Vertigo and BPPV: When Dizziness Is Harmless and When It Is an Emergency

When someone says “I am dizzy”, ask what they mean, because the answer points toward very different causes:

• Vertigo: a false sense that you or the room is spinning or moving. Nausea and vomiting often come with it. It usually comes from the inner ear, its nerve, or certain parts of the brain.
• Lightheadedness: feeling faint, woozy or as though the blood is draining from the head, especially on standing quickly. Common causes are a drop in blood pressure on standing, dehydration, anaemia, low blood sugar, some medicines and heart rhythm problems.
• Unsteadiness: being unsafe on your feet without any spinning, linked to nerve damage in the feet, cerebellar or brain disorders, Parkinson’s disease, stroke or simply ageing.

This guide focuses on vertigo, because it is the most frightening and the one where a harmless cause and a dangerous cause can look alike at first.

Deep in the inner ear sit the balance organs: three fluid-filled semicircular canals and two small chambers that contain microscopic calcium carbonate crystals. These crystals help detect gravity and head tilt. Sometimes a few break loose and wander into one of the canals, most often the posterior one. Whenever the head moves, the loose crystals drift and push the fluid, so the brain receives a spinning signal that does not match what the body is really doing.

The name says it all: benign because it does not signal a tumour or stroke, paroxysmal because it comes in short bursts, positional because it is triggered by head position. It becomes more common with age and may follow a head injury, long periods in bed or inner-ear inflammation, though often there is no clear reason. It is also one of the common reasons older people fall.

• A strong spinning sensation that starts within seconds of a head movement: rolling in bed, lying down, sitting up, tilting the head back, bending to pick something up.
• Each episode lasts from a few seconds to under a minute, followed by queasiness or a sense of unsteadiness that can linger.
• Often worst on getting out of bed in the morning.
• No other nerve symptoms: no slurred speech, no weakness, no double vision.
• The examiner can see brief, characteristic eye movements during an episode.
• Hearing loss and ringing in the ears are not part of BPPV. If they appear, another cause should be sought.

Dizziness that is constant for hours or days, regardless of head movement, does not fit BPPV and needs a different assessment.

A clear description saves time and unnecessary tests. Before the visit, note down:

• Is it spinning, faintness or unsteadiness?
• When did it start, and was it sudden or gradual?
• How long does each episode last: seconds, minutes, hours or days?
• What triggers it: turning in bed, standing up, looking up, or nothing at all?
• Any headache, neck pain, double vision, slurred speech, weakness, numbness, ringing in the ear or hearing loss?
• Any recent fall, head injury or fainting?
• Which medicines are being taken, and have they changed recently?
• History of high blood pressure, diabetes, heart disease or migraine?

Clinicians increasingly think about vertigo in terms of timing and triggers, not only the feeling itself. Brief episodes triggered by head position suggest BPPV. A continuous episode lasting days with no trigger raises other possibilities, including inflammation of the balance nerve and, importantly, stroke.

Diagnosis rests mainly on the story and a bedside test, not on scans. A clinician moves the head into specific positions, such as the Dix-Hallpike manoeuvre for the posterior canal or a supine roll test for the horizontal canal, while watching the eyes for the typical movement. It can bring on a short spell of vertigo, so it is done carefully with the person supported.

If the story and the examination are typical and there are no worrying neurological signs, brain imaging is usually not needed. If the picture is unusual, if there are warning signs, or if treatment does not work, the doctor may order an MRI or hearing tests.

The mainstay of treatment is a short sequence of head and body movements that guides the crystals back to where they no longer cause trouble. The best known is the Epley manoeuvre, with the Semont manoeuvre and others used for particular types. Current clinical guidelines recommend these manoeuvres as first-line treatment, and most people improve after one or a few sessions, although vertigo can come back.

Tablets sold for dizziness may calm nausea or ease a severe spell for a short time, but they do not fix BPPV, and sedating ones can cause drowsiness and falls in older adults. They are generally not used as the sole treatment. Take medicines only as prescribed.

The correct manoeuvre depends on which canal and which ear are affected, so getting the diagnosis right comes first. A manoeuvre done on the wrong side or for the wrong canal may do nothing.

Some people are taught a version by a clinician to repeat at home if vertigo returns, once the diagnosis and the affected side are confirmed. Copying a video before you have been diagnosed is not wise. The side may be wrong, the problem may not be BPPV at all, and neck, back or eye conditions can make some positions unsafe.

What you can do during an episode:

• Sit or lie down immediately somewhere safe. Do not try to walk or use stairs.
• Fix your eyes on a still object and breathe slowly.
• Wait until the spell has completely passed, then rise in stages: sit on the edge of the bed for a minute, then stand while holding something steady.
• Avoid driving, ladders and heights while episodes are happening.
• Do not make sudden head movements until you have been assessed.

• Vestibular neuritis: intense continuous vertigo for days, with nausea and unsteadiness, often after a viral illness. Stroke has to be excluded first.
• Ménière’s disease: spells lasting minutes to hours with ringing, fluctuating hearing loss and a feeling of fullness in the ear.
• Vestibular migraine: vertigo in someone with a history of migraine, often with sensitivity to light or motion.
• Orthostatic hypotension: lightheadedness on standing, easing when sitting.
• Medicines: some blood-pressure drugs, sedatives, antibiotics and psychiatric medicines. Do not stop them on your own; ask the prescriber.
• Anaemia, dehydration, low blood sugar and heart rhythm problems.
• Anxiety and panic, which can amplify dizziness and linger after a genuine vertigo episode.
• The neck: a true spinning vertigo is rarely caused by the neck, although it can add to a feeling of unsteadiness. It should not be blamed before other causes are excluded.

Strokes in the back of the brain, in the cerebellum or brainstem, can begin with severe vertigo that looks much like an inner-ear problem at first. The classic signs, such as facial droop or arm weakness, may be absent. A CT scan can look normal early on in this type of stroke, which is one reason doctors take sudden continuous vertigo seriously, particularly in people with high blood pressure, diabetes, high cholesterol, smoking, irregular heartbeat or older age.

Go to the emergency department or call an ambulance if vertigo comes with any of these:

• Sudden severe headache, or neck pain, especially after an injury or sudden twisting movement.
• Inability to stand or walk without falling, even when leaning on something.
• Double vision, loss of vision or continuous abnormal eye movements.
• Slurred speech or difficulty swallowing.
• Weakness or numbness in the face, arm or leg, or clumsiness of one hand.
• Sudden hearing loss in one ear.
• Chest pain, a racing or irregular heartbeat, or fainting.
• Constant vertigo with unrelenting vomiting, confusion or severe drowsiness.

Specialised bedside eye tests exist for people with acute continuous vertigo, but they are for trained clinicians. Do not try to test yourself. Read stroke emergency signs and mini-stroke warning signs.

Vertigo raises the risk of falls, especially at night and in older people, and a fracture can derail recovery. Practical steps:

• Night lights between bed and bathroom; remove loose rugs and cables.
• Sit on the edge of the bed for a minute before standing, especially at night.
• Grab bars, a shower seat and non-slip mats in the bathroom.
• Closed, firm shoes rather than slippers.
• A cane or walker only if a clinician recommends it, with training in using it.
• Avoid fast head movements when bending or reaching up, for example when hanging washing or using high shelves.

More on this in fall prevention for neurological patients and how balance, the inner ear and body sense work together.

Physiotherapy does not replace the doctor who makes the diagnosis, but it has a real role afterwards. Clinicians trained in vestibular rehabilitation may perform repositioning manoeuvres when the diagnosis supports them, assess balance, walking and fall risk, and set graded exercises that help the brain compensate for an inner-ear problem. Typical exercises include keeping the eyes fixed on a target while the head moves, balance tasks on different surfaces and walking while turning the head, made harder step by step as the person tolerates.

The Bedaya team begins with a home assessment of balance, gait and hazards, and works alongside the ENT specialist or neurologist. We do not start any manoeuvre before the diagnosis is confirmed and the neurological picture is clear. Learn more about our balance and vestibular rehabilitation service, post-stroke balance disorder programme and geriatric neuro-rehabilitation.

After a repositioning manoeuvre, people may feel unsteady or queasy for hours or a few days, and are usually advised to avoid sharp head movements and driving that day, following the clinician’s instructions. Episodes often settle quickly, but BPPV can return after weeks, months or years in some people. That does not mean the treatment failed; crystals can loosen again. If it returns, go back to the clinician for reassessment and repeat treatment.

If unsteadiness persists even when the spinning has gone, a vestibular rehabilitation programme supervised by a trained therapist may help.