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Dizziness and Vertigo

By

David M. Kaylie

, MS, MD, Duke University Medical Center

Last full review/revision Mar 2021| Content last modified Mar 2021
Click here for the Professional Version
Topic Resources

Dizziness is an inexact term people often use to describe various related sensations, including

  • Faintness (feeling about to pass out)

  • Light-headedness

  • Dysequilibrium (feeling off balance or unsteady)

  • A vague spaced-out or swimmy-headed feeling

  • Vertigo (a sensation of movement when there is no actual movement)

Vertigo is a type of dizziness felt as a sensation of movement when there is no actual movement. People usually feel that they, their environment, or both are spinning. The feeling is similar to that produced by the childhood game of spinning round and round, then suddenly stopping and feeling the surroundings spin. Occasionally, people simply feel pulled to one side. Vertigo is not a diagnosis. It is a description of a sensation.

People with vertigo may also have nausea and vomiting, difficulty with balance, and/or trouble walking. Some people have a rhythmic jerking movement of the eyes (nystagmus) during an episode of vertigo.

Different people often use the terms “dizziness” and “vertigo” differently, perhaps because these sensations are hard to describe in words. Also, people may describe their sensations differently at different times. For example, the sensations might feel like light-headedness one time and like vertigo the next.

However it is described, these sensations can be disturbing and even incapacitating, particularly when accompanied by nausea and vomiting. Symptoms cause particular problems for people doing an exacting or dangerous task, such as driving, flying, or operating heavy machinery.

Dizziness accounts for about 5 to 6% of doctor visits. It may occur at any age but becomes more common as people age. It affects about 40% of people older than 40 at some time. Dizziness may be temporary or chronic. Dizziness is considered chronic if it lasts more than a month. Chronic dizziness is more common among older people.

Did You Know...

  • Most of the time, dizziness, even if incapacitating, does not result from a serious disorder.

  • In older people, dizziness often does not have a single, obvious cause.

Causes of Dizziness and Vertigo

Vertigo is usually caused by disorders of the parts of the ear and brain that are involved in maintaining balance:

The inner ear contains structures (the semicircular canals, saccule, and utricle) that enable the body to sense position and motion. Information from these structures is sent to the brain through the vestibulocochlear nerve (8th cranial nerve, which is also involved in hearing). This information is processed in the brain stem, which adjusts posture, and the cerebellum, which coordinates movements, to provide a sense of balance. A disorder in any of these structures can cause vertigo. Disorders of the inner ear sometimes also cause decreased hearing and/or ringing in the ear (tinnitus Ear Ringing or Buzzing Ringing in the ears (tinnitus) is noise originating in the ear rather than in the environment. It is a symptom and not a specific disease. Tinnitus is very common—10 to 15% of people experience... read more ). (See figure A Look Inside the Ear A Look Inside the Ear Dizziness is an inexact term people often use to describe various related sensations, including Faintness (feeling about to pass out) Light-headedness Dysequilibrium (feeling off balance or... read more .)

A Look Inside the Ear

Inside the Ear

Common causes

Although there is some overlap, causes of dizziness can roughly be divided into those with and without vertigo.

The most common causes of dizziness with vertigo include the following:

Vestibular migraine headache is increasingly recognized as a common cause of dizziness with vertigo. This type of migraine Migraines A migraine headache is typically a pulsating or throbbing pain that ranges from moderate to severe. It can affect one or both sides of the head. It is often worsened by physical activity, light... read more most often occurs in people who have a history or family history of migraines. People often have headache with the vertigo or dizziness. Some have other migraine-like symptoms, such as seeing flashing lights, having temporary blind spots, or being very sensitive to light and sound. People may also have hearing loss, but it is not a common symptom.

The most common causes of dizziness without vertigo include the following:

  • Drug effects

  • Multifactorial causes

Several kinds of drugs can cause dizziness. Some drugs are directly toxic to the nerves of the ears and/or balance organs (ototoxic drugs Ear Disorders Caused by Drugs Many drugs can damage the ears (ototoxic drugs). Some ototoxic drugs include the antibiotics streptomycin, tobramycin, gentamicin, neomycin, and vancomycin, certain chemotherapy drugs (for example... read more ). These drugs tend to cause dizziness and an inability to focus on a visual target (oscillopsia). Other drugs, for example, sedatives, affect the brain as a whole. In older people, dizziness often is due to several factors, usually a combination of drug side effects plus an age-related decrease in sensory function.

Dizziness without vertigo may occur when the brain receives insufficient oxygen and glucose, such as may be related to nonneurologic disorders including heart and lung disorders or severe anemia.

Very often, no particular cause is found, and symptoms go away without treatment.

Less common causes

Less common causes of dizziness include a tumor of the vestibulocochlear nerve (vestibular schwannoma Vestibular Schwannoma A vestibular schwannoma (also known as an acoustic neuroma) is a noncancerous (benign) tumor that originates in the cells that wrap around the vestibular nerve (Schwann cells). These tumors... read more Vestibular Schwannoma ); a tumor Overview of Brain Tumors A brain tumor can be a noncancerous (benign) or cancerous (malignant) growth in the brain. It may originate in the brain or have spread (metastasized) to the brain from another part of the body... read more , stroke Overview of Stroke A stroke occurs when an artery to the brain becomes blocked or ruptures, resulting in death of an area of brain tissue due to loss of its blood supply (cerebral infarction) and symptoms that... read more , or transient ischemic attack (TIA Transient Ischemic Attacks (TIAs) A transient ischemic attack (TIA) is a disturbance in brain function that typically lasts less than 1 hour and results from a temporary blockage of the brain’s blood supply. The cause and symptoms... read more ) affecting the brain stem; an injury to the eardrum, inner ear, or base of the skull; multiple sclerosis Multiple Sclerosis (MS) In multiple sclerosis, patches of myelin (the substance that covers most nerve fibers) and underlying nerve fibers in the brain, optic nerves, and spinal cord are damaged or destroyed. The cause... read more ; low blood sugar Hypoglycemia Hypoglycemia is abnormally low levels of sugar (glucose) in the blood. Hypoglycemia is most often caused by drugs taken to control diabetes. Much less common causes of hypoglycemia include other... read more ; and pregnancy Physical Changes During Pregnancy Pregnancy causes many changes in a woman’s body. Most of them disappear after delivery. These changes cause some symptoms, which are normal. However, certain disorders, such as gestational diabetes... read more Physical Changes During Pregnancy .

Evaluation of Dizziness and Vertigo

The following information can help people with dizziness decide whether a doctor’s evaluation is needed and help them know what to expect during the evaluation.

Warning signs

In people with dizziness, certain symptoms and characteristics are cause for concern. They include

  • Headache

  • Neck pain

  • Difficulty walking

  • Loss of consciousness (fainting)

  • Other neurologic symptoms (such as trouble hearing, seeing, speaking, or swallowing or difficulty moving an arm or leg)

When to see a doctor

People who have warning signs, those whose symptoms are severe or have been continuous for over an hour, and those with vomiting should go to a hospital right away. Other people should see their doctor as soon as possible. People who had a single, brief (less than 1 minute), mild episode with no other symptoms may choose to wait and see whether they have another episode.

What the doctor does

In people with dizziness, doctors first ask questions about the person's symptoms and medical history. Doctors then do a physical examination. What they find during the history and physical examination often suggests a cause of the dizziness and the tests that may need to be done (see table Some Causes and Features of Dizziness Some Causes and Features of Dizziness Dizziness is an inexact term people often use to describe various related sensations, including Faintness (feeling about to pass out) Light-headedness Dysequilibrium (feeling off balance or... read more ).

In addition to warning signs, important features that doctors ask about include severity of the symptoms (has the person fallen or missed work), presence of vomiting and/or ringing in the ears, whether symptoms come and go or have been continuous, and possible triggers of the symptoms (for example, changing position of the head or taking a new drug).

During the physical examination, the ear, eye, and neurologic examinations are particularly important. Hearing is tested, and the ears are examined for abnormalities of the ear canal and eardrum. The eyes are checked for abnormal movements, such as nystagmus.

Nystagmus suggests a disorder affecting the inner ear or various nerve connections in the brain stem. With nystagmus, the eyes rapidly and repeatedly jerk in one direction and then return more slowly to their original position. Doctors deliberately try to trigger nystagmus if people do not have it spontaneously because the direction in which the eyes move and how long the nystagmus lasts help doctors diagnose the cause of vertigo. To trigger nystagmus, doctors first lay people on their back and gently roll them from side to side while watching their eyes. Specialists sometimes have the person wear thick, one-way, magnifying glasses called Frenzel lenses. Doctors can easily see the person's magnified eyes through the lenses, but the person sees a blur and cannot visually fixate on anything (visual fixation makes it harder to trigger nystagmus). During the maneuver to induce nystagmus, eye movements may be recorded by using electrodes (sensors that stick to the skin) placed around each eye (electronystagmography) or by a video camera attached to the Frenzel lenses (video electronystagmography). If no nystagmus occurs with rolling side to side, doctors try other maneuvers. These other maneuvers include putting ice-cold water into the ear canal (caloric testing) and rapidly changing the position of the person's head (Dix-Hallpike maneuver Benign Paroxysmal Positional Vertigo Benign paroxysmal positional vertigo, or BPPV, is a common disorder causing short episodes of vertigo (a false sensation of moving or spinning) in response to changes in head position that stimulate... read more Benign Paroxysmal Positional Vertigo ).

Doctors also do a complete neurologic examination, paying particular attention to tests of walking, balance, and coordination.

Table
icon

Testing

The need for tests in people with dizziness or vertigo depends on what doctors find during the history and physical examination, particularly whether warning signs are present.

For people with a sudden attack of dizziness that is still going on, doctors usually apply a fingertip oxygen sensor, measure blood glucose from a drop of blood from the fingertip. Some women get a pregnancy test.

People with warning signs typically require gadolinium-enhanced magnetic resonance imaging (MRI), as do people without warning signs who have had symptoms for a long time.

Comprehensive vestibular testing is sometimes done. This testing includes video electronystagmography (computerized recording and analysis of abnormal eye movements), rotary chair testing (looking for abnormal eye movements while sitting in a chair that is rotated), and vestibular-evoked myogenic potential testing. These tests are typically done by doctors who specialize in the care of the ear (otolaryngologists).

Electrocardiography (ECG), Holter monitoring for heart rhythm abnormalities, echocardiography, and exercise stress testing may be done to evaluate heart function. For dizziness that occurs only when standing up Testing In some people, particularly older people, blood pressure drops excessively when they sit or stand up (a condition called orthostatic or postural hypotension). Symptoms of faintness, light-headedness... read more , specific tests may be needed.

Treatment of Dizziness and Vertigo

The cause of dizziness is treated whenever possible. Treatment includes stopping or reducing the dose of any drug that is the cause or switching to an alternative drug.

Nausea and vomiting can be treated with drugs such as meclizine or promethazine.

Vertigo caused by disorders of the inner ear, such as Meniere disease Meniere Disease Meniere disease is a disorder characterized by recurring attacks of disabling vertigo (a false sensation of moving or spinning), fluctuating hearing loss (in the lower frequencies), and noise... read more , labyrinthitis Purulent Labyrinthitis Purulent (suppurative) labyrinthitis is a bacterial infection of the inner ear that often causes deafness and loss of balance. The labyrinth is the bony cavity that contains the inner ear. The... read more , migraine associated vertigo, or vestibular neuronitis Vestibular Neuronitis Vestibular neuronitis is a disorder characterized by a sudden severe attack of vertigo (a false sensation of moving or spinning) caused by inflammation of the vestibular nerve, the branch of... read more , can often be relieved by benzodiazepine drugs such as diazepam or lorazepam. Antihistamine drugs such as meclizine are an alternative. Vertigo in people with benign paroxysmal positional vertigo Benign Paroxysmal Positional Vertigo Benign paroxysmal positional vertigo, or BPPV, is a common disorder causing short episodes of vertigo (a false sensation of moving or spinning) in response to changes in head position that stimulate... read more Benign Paroxysmal Positional Vertigo is treated with the Epley maneuver The Epley Maneuver: A Simple Cure for a Common Cause of Vertigo Benign paroxysmal positional vertigo, or BPPV, is a common disorder causing short episodes of vertigo (a false sensation of moving or spinning) in response to changes in head position that stimulate... read more The Epley Maneuver: A Simple Cure for a Common Cause of Vertigo (a somersault-like maneuver of the head) done by an experienced practitioner. Meniere disease Meniere Disease Meniere disease is a disorder characterized by recurring attacks of disabling vertigo (a false sensation of moving or spinning), fluctuating hearing loss (in the lower frequencies), and noise... read more is best managed by an otolaryngologist with training in management of this chronic disorder, but initial management consists of a low-salt diet and a diuretic ("water pills"), which may not be effective in all people with the disorder. In people with vertigo that occurs with migraines, the migraine is treated.

If vertigo persists for a long time, some people benefit from physical therapy to help them cope with their disturbed sense of balance. Therapists may also recommend such strategies as

Essentials for Older People

As people grow older, many factors make dizziness and vertigo more common. The organs involved in balance, particularly the structures of the inner ear, function less well. It becomes harder to see in dim light. The body's mechanisms that control blood pressure respond more slowly (for example, to standing up). Older people are also more likely to be taking drugs that can cause dizziness.

Although dizziness and vertigo are unpleasant at any age, they cause particular problems for older people. Frail people have a much higher risk of falling when they are dizzy. Even if they do not fall, their fear of falling often significantly affects their ability to do daily activities.

The drugs that help relieve vertigo can make people feel sleepy. This effect is more common and sometimes more severe in older people.

Even more so than younger people, older people with dizziness or vertigo may benefit from general physical therapy Physical Therapy (PT) Physical therapy, a component of rehabilitation, involves exercising and manipulating the body with an emphasis on the back, upper arms, and legs. It can improve joint and muscle function, helping... read more and exercises to strengthen their muscles to help them maintain their independence. Physical therapists can also provide important safety information for older or disabled people to help prevent falls.

Key Points about Dizziness and Vertigo

  • Dizziness and vertigo often result from disorders that affect the inner ear or the parts of the brain involved in balance or from use of certain prescription drugs.

  • Symptoms may include faintness, loss of balance, vertigo, difficult-to-describe light-headed or swimming sensations, or a combination.

  • Severe headache and any sign of difficulty with brain function (such as difficulty walking, talking, seeing, speaking, or swallowing) are warning signs, but even vague symptoms may result from a serious disorder.

  • People with warning signs should see a doctor right away, and they often require testing.

  • Drugs, such as diazepam or meclizine, often help relieve vertigo, and prochlorperazine can help relieve nausea.

Drugs Mentioned In This Article

Generic Name Select Brand Names
COMPRO
PROMETHEGAN
ARALEN
LASIX
ANTIVERT
ATIVAN
VALIUM
QUALAQUIN
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