What is it?
"Dizziness" is one of the most common complaints brought to a GP, but the word covers several quite different experiences. Distinguishing between them matters, because the causes — and the treatments — are different.
Dizziness is a broad umbrella term. It includes lightheadedness (the feeling that you might faint, often with a sensation of the world going grey at the edges), a sense of unsteadiness or imbalance, and the more specific experience of vertigo.
Vertigo is not just feeling dizzy — it is the distinct sensation that either you or the world around you is spinning, rotating, or moving, when no actual movement is occurring. People often describe it as feeling as if the room is turning, or as if they are on a boat. It may be accompanied by nausea and, in some cases, by nystagmus (involuntary, rhythmic flickering movements of the eyes) — an important sign that clinicians look for.1
Vertigo has two main origins in medicine:
- Peripheral vertigo — arising from a problem in the vestibular system (the balance system housed within the inner ear and its connecting nerve). This is by far the more common type, and most causes are benign and highly treatable.
- Central vertigo — arising from a problem in the brain itself, particularly the brainstem or cerebellum (the part of the brain at the back of the skull that co-ordinates balance and movement). Central causes are less common but more serious, and include stroke or tumour affecting the posterior circulation (the blood supply to the brainstem and cerebellum).
The most common causes of peripheral vertigo seen in UK primary care are:
- BPPV (Benign Paroxysmal Positional Vertigo) — the single most frequent cause of vertigo. Brief, intense spinning episodes triggered by specific head movements, caused by displaced calcium crystals within the semicircular canals (three fluid-filled tubes in the inner ear that detect rotational head movement).
- Vestibular neuritis — inflammation of the vestibular nerve (the nerve carrying balance signals from the inner ear to the brain), typically following a viral illness, causing a single prolonged episode of severe vertigo lasting hours to days.
- Labyrinthitis — inflammation of the labyrinth (the inner ear structure as a whole, which includes both the hearing and balance organs), causing vertigo alongside changes in hearing.
- Ménière's disease — a condition of the inner ear causing recurring episodes of vertigo, fluctuating hearing loss, tinnitus (ringing in the ears), and a feeling of pressure or fullness in the affected ear.
Why does it matter?
Dizziness and vertigo are among the most frequent presentations in UK primary care, and BPPV alone has a 1-year prevalence (the proportion of the population affected in any given year) of around 1.6%.2 For women the condition is approximately twice as common as for men, and prevalence rises with age.
The impact is significant. Vertigo causes falls — a particular concern in older adults, where BPPV has been identified in over half of patients admitted to hospital following a fall. The psychological burden is also substantial: sustained dizziness leads to anxiety, avoidance of activity, reduced quality of life, and often lengthy periods of unnecessary medical investigation.
What makes the 8% figure particularly striking is what it tells us about the gap between what medicine can achieve and what is routinely happening. The Epley manoeuvre (see Key Terms above) — a simple, non-invasive procedure that takes a few minutes — is one of the most effective treatments in all of medicine for BPPV. Yet in a large population study, the vast majority of affected people never received it.2 A UK-based audit of 20 patients traced from primary care to eventual treatment found an average wait of 93 weeks from first referral to effective treatment — 58 weeks within primary care alone.6
What your doctor might discuss
When a person presents with dizziness or vertigo, the clinical history is the most important diagnostic tool. Specific questions help distinguish between the different causes.
Duration of individual episodes is highly informative. Episodes lasting seconds to a minute or two, triggered by head position changes (rolling over in bed, looking up, bending forward), point strongly towards BPPV (see Key Terms above). Episodes lasting hours, accompanied by tinnitus (ringing in the ears), hearing changes, and ear fullness, suggest Ménière's disease. A single prolonged episode lasting hours to days — particularly following a recent viral upper respiratory tract infection — is characteristic of vestibular neuritis or labyrinthitis.
Associated symptoms are equally important. Hearing loss, ear fullness, or tinnitus (see Key Terms above) suggest an inner ear origin. Headache, new visual disturbance (such as diplopia — double vision), facial numbness, difficulty speaking or swallowing, or sudden severe unsteadiness point towards a possible central cause that warrants urgent assessment.
Physical examination typically includes otoscopy (examination of the ear canal and eardrum), neurological assessment, and in cases where BPPV is suspected, the Dix-Hallpike test (see Key Terms above). A positive Dix-Hallpike test — in which the manoeuvre reproduces vertigo and triggers characteristic nystagmus (see Key Terms above) — confirms BPPV and guides treatment.
The Epley manoeuvre (see Key Terms above) is the first-line treatment for BPPV confirmed by Dix-Hallpike testing. It is safe, effective, and can be performed in the GP surgery or by a physiotherapist. NICE guidance supports its use in primary care when the clinician has the appropriate training and the patient does not have an unstable cervical spine (neck spine) condition that would make head movement unsafe.1
Vestibular neuritis and labyrinthitis are managed differently. In the acute phase — the first one to three days of severe spinning — short-term use of prochlorperazine (Stemetil; a medication that reduces nausea and suppresses vestibular signals) or antihistamines such as cinnarizine (Stugeron) is clinically recognised and appropriate practice to relieve distressing symptoms. However, continuing these medications beyond the acute phase is not supported by evidence and is actively counterproductive: the brain needs to receive the altered signals from the damaged vestibular system in order to compensate and recover — a process called vestibular compensation. Prolonging suppression delays that process. Early mobilisation and, where recovery is slow, referral to vestibular rehabilitation (see Key Terms above) are evidence-based approaches.
Ménière's disease is managed in UK practice with lifestyle adjustments including a low-salt diet (reducing dietary sodium is thought to reduce fluid pressure within the inner ear) and avoidance of caffeine and alcohol. Betahistine (Serc; an oral medication thought to increase blood flow within the inner ear's small blood vessels) is widely prescribed to reduce the frequency of attacks, and many patients report benefit from it. However, the evidence base for betahistine is contested: the BEMED trial — a large, multicentre, double-blind randomised controlled trial published in the BMJ in 2016 — found no significant difference in vertigo attack frequency between betahistine (at both low and high doses) and placebo over nine months.7 All three groups showed a decline in attacks over the trial period, suggesting a strong placebo effect and possibly the natural history of the condition. Betahistine continues to be used in UK practice — it is well tolerated with a low side-effect profile — but this is an area where the evidence does not clearly confirm the benefit that clinical experience sometimes suggests. Referral to audiology (hearing and balance specialists) is the usual pathway when more than one episode has occurred.
Certain patterns of vertigo are clinically recognised as potentially indicating a posterior circulation stroke (a stroke affecting the brainstem or cerebellum) and are time-sensitive. These include:
- Sudden onset of severe vertigo with new, severe headache or neck stiffness
- Vertigo accompanied by diplopia (double vision), dysarthria (slurred or unclear speech), dysphagia (difficulty swallowing), or weakness of the face or limbs
- Sudden complete inability to stand or walk, not explained by positional vertigo
- Spontaneous vertical nystagmus (upward or downward flickering eye movements at rest, not triggered by a positional manoeuvre)
These patterns are clinically recognised as time-sensitive — 111 and urgent GP services exist for this presentation. The HINTS examination (see Key Terms above) is a bedside oculomotor (eye movement) examination that trained clinicians use to help assess whether acute vestibular syndrome has a peripheral or central origin.5 It requires specific training and is not universally available in every GP surgery — NICE guidance recommends its use where a trained clinician is present, and immediate referral via local stroke pathways where one is not.
What the research shows
The Cochrane systematic review of the Epley manoeuvre (a canalith repositioning procedure — see Key Terms above) for posterior canal BPPV included 11 randomised controlled trials covering 745 participants. The review concluded that the Epley manoeuvre is a safe and effective treatment for BPPV, with outcomes superior to sham (false) manoeuvres, Brandt-Daroff exercises alone, and no treatment. Outcomes were comparable to alternative repositioning manoeuvres such as the Semont and Gans manoeuvres. The recurrence rate of BPPV after treatment was 36% at 48 months — reinforcing that BPPV can return and that patients benefit from understanding this possibility.
Hilton MP, Pinder DK. Cochrane Database Syst Rev. 2014;(12):CD003162.3
The Cochrane review of vestibular rehabilitation (a physiotherapy-based programme of graded exercises — see Key Terms above) for unilateral peripheral vestibular dysfunction (one-sided inner ear impairment) found moderate to strong evidence in favour of vestibular rehabilitation over control or no treatment. The primary outcome — frequency of dizziness — showed an odds ratio (OR; a measure of how much more likely improvement is in the treated group compared to control) of 2.67 (95% CI 1.85 to 3.86) across four studies including 565 participants. Secondary outcomes including activity limitation and disability also favoured rehabilitation. The review supports vestibular rehabilitation as a safe, effective management approach — particularly for vestibular neuritis recovery where central compensation (the brain adapting to altered inner ear signals) is incomplete.
McDonnell MN, Hillier SL. Cochrane Database Syst Rev. 2015;(1):CD005397.4
A large, nationally representative population-based study of BPPV in Germany found that, despite 86% of affected individuals seeking medical help or experiencing disruption to daily activities, only 8% received effective treatment. The study also found that most participants underwent costly diagnostic investigations rather than the simple positional tests and repositioning manoeuvres that would have confirmed and resolved the diagnosis. A separately published UK audit of 20 patients traced from primary care through to eventual treatment found an average wait of 93 weeks — with 58 weeks of that delay occurring within primary care alone.6 The condition affects twice as many women as men and prevalence increases with age, with migraine, hypertension (high blood pressure), and a history of stroke as independently associated factors.
von Brevern M et al. J Neurol Neurosurg Psychiatry. 2007;78(7):710–715.2
Vertigo — and BPPV in particular — is one of the most striking examples in medicine of a large gap between what is known and what is routinely done. The condition is common, well understood, and in the case of BPPV, responds to a simple physical procedure that takes a matter of minutes. Yet population studies consistently show that most people with BPPV never receive effective treatment, spending months or years with an avoidable and often disabling condition.
Understanding the difference between the brief positional vertigo of BPPV, the prolonged vertigo of vestibular neuritis, the episodic pattern of Ménière's disease, and the red-flag patterns that suggest a central cause — is valuable context for anyone experiencing these symptoms.
Anything personally relevant is a conversation for you to have with your GP or healthcare professional.
References
1. National Institute for Health and Care Excellence. Vertigo — Clinical Knowledge Summaries. NICE CKS. Last revised 2022. Available at: cks.nice.org.uk/topics/vertigo
2. von Brevern M, Radtke A, Lezius F, Feldmann M, Ziese T, Lempert T, Neuhauser H. Epidemiology of benign paroxysmal positional vertigo: a population based study. J Neurol Neurosurg Psychiatry. 2007 Jul;78(7):710–715. doi: 10.1136/jnnp.2006.100420. PMID: 17135456.
3. Hilton MP, Pinder DK. The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo. Cochrane Database Syst Rev. 2014 Dec 8;2014(12):CD003162. doi: 10.1002/14651858.CD003162.pub3. PMID: 25485940.
4. McDonnell MN, Hillier SL. Vestibular rehabilitation for unilateral peripheral vestibular dysfunction. Cochrane Database Syst Rev. 2015 Jan 13;2015(1):CD005397. doi: 10.1002/14651858.CD005397.pub4. PMID: 25581507.
5. National Institute for Health and Care Excellence. Suspected neurological conditions: recognition and referral — NG127. NICE, 2019 (updated 2023). Available at: nice.org.uk/guidance/ng127
6. Fife D, FitzGerald JE. Do patients with benign paroxysmal positional vertigo receive prompt treatment? Analysis of waiting times and human and financial costs associated with current practice. Int J Audiol. 2005 Jan;44(1):50–57. doi: 10.1080/14992020400022629. PMID: 15796102.
7. Adrion C, Fischer CS, Wagner J, Gürkov R, Mansmann U, Strupp M; BEMED Study Group. Efficacy and safety of betahistine treatment in patients with Meniere's disease: primary results of a long term, multicentre, double blind, randomised, placebo controlled, dose defining trial (BEMED trial). BMJ. 2016;352:h6816. doi: 10.1136/bmj.h6816.