Vertigo and balance problems

Overview

The NHS describes vertigo as a symptom rather than a condition in itself. Inner ear problems, which affect balance, are the most common causes, and the NHS lists benign paroxysmal positional vertigo (BPPV), labyrinthitis, vestibular neuritis and Ménière's disease among them. BPPV causes brief, intense spells of vertigo triggered by a change in head position, while Ménière's disease involves episodes of vertigo with hearing loss, tinnitus and a feeling of fullness in the ear. Most people with vertigo improve without treatment, and treatment depends on the cause.

Symptoms

What a clinician may find

• Involuntary eye movements called nystagmus, with vertigo, when the Dix-Hallpike head-position test is carried out in BPPV

Complications

• BPPV can recur, and in some people it becomes a persistent or recurrent problem
• Hearing loss in Ménière's disease

Diagnosis

BPPV is diagnosed mainly from the history of symptoms and from typical findings on the Dix-Hallpike manoeuvre, a head-position test. For Ménière's disease, no single test confirms the diagnosis, which rests on the pattern of recurring attacks and hearing tests. For suspected Ménière's disease, the NHS says a GP will check the ears, head and neck.

Treatment

Treatment depends on the cause; for vertigo in general the NHS says antihistamines can sometimes help and balance exercises may be recommended. BPPV often settles by itself or with canalith repositioning manoeuvres done in a clinic. Ménière's disease cannot be cured, but treatment can help the symptoms, and the NIDCD says diet changes, stopping smoking and anti-vertigo or anti-nausea medicines may be recommended. NHS 111 Wales says surgery on the inner ear is rarely offered, when symptoms are hard to control.

Prevention

The NHS suggests lifestyle changes such as drinking plenty of fluids, avoiding caffeine, not smoking and not drinking alcohol can help manage Ménière's disease.

Key facts

What is vertigo, and what causes it?

Vertigo is the feeling that you, or the environment around you, is moving or spinning. The NHS describes it as a symptom rather than a condition in itself. Attacks can be short, and sometimes they last much longer. Inner ear problems, which affect balance, are the most common causes. The NHS lists benign paroxysmal positional vertigo (BPPV), labyrinthitis, vestibular neuritis and Ménière's disease as common causes.

The NHS describes BPPV as one of the most common causes of vertigo. Most people with vertigo improve without treatment, and what is done depends on the cause. This page looks mainly at BPPV and Ménière's disease, two inner ear conditions that the NHS and the US National Institute on Deafness and Other Communication Disorders (NIDCD) describe.

What is BPPV and how does it feel?

The NIDCD describes BPPV as a brief, intense episode of vertigo triggered by a specific change in the position of the head. The NHS likewise says specific head movements can bring on the vertigo. The NIDCD gives examples such as bending down, tilting the head to look up or over a shoulder, or rolling over in bed. It says BPPV can follow a head injury or develop simply with age.

An NIDCD handout explains that the condition arises when loose otoconia tumble into one of the semicircular canals and affect how the cupula works. Otoconia are tiny crystals in the inner ear, and the semicircular canals are the fluid-filled loops that sense head movement. A medical review says BPPV is frequently resolved on its own or through canalith repositioning manoeuvres carried out in a clinic. StatPearls, an online medical reference, describes the overall outlook as favourable. The review adds that the course can range from a problem that is treated simply to one that persists or recurs and causes disability. NICE guideline NG127 notes that BPPV is common after a head injury or labyrinthitis.

What is Ménière's disease?

The NIDCD describes Ménière's disease as episodes of vertigo, hearing loss, tinnitus (a ringing or buzzing in the ear) and a feeling of fullness in the ear. The NHS lists feeling that you or everything around you is spinning, losing your balance and hearing loss among the symptoms.

An NHS Lanarkshire page says attacks usually last a few hours. It adds that the symptoms can be very troublesome and worrying. The NIDCD links Ménière's disease with a fluid imbalance in the labyrinth, a part of the inner ear, caused by a build-up of a fluid called endolymph. It says theories vary about what causes the condition, and MedlinePlus says the cause is unknown. The NHS says Ménière's disease cannot be cured, but treatment can help with the symptoms.

How is vertigo diagnosed?

For BPPV, diagnosis rests mainly on the history of symptoms and on typical findings during the Dix-Hallpike manoeuvre, a head-position test. NICE Clinical Knowledge Summaries (CKS) says posterior canal BPPV is diagnosed if the manoeuvre provokes vertigo and torsional, upbeating nystagmus, which means involuntary eye movements. NICE guideline NG127 recommends offering the Hallpike manoeuvre to adults with brief rotational vertigo triggered by head movement, if a trained health professional is available, and offering canalith repositioning if BPPV is diagnosed.

For Ménière's disease, no single test confirms the diagnosis. It rests on the pattern of recurring attacks and on hearing tests, and diagnostic criteria require more than one episode of vertigo. The NHS says a GP will check the ears, head and neck when Ménière's disease is suspected. NG127 also asks clinicians to be alert to vestibular migraine, which is migraine-associated vertigo, in adults with episodes of dizziness lasting from 5 minutes to 72 hours and a history of recurrent headache. For sudden-onset acute vestibular syndrome, NG127 advises immediate referral unless BPPV or postural hypotension explains the problem.

How are BPPV and Ménière's disease treated?

The NHS says treatment for vertigo depends on the cause. It adds that antihistamines can sometimes help and that balance exercises may be recommended. For BPPV, NHS patient leaflets describe the Epley manoeuvre, a series of four head movements, as a treatment. NICE guideline NG127 recommends offering canalith repositioning when BPPV is diagnosed, if a trained health professional is available.

For Ménière's disease, the NHS says treatment mainly eases symptoms, with medicines for dizziness and nausea, and that tinnitus may also need treatment. The NIDCD says a specialist ear, nose and throat doctor (otolaryngologist) may recommend changes to diet and, for smokers, stopping smoking. It adds that anti-vertigo or anti-nausea medicines may relieve symptoms, though they can cause drowsiness. NHS 111 Wales says surgery on the inner ear is rarely offered, when symptoms are hard to control.

Self-care, living with vertigo and when to get help

For vertigo attacks, the NHS suggests lying still in a dark room, sitting down as soon as dizziness begins, and getting up slowly after lying down. It also suggests a walking stick for people at risk of falling. For Ménière's disease, the NHS says drinking lots of fluids, avoiding caffeine, not smoking and not drinking alcohol can help manage it.

A routine GP appointment is advised by the NHS if vertigo does not go away or keeps coming back. An urgent GP appointment or a call to NHS 111 is advised if vertigo comes with a severe headache, sickness or a high temperature. Call 999 or go to A&E if vertigo comes with double or lost vision, hearing loss, difficulty speaking, or weakness, numbness or tingling in the limbs.

Frequently asked questions