Vertigo, typically a symptom of other health conditions, triggers the feeling of dizziness and spinning even when you’re not moving. If you have vertigo, you may also feel sick or vomit and experience balance problems, hearing issues and tinnitus, headaches, motion sickness, fullness in the ears, or a condition called nystagmus that leads to rapid side-to-side eye twitches.
Vertigo often develops because of inner ear problems, including ear surgery, a condition leading to irregular bone growth near the ear known as otosclerosis, fluid leakage from the inner to the middle ear, or shingles around the ear. These cause the most common type of vertigo: peripheral vertigo, which includes conditions like benign paroxysmal positional vertigo (BPPV), the most common vertigo cause, as well as labyrinthitis, vestibular neuritis, and Ménière’s disease.
A more severe type of vertigo may occasionally result from conditions affecting the brain, including:
The following explains how a doctor determines the cause of vertigo and what comes next.
Your medical history can offer important clues about the cause of your vertigo. According to Justin S. Golub, MD, an associate professor and the vice chair of faculty development in the department of otolaryngology–head and neck surgery at the Columbia University Vagelos College of Physicians and Surgeons in New York City, a general physician should first see most people with vertigo. “They should get a good medical history, make sure the symptom is actually vertigo, and check that no medical problems are causing the symptom,” he says. Diabetes, low blood pressure, rapid breathing, dehydration, and anxiety can all cause vertigo-like symptoms.
If because of other symptoms a physician suspects that you have had a stroke, or if you’re an older adult who received a blow to the head, they may immediately request imaging scans.
They may also ask about any other medications you currently take, since vertigo might be an adverse effect of certain drugs. These drugs include:
Tell your doctor about any medical issues and if you have a family history of vertigo. Teshamae Monteith, MD, the chief of the headache division and an associate professor of clinical neurology at the University of Miami, suggests that the cause of vertigo might be difficult to determine.
“While vertigo may sometimes be clear-cut based on history and examination, it can be challenging because overlapping symptoms and comorbid conditions can lead to vertigo,” advises Dr. Monteith. “For example, there is a two-way relationship between Ménière’s disease and migraine, which both can present with vertigo. Patients with BPPV may also have headaches, and when both conditions are present, it may be complicated.”
Your physician will perform a complete physical exam to help determine the cause of vertigo. He or she might check how you walk and your balance using various tests. These might include:
Romberg’s Test The general physician asks an individual to stand with their feet together and arms to their side. “This tells you about a patient’s balance,” advises Dr. Golub. If you feel unsteady in this position, it might suggest brain or spinal cord problems. To prepare, the physician will stand close to you to reduce the risk of falls or balance problems during the test.
Fukuda Test A physician may ask you to close your eyes and march on the spot for 30 seconds. “This test can sometimes tell you whether there is dysfunction of the part of the inner ear that supports balance,” says Golub.
Head Movement Testing The healthcare provider gently rotates the head from side to side while you keep your eyes focused on a particular target, like a spot on the wall. While you’re doing this, they’ll closely watch your eye movements. “This also tells a provider about a patient’s inner ear balance function,” maintains Golub.
In addition, a medical professional will carry out blood tests to check for infections. Golub suggests that if migraine headaches are a possible underlying cause, a general physician may refer you to a doctor specializing in conditions affecting the nerves, or a neurologist. Here, you might undergo nerve function testing.
“Vertigo is not a diagnosis, it is a symptom,” says Golub. “For example, pain is a symptom. You don’t get diagnosed with pain: if you say you have pain, then you have pain. Similarly, if you have the feeling of vertigo, you have the feeling of vertigo. The goal is to figure out the cause of the vertigo.”
He says that a medical history and physical exam may be the only investigations necessary for some people. “Often, vertigo goes away, and no treatment is necessary. It commonly becomes clear that the symptom is not actually vertigo but something else,” he adds.
If a physician can’t identify the cause of vertigo, they may refer you to an ENT doctor for further testing, known as a vestibular test battery. This test takes around two hours and can show whether vertigo is occurring because of problems with the vestibular system in your ears.
Ahead of any vestibular testing, you might need to prepare in the following ways:
Make plans to get home after the tests that don’t involve driving, as you may feel dizzy.
Follow a doctor’s instructions around any regular medications you take, as you may need to avoid some before the test.
A doctor restricts what you eat or drink before the test, including alcohol.
Forgo wearing eye makeup, to help make your eye movements more visible.
Vestibular testing might only sometimes give clear results, per Monteith. “Vestibular tests can be abnormal if people are asymptomatic and nondiagnostic in people with symptoms.”
Rotary Chair
During a rotary chair test, you’ll put on special goggles and sit in a motor-driven chair that tilts to the left and right as you keep your eyes open. The goggles track your eye movements, showing how your vestibular system and eyes work together.
Modified Clinical Test of Sensory Interaction on Balance (mCTSIB)
This test checks how your sense of touch, inner ears, and vision interact to trigger dizziness.You’ll stand without shoes on a firm surface followed by a soft foam surface, staying as steady as you can on both for 30 seconds. The doctor might ask that you do this test with closed and open eyes.
Vestibular Evoked Myogenic Potentials (VEMP)
This shows how two organs in the ear, the saccule and utricle, work. The doctor places electrodes on your neck and has you turn your head from right to left while wearing headphones and focusing on a particular visual target. The electrodes measure how the neck muscles respond to sound signals.
VNG
“If the physician refers the patient to an ear, nose, throat, or ENT doctor, the ENT will perform a careful ear exam and sometimes a hearing test. Rarely, ENTs administer a specialized inner ear balance test called videonystagmography (VNG) or electronystagmography (ENG).”
This test measures nystagmus, which can point to inner ear balance issues and highlight ear-related causes of vertigo. In doing so, it can show the health of nerves in the brain linked to eye movement control. During a VNG, a person sits in a dark room wearing specialized goggles.
A VNG has three parts:
Follow moving lights with the eyes and look at fixed lights
Move the head and body into different positions to check whether these trigger nystagmus.
Caloric testing, in which an ENT checks the vestibular (or balance-related) system in each ear using cold water or air
A VNG may cause some discomfort during the test and dizziness afterward.
Dynamic Visual Acuity Testing
This can help a doctor measure your ability to use your vestibular system while moving your head. Sitting in front of a computer, you’ll have to identify a target both while sitting still, while moving from side to side, and while moving up and down.
An ENT may refer you to another specialist for magnetic resonance imaging (MRI) or computed tomography (CT) scans to check the underlying causes of vestibular problems. According to Golub, this may include:
An MRI of the brain
An MRI of the inner ear
A CT scan of the whole head
Golub says, “We do this in select cases if specific symptoms are happening, such as one-sided sensorineural hearing loss or if there are concerning headaches.” An MRI scan may show soft tissue damage in the ear, or a CT scan might reveal inner ear bone damage. Monteith says that “when they suspect central causes, a doctor will consider brain imaging.”
The next steps after confirming vertigo depend on the underlying cause. “Depending on the cause of the vertigo, they can expect treatment and improvement in symptoms over time,” advises Monteith. “This may include vestibular rehabilitation, home exercises, and medications.” Different specialists may need to treat vertigo that occurs for different causes, such as:
An ENT specialist
An audiologist to manage ear-linked dizziness
A neurologist, who specializes in treating central vertigo and related neurological disorders
An eye specialist if any related vision changes have occurred
A vestibular physical therapist, who specializes in vestibular rehabilitation
Vestibular rehabilitation is a type of physical therapy in which a person can retrain their brain to process signals linked to balance using head and eye movements. If a person has BPPV, certain upper body and head movements can help shift out-of-place crystals in the ear back into the right place.
Over-the-counter (OTC) antihistamine medications like meclizine (Antivert, Dramamine Less Drowsy) and dimenhydrinate (Dramamine) can help reduce how much the brain responds to ear signals that trigger vertigo. These may cause drowsiness. Prescription-only benzodiazepine medications can slow the brain’s response to vertigo-causing signals from the ears.
If symptoms don’t improve, contact a primary care physician. They may be able to investigate and rule out other causes.
The Takeaway
Determining the cause of vertigo can be challenging.
A general physician can identify the cause of some types of vertigo by taking a medical history and carrying out a physical examination, including tests like Romberg’s test and the Fukuda test.
If your physician suspects a cause within the vestibular system, they may refer you to an ENT specialist for a vestibular test battery. If the cause might be brain issues, you may need to undergo MRI or CT scans.
If vertigo is a new and disabling symptom, see a doctor for evaluation.
