Vertigo: Why the Room Spins, What’s Causing It, and How It’s Treated
Vertigo — the sudden, disorienting sensation that you or the world around you is spinning — is one of the most frightening symptoms a patient can experience. It sends thousands of people to emergency rooms every year, convinced they are having a stroke or a heart attack. In the majority of cases, the cause is benign, treatable, and located in the inner ear.
Vertigo vs Dizziness — The Distinction That Guides Diagnosis
The most important first step is distinguishing true vertigo from non-specific dizziness. Vertigo is a hallucination of movement — a spinning, tilting or rotating sensation. Non-specific dizziness is a broader term covering lightheadedness, unsteadiness or a swimming sensation without true rotational movement.
True vertigo almost always originates from the vestibular system — either the inner ear (peripheral vertigo) or, less commonly, the brainstem and cerebellum (central vertigo). Peripheral causes are far more common and far more treatable.
The Most Common Cause: BPPV
Benign Paroxysmal Positional Vertigo (BPPV) accounts for approximately 30–40% of all vertigo presentations. It occurs when calcium carbonate crystals (otoconia) that normally sit on a sensory membrane in the utricle (one of the inner ear organs) become dislodged and migrate into one of the three semicircular canals.
The result is brief but intense vertigo triggered by specific head movements — lying down, rolling over in bed, looking up, or tilting the head. Each episode typically lasts 20–60 seconds and is accompanied by characteristic nystagmus (rhythmic eye movements). BPPV is entirely benign and resolves with in-clinic canalith repositioning manoeuvres (Epley manoeuvre) in the majority of patients — often in a single session.
Meniere’s Disease
Meniere’s disease is characterised by the tetrad of episodic vertigo (lasting 20 minutes to 24 hours), fluctuating sensorineural hearing loss, tinnitus and aural fullness. It is caused by endolymphatic hydrops — abnormal accumulation of fluid in the inner ear labyrinth.
Management includes a low-sodium diet (less than 1.5g sodium per day), adequate hydration, avoidance of caffeine and alcohol, betahistine, diuretics and vestibular rehabilitation. Intratympanic steroid or gentamicin injections are used for refractory cases. Surgery (endolymphatic sac decompression or labyrinthectomy) is rarely required.
Vestibular Neuritis and Labyrinthitis
Vestibular neuritis presents as sudden, severe, constant vertigo lasting days — often preceded by a viral illness. There is no hearing loss (distinguishing it from labyrinthitis, where hearing is also affected). The acute phase is managed with vestibular suppressants and corticosteroids; recovery is supported by early vestibular rehabilitation exercises, which retrain the brain to compensate for the unilateral vestibular loss.
Red Flags That Mean It’s NOT the Inner Ear
Certain features suggest central vertigo — originating in the brainstem or cerebellum — which requires urgent neurological evaluation:
- Vertigo with sudden severe headache (“thunderclap headache”)
- Vertigo with double vision, difficulty swallowing or speaking
- Vertigo with limb weakness or facial numbness
- Vertigo with inability to walk or stand (ataxia out of proportion to dizziness)
- Purely vertical nystagmus or nystagmus that changes direction
- New onset severe vertigo in a patient with vascular risk factors (hypertension, diabetes, smoking)
These warrant immediate emergency evaluation to exclude cerebellar stroke or brainstem lesion.
What to Expect at an ENT Vertigo Consultation
A comprehensive vestibular evaluation includes a detailed history of each episode, Dix-Hallpike testing for BPPV, pure tone audiometry and tympanometry, and bedside neurological assessment. Based on findings, targeted treatment — whether Epley manoeuvre, medication, vestibular rehabilitation exercises or further imaging — is initiated. Most patients with peripheral vertigo see significant improvement within 2–4 weeks of appropriate management.
Dr Pranshu Mehta is an ENT Surgeon at Rog Nidan ENT & Dental Clinic, C-2/275 Janakpuri, New Delhi. For vertigo evaluation: WhatsApp +91 98186 35660. Watch: @TheENTSurgeons on YouTube.