VERTIGO

WHAT IT IS AND WHAT IT IS NOT

CAUSES – TREATMENTS – OUTCOMES

In Brief

• Vertigo is the feeling that you or your surroundings are spinning while everything is still; it is a symptom, not the name of a disease.

• Balance depends on the inner ear, the eyes and the muscles and joints working together; the inner ear is the most common source of vertigo.

• The most common causes are displaced ear crystals (BPPV), vestibular migraine, Ménière’s disease and inflammation of the balance nerve.

• Most causes can be treated once the right diagnosis is made; a detailed examination is the basis of diagnosis.

⚠️ Emergency: If dizziness comes with slurred speech, a drooping face, weakness in an arm or leg, double vision or being unable to walk, do not wait – call 112 (emergency).

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Vertigo is classically described as dizziness. It may be felt as the surroundings spinning or moving from side to side, or as a sensation that we ourselves are moving. It is one of many similar complaints that fall under balance disorders, and it is the most common of them. Dizziness is often described simply as a “spinning head”, but it actually covers many sub-types that differ from classic vertigo. Terms such as a rocking, on-a-boat sensation (mal de débarquement), lightheadedness, feeling faint and fainting (syncope) all fall under dizziness. Patients with these complaints come to clinics describing them as dizziness, just like vertigo. Vertigo can seriously affect daily life and may bring other health problems with it.

 

What Are the Common Causes of Vertigo?

Our balance system essentially rests on three pillars: the ears, the eyes and the musculoskeletal system. Information from these is sent to the central nervous system, processed, and sent back to the same systems to help maintain balance. Any disorder in these systems can cause balance problems, most notably vertigo. Of these three systems, vertigo most often originates from diseases of the ear. The most common of these are Benign Paroxysmal Positional Vertigo (BPPV) (displacement of calcium carbonate crystals), Ménière's disease (inner-ear pressure syndromes), vestibular neuritis (inflammation of the balance nerve) and otitis media (middle-ear infections). Beyond these, there are dozens of other ear conditions that can cause vertigo. Most of them can be diagnosed successfully, and their follow-up and treatment give good results.

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Diseases of the central nervous system that cause vertigo must also be recognized and carefully distinguished. After BPPV, the second most common cause of vertigo is migraine-related vertigo (vestibular migraine). Although it is a central nervous system condition, its symptoms closely resemble ear-related causes of vertigo. Its similarity to Ménière's disease in particular can make diagnosis difficult and delay treatment. Both conditions peak in women aged 30–50. Multiple sclerosis (MS) is another important cause of vertigo and is often confused with ear diseases; MS plaques located along the balance and hearing pathways can present as vertigo. A correct diagnosis in these patients also helps prevent serious complications later on, so an ENT and neurology evaluation is important.

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Vertigo is not limited to adults. Dizziness in childhood should be taken seriously and always evaluated by a specialist. It can accompany many childhood conditions, especially migraine, middle-ear infections and eye problems. Vertigo associated with middle-ear infection must be recognized and treated early, as it may herald complications such as meningitis or brain abscess.

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In older adults the order of frequency of causes is similar, but dizziness can also be a sign of cardiovascular disease linked to stroke risk, so it should be taken seriously. Recurrent vertigo accompanied by hearing loss, or by brief but severe nausea and vomiting, may carry a risk of stroke and should be investigated.

 

Peripheral causes of vertigo (ear and balance nerve):

• Benign Paroxysmal Positional Vertigo (BPPV) (20%)

• Ménière's disease and related syndromes (endolymphatic hydrops – inner-ear pressure syndromes)               

• Vestibular neuritis (inflammation of the balance nerve)

• Perilymphatic fistula

• Acute and chronic otitis media (middle-ear infections)

• Chronic otitis media with cholesteatoma

• Labyrinthitis

• Ototoxicity (inner-ear damage from medications)

• Trauma causing labyrinthine contusion

• Cerebellopontine angle tumors

• Labyrinthine ischemia

• Congenital inner-ear anomalies

• Otosclerosis

 

Central causes of vertigo (central nervous system):

• Vestibular migraine (migrainous vertigo)

• Basilar-type migraine

• Transient ischemic attack (TIA) due to vertebrobasilar insufficiency

• MS (multiple sclerosis)

• Brain tumors

• Brainstem stroke (Wallenberg syndrome, lateral pontomedullary syndrome)

• Encephalitis

• Medications

• Epileptic seizures (epileptic vertigo – vestibular epilepsy)

• Cervical vertigo (cervical spondylosis – neck-related vertigo)

• Head injuries

• Hereditary ataxia syndromes

 

How Is Vertigo Diagnosed?

The past century brought revolutionary advances in the diagnosis and treatment of vertigo. Until the mid-1900s, our knowledge of how to diagnose and treat vertigo was very limited. As the anatomy and physiology of the balance system became better understood, major progress was made both in examination methods and in technology-based diagnostic devices. Today, the great majority of conditions that cause vertigo can be readily diagnosed and successfully treated. With devices such as VNG (videonystagmography), vHIT (video head impulse test), VEMP (vestibular evoked myogenic potentials) and fHIT (functional head impulse test) now part of daily practice, diagnosis, treatment and follow-up are carried out successfully. In Türkiye we use all of these technologies for diagnosis and treatment, in step with the rest of the world.

In addition, imaging methods such as CT, MRI and MR angiography are used when needed to support the diagnosis. We rely on these imaging methods to identify important causes of vertigo such as multiple sclerosis, acoustic tumors and vertebrobasilar insufficiency.

 

Where Do We Stand in Vertigo Treatment?

Once the condition causing vertigo has been identified, it is treated successfully using established treatment algorithms.

In positional vertigo (BPPV), the most important cause of vertigo, repositioning maneuvers give very successful results. The right maneuver for the right canal treats the condition in a very short time. When treatment is delayed and BPPV becomes prolonged, maneuvers become less and less successful. For this reason, anyone who has recently developed dizziness and nausea with movement should be evaluated by an ENT specialist for early diagnosis and successful treatment.

Another common condition is vestibular migraine, one of the two most frequent causes of recurrent dizziness. Botulinum toxin (Botox) injections into painful areas give very good results in the long-term treatment of vertigo related to this condition, and medication can be used as an alternative. After BPPV, vestibular migraine is the second most common cause of vertigo.

Of all the conditions that cause vertigo, Ménière's disease has the greatest impact on social life. It can cause very severe vertigo attacks that last for hours and occur anywhere from once a year to almost every day. In this disease, which seriously affects social and working life, vertigo is accompanied by hearing loss and by ringing in the ears (tinnitus) that may be present almost constantly. Diagnosing and treating the disease is essential for these patients to return to daily life. A treatment plan that starts with dietary changes, moves on to treatments given into the ear and sometimes requires surgery should be chosen carefully for each patient. Although it was first described 160 years ago and still keeps some of its mystery, today it can be treated successfully.

 

Vertigo Is Not Just Vertigo!

Conditions that cause vertigo can bring other health problems with them. Vertigo that is not treated properly and in time may later be associated with cardiovascular, gastrointestinal and psychological problems. Many patients with vertigo develop anticipatory anxiety, which reduces their quality of life. Major depression can develop, especially in conditions that cause recurrent vertigo, such as Ménière's disease and vestibular migraine, and these patients' quality of life is affected far more than with other causes of vertigo. The average time to diagnosis in Ménière's disease is about 4.5 years, which is why serious psychological problems often accompany the other symptoms.

Another important issue is cardiovascular problems that occur with vertigo. The vestibular system is physically connected to the cardiovascular system, and vertigo is often accompanied by heart rhythm disorders and high blood pressure. In patients whose condition persists for a long time without timely treatment, high blood pressure and arrhythmias can be seen.

The vestibular system is also connected to the gastrointestinal system. Gastroesophageal and laryngopharyngeal reflux and diarrhea are common with vertigo. In long-standing untreated cases, reflux-related chest pain, hoarseness, chronic sore throat and recurrent abdominal pain can occur.

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An app for recording attacks: You can use the Dizziness Diary app to record your attacks, eye videos and test results on your phone and share them with your doctor at your visit.

 

Research by Assoc. Prof. Mehmet Sürmeli on This Topic

The following studies were published in international peer-reviewed journals.

• Vertiginous epilepsy: documentation of clinical and electrophysiological findings of nine patients. Sürmeli R, Yalçın AD, Sürmeli M, Günay G. Epileptic Disord. 2020. PubMed →

• Evaluation of saccadic abnormalities in multiple sclerosis using a novel clinical saccadometry test. Polat Z, Akbulut AA, Satıcı S, Sürmeli R, Sürmeli M. Audiol Neurootol. 2025. PubMed →