorienting feelings generally subside pretty quickly, usually in less than a minute. “Positional” means it’s triggered by certain head movements. And “vertigo” refers, of course, to that feeling of riding a wild merry-go-round.

So if you experience a very sudden attack of vertigo when you move your head up or down, or sit up in bed, which might be accompanied by nausea and feeling disoriented or unsteady on your feet, you most likely have BPPV, the most common disorder of the inner ear.

While BPPV is most common in people over 60, it can occur in people of any age and is more common in women than in men.

[See: 14 Ways to Protect Seniors From Falls.]

BPPV is sometimes associated with certain other occurrences or conditions — a bump on the head, migraine, other inner ear problems, diabetes, osteoporosis and lying in bed for long periods of time. But in the vast majority of cases there is no known cause.

We do know that the condition arises when tiny calcium crystals (called otoconia) break loose from their normal location in your inner ear and disrupt the usual coordination between your brain and inner ear that makes you feel steady and balanced. But exactly why these particles get knocked off and start floating around can be a mystery.

Most cases of BPPV tend to resolve on their own within a few weeks, and the dizzy spells tend to become less severe over time. But some cases are more severe or persistent, and even mild cases of BPPV can recur at any time. The worry for many of my patients is that they’ll have one of these attacks while doing something that absolutely requires their steadiness and full attention, like driving or holding a child. Because treatment is fast and effective in 80 percent of cases, it’s a good idea to see your doctor, both for the treatment and also to confirm that you have BPPV.

Older patients, in particular, should see a doctor if they experience vertigo, especially if they have a history or fear of falling.

[See: Osteoarthritis and Activity: Walking It Out.]

Vertigo Diagnosis and Treatment

Since BPPV symptoms can be alarming, my patients find it reassuring when I’m able to quickly rule out other far less common causes of vertigo, any of a wide range of medical issues that can include diseases of the brain or more serious inner ear problems.

Diagnosis of BPPV is usually very straightforward. Lab tests and other diagnostic tools, like brain scans and X-rays, are unnecessary because they can’t confirm the condition. Instead, we’ll talk to you about your symptoms, take a medical history and perform a simple bedside test to confirm the diagnosis.

We may ask you to lie down, and then we’ll move your head into a position that makes the crystals move and triggers BPPV symptoms. The most common exams are the Dix-Hallpike test and the supine roll test. These may include hanging your head a little off the exam table or rolling your head left and right while you’re lying on the table. We also look for involuntary rhythmic eye movements called nystagmus that often (but don’t always) accompany BPPV symptoms.

If initial testing indicates BPPV, we sometimes proceed with making specific head adjustments. Two of the most common are the Epley maneuver and the Lempert 360-degree roll maneuver. These help the particles float out of the part of the ear canal where they’re causing problems. These treatments only take a few minutes and are sometimes performed immediately by your diagnosing physician; or, you might be sent to an audiologist. For the purpose of diagnosis, we typically do not offer patients medications such as antihistamines or benzodiazepines to suppress the BPPV symptoms during the examination and treatment.

These maneuvers usually resolve the problem right away, though sometimes patients need to be treated a few times. We can also teach you to do these movements at home, which is very helpful if your BPPV symptoms are persistent or if they recur. Additionally, we may offer a physical therapy referral.

While most of my patients find success in managing their BPPV through these head reconditioning maneuvers, there are some who experience persistent symptoms despite therapy. We recommend patients be reassessed within one month of treatment to document whether symptoms have resolved or still persist. If symptoms continue, we consider a further workup, often with the help of our neurology colleagues, to rule out other causes of vertigo.

Whether you suffer a single episode of BPPV, or find yourself managing the condition over months or years, it’s important to take steps to avoid complications like falls. If you begin to feel dizzy, sit down immediately. Make sure you have good lighting in place if you get up at night and, if needed, use a cane or other assistive device to help with stability.

[See: 11 Things Seniors Should Look for in a Health Provider.]

Some patients worry that vertigo is too trivial a problem with which to bother their doctor — that we’ll think it’s silly or too minor to be taken seriously. But we know how debilitating and frightening these episodes can be.

And because we can help you feel better very quickly — and perhaps prevent accidents like falls — I would encourage anyone suffering from vertigo to see their doctor for diagnosis and treatment right away. For more information on the treatment of BPPV, read the 2017 Clinical Practice Guideline by the America Academy of Otolaryngology–Head and Neck Surgery.

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