What Is Vertigo?
Vertigo is the illusion of movement — usually rotational — of one's own body or of the environment. It is not synonymous with dizziness, which is a broader term encompassing imbalance, sensation of floating, and presyncope. Vertigo specifically indicates a dysfunction of the vestibular system, peripheral or central.
The vestibular system detects head movement and position in space, integrating this information with visual and proprioceptive signals to maintain balance and stabilize gaze. When vestibular activity becomes asymmetric — from a unilateral lesion or dysfunction — the brain interprets this asymmetry as movement, generating the sensation of vertigo.
Vertigo is an extremely common symptom and one of the most frequent reasons for emergency and urgent-care visits. The most common cause is benign paroxysmal positional vertigo (BPPV), accounting for approximately 25-30% of cases.
Illusion of Movement
Vertigo is the false perception that the body or environment is rotating. It differs from nonspecific dizziness or instability.
Peripheral vs. Central
Distinguishing peripheral (inner ear) from central (brainstem/cerebellum) causes is crucial for management.
Highly Treatable
Many peripheral causes of vertigo respond well to treatment. In BPPV, for example, repositioning maneuvers (Epley, Semont) often relieve symptoms in one or a few sessions — although recurrences may occur.
Pathophysiology
Balance depends on integration of three sensory systems: vestibular (inner ear), visual, and proprioceptive (receptors in joints, muscles, and feet). This information converges in the vestibular nuclei of the brainstem, which process it and generate motor responses to maintain posture and gaze stabilization.
The peripheral vestibular apparatus has two components: the semicircular canals (anterior, posterior, and horizontal), which detect angular acceleration (head rotations), and the otolithic organs (utricle and saccule), which detect linear acceleration and position relative to gravity.
Under normal conditions, both labyrinths send symmetric signals to the vestibular nuclei. A unilateral lesion creates asymmetry: the affected side sends fewer signals, and the brain interprets this difference as if the head were rotating toward the healthy side. The result is rotatory vertigo and nystagmus (involuntary eye movement) with the fast phase beating toward the healthy side.
Types and Causes
Distinguishing peripheral from central vertigo is fundamental because central causes may represent neurologic emergencies — posterior fossa stroke, for example. History, nystagmus examination, and specific vestibular tests guide this differentiation.
PERIPHERAL VS. CENTRAL VERTIGO
| FEATURE | PERIPHERAL | CENTRAL |
|---|---|---|
| Onset | Sudden, episodic | Gradual or sudden |
| Intensity | Intense, rotatory | Moderate, less defined |
| Duration | Seconds to hours | Days to weeks, or continuous |
| Nystagmus | Horizontal/rotatory, inhibited by fixation | Vertical, multidirectional, not inhibited by fixation |
| Nausea/vomiting | Intense | Variable |
| Hearing loss | May be present (Ménière) | Generally absent |
| Neurologic signs | Absent | Diplopia, dysphagia, dysarthria, paresis |
| Main causes | BPPV, vestibular neuritis, Ménière | Stroke, multiple sclerosis, tumor, vestibular migraine |
MAIN CAUSES OF VERTIGO
| CAUSE | MECHANISM | EPISODE DURATION |
|---|---|---|
| BPPV | Displaced otoconia in semicircular canals | Seconds (< 1 minute) |
| Vestibular neuritis | Inflammation of the vestibular nerve (post-viral) | Days (single episode, gradual improvement) |
| Ménière's disease | Endolymphatic hydrops | 20 minutes to hours |
| Vestibular migraine | Central vestibular dysfunction associated with migraine | Minutes to 72 hours |
| Posterior fossa stroke | Ischemia of cerebellum/brainstem | Continuous, acute |
| Vestibular schwannoma | Tumor of the vestibulocochlear nerve | Progressive imbalance |
Symptoms
Symptoms vary by cause, but true vertigo is always accompanied by nystagmus and frequently by autonomic symptoms such as nausea and vomiting. Intensity does not necessarily correlate with severity — BPPV causes very intense vertigo but is benign.
Common Symptoms in Vertigo
- 01
Sensation of rotation
The patient feels the environment spinning around them or feels themselves spinning. It is the cardinal symptom of vertigo.
- 02
Nystagmus
Involuntary and rhythmic eye movement. Its direction and characteristics help localize the cause.
- 03
Nausea and vomiting
Autonomic response to vestibular asymmetry. May be intense in BPPV and vestibular neuritis.
- 04
Imbalance
Tendency to fall toward the side of the lesion. Difficulty maintaining upright posture.
- 05
Oscillopsia
Sensation that the environment is "swaying" or "shaking" during head movements.
- 06
Auditory symptoms
Tinnitus, hearing loss, and aural fullness when the cause involves the inner ear (Ménière's).
Diagnosis
Vertigo diagnosis is predominantly clinical, based on history (duration, triggers, associated symptoms) and otoneurologic examination. Temporal characterization of episodes is one of the most important diagnostic tools.
Specific vestibular tests include the Dix-Hallpike maneuver (diagnosis of posterior canal BPPV), the head impulse test (assesses the vestibulo-ocular reflex), and the Romberg test (assesses sensory integration for balance).
🏥Diagnostic Approach to Vertigo
Fonte: Bárány Society — International diagnostic criteria
Targeted History
- 1.Duration of each episode: seconds (BPPV), hours (Ménière's), days (neuritis)
- 2.Triggering factors: position change (BPPV), spontaneous (Ménière's, neuritis)
- 3.Associated auditory symptoms: tinnitus, hearing loss, aural fullness
- 4.Headache: present in vestibular migraine
- 5.Neurologic symptoms: diplopia, dysphagia, weakness (central cause)
Otoneurologic Examination
- 1.Dix-Hallpike maneuver: posterior canal BPPV
- 2.Roll test (supine): horizontal canal BPPV
- 3.Head impulse test (HIT): vestibulo-ocular reflex
- 4.Assessment of spontaneous and provoked nystagmus
- 5.Dynamic visual acuity test
- 6.Focused neurologic examination (cranial nerves, cerebellum)
Complementary Tests
- 1.Audiometry: if auditory symptoms
- 2.Videonystagmography (VNG): objective vestibular assessment
- 3.vHIT (video Head Impulse Test): semicircular canal function
- 4.Brain MRI: if suspicion of central cause or schwannoma
Differential Diagnosis
Vertigo can have widely varied causes with distinct prognoses and treatments. Clinical differentiation is essential to avoid both undertreatment and unnecessary investigation.
DIAGNÓSTICO DIFERENCIAL
Differential Diagnosis
Ménière's Disease
Read more →- Recurrent episodes
- Fluctuating hearing loss
- Tinnitus and aural fullness
Testes Diagnósticos
- Audiometry
- Electrocochleography
Benign Paroxysmal Positional Vertigo (BPPV)
- Triggered by head position change
- Lasts seconds
- Positive Dix-Hallpike
Testes Diagnósticos
- Dix-Hallpike maneuver
Vestibular Neuritis
- Continuous vertigo for days without hearing loss
- After viral infection
- No ipsilateral autonomic symptoms
Testes Diagnósticos
- Head impulse test
- VNG
Posterior Fossa Stroke
- Sudden onset, without prodromal nausea
- Other cerebellar signs
- Cardiovascular risk factors
- Cerebellar stroke = neurologic emergency
Testes Diagnósticos
- Urgent CT/MRI
Multiple Sclerosis
Read more →- Young adults
- Multiple neurologic episodes
- MRI lesions
Testes Diagnósticos
- Brain/spine MRI
Peripheral vs. Central Vertigo: The Essential Distinction
The most critical distinction in vertigo evaluation is between peripheral causes (inner ear/vestibular nerve) and central causes (brainstem/cerebellum). Central causes, especially posterior fossa stroke, can be life-threatening. The HINTS exam (Head Impulse, Nystagmus, Test of Skew) has higher sensitivity than CT in the first 24-48 hours for detecting cerebellar stroke in patients with acute vestibular syndrome (continuous vertigo with spontaneous nystagmus). It does not apply routinely to episodic vertigo such as BPPV. Vertical, multidirectional nystagmus or nystagmus not inhibited by visual fixation are warning signs for central cause.
BPPV and vestibular neuritis are the most common peripheral causes and are frequently confused. In BPPV, vertigo lasts seconds and is triggered by position — the Dix-Hallpike confirms the diagnosis and allows immediate treatment with the Epley maneuver. In vestibular neuritis, vertigo is continuous for days, without hearing loss, with a positive head impulse test (HIT) ipsilateral to the lesion. Neuritis treatment is symptomatic in the acute phase, and vestibular rehabilitation accelerates central compensation.
Ménière's Disease and Vestibular Migraine: Diagnosis by Temporal Pattern
Ménière's disease and vestibular migraine are recurrent causes of vertigo that require specific diagnostic criteria. In Ménière's, episodes last 20 minutes to 12 hours with auditory fluctuation, tinnitus, and associated aural fullness. In vestibular migraine, episodes may last minutes to 72 hours, frequently with a history of migrainous headache or visual phenomena. Audiometry is fundamental to document hearing loss in the low frequencies of Ménière's, while response to migraine prophylaxis supports the diagnosis of vestibular migraine.
Multiple sclerosis can cause vertigo through demyelinating plaques in the brainstem or cerebellum. Consider it in young adults with recurrent neurologic episodes in different locations. MRI with gadolinium is essential for diagnosis and should be ordered when vertigo presents in a context atypical for the usual peripheral causes.
Role of Acupuncture in Differential Diagnosis
The acupuncture physician evaluating patients with vertigo should master otoneurologic differential diagnosis before planning treatment. Acupuncture is most effective as adjunct in cervicogenic vertigo, residual post-compensation symptoms, and in autonomic components of Ménière's disease. BPPV requires repositioning maneuvers as primary treatment — acupuncture does not replace the Epley maneuver, but may complement care for residual symptoms.
Patients with posterior fossa stroke or multiple sclerosis need immediate specialized neurologic treatment. Acupuncture may form part of the neurologic rehabilitation plan for these conditions, but urgent referral is mandatory when central signs are present.
Treatment
Treatment of vertigo depends on the cause. BPPV is treated with repositioning maneuvers (Epley, Semont). Success rate per session is typically 50-80% for posterior canal BPPV, with cumulative improvement in 1-2 sessions. Vestibular neuritis requires symptomatic treatment in the acute phase and vestibular rehabilitation in the chronic phase.
Acute Phase
First 24-72 hoursVestibular suppressant medications (meclizine, dimenhydrinate, ondansetron) to control nausea and intense vertigo. Use for the shortest time possible, as they delay central compensation.
Repositioning Maneuvers
BPPV — single sessionEpley maneuver for posterior canal, Lempert (roll maneuver) for horizontal canal. Success rate >80% in one session. May be repeated if necessary.
Vestibular Rehabilitation
4-12 weeksSpecific exercises that promote central compensation. Include habituation, gaze stabilization, and balance exercises. Strong evidence for chronic vertigo.
Specific Treatment
According to diagnosisMénière's: low-sodium diet, betahistine, diuretics. Vestibular migraine: migraine prophylaxis. Schwannoma: observation, radiosurgery, or surgery.
Acupuncture as Treatment
Acupuncture is used as complementary therapy for vertigo, with proposed mechanisms — still under investigation — that include possible influence on vestibular nuclei, effects on inner-ear blood flow, and autonomic modulation that could attenuate sympathetic components of symptoms.
Preclinical animal studies suggest that electroacupuncture at points such as PC-6, GB-20, and GB-43 may influence neural activity in the vestibular nuclei and reduce activation markers (c-Fos). However, direct extrapolation of these experimental findings to clinical practice in humans requires caution and confirmation in controlled trials.
In clinical practice, acupuncture may be useful as an adjunct to vestibular rehabilitation, especially in patients with persistent residual symptoms, cervicogenic vertigo, and associated nausea. Importantly, BPPV should be treated primarily with repositioning maneuvers.
Prognosis
Vertigo prognosis is generally favorable, depending on the cause. BPPV has an excellent prognosis with repositioning maneuvers, although it may recur in 15-30% of cases within the first year. Vestibular neuritis resolves well with central compensation, but recovery may take weeks to months.
Vestibular rehabilitation is fundamental to optimize recovery across all causes. Prolonged rest and overuse of vestibular suppressants delay central compensation and should be avoided.
Myths and Facts
Myth vs. Fact
Vertigo is caused by 'labyrinthitis'.
The term 'labyrinthitis' is frequently used incorrectly for any dizziness. True labyrinthitis (inflammation of the labyrinth) is rare. The most common causes are BPPV, vestibular neuritis, and vestibular migraine.
Myth vs. Fact
Staying still and avoiding movement is best for people with vertigo.
Prolonged rest delays central compensation. Vestibular rehabilitation — with progressive head-movement and balance exercises — is the most effective treatment for long-term recovery.
Myth vs. Fact
All dizziness is vertigo.
Vertigo is a specific type of dizziness — the sensation of rotation. Other types include presyncope (a sensation of fainting, cardiovascular in origin), imbalance (postural instability), and nonspecific dizziness (psychogenic or multifactorial).
When to Seek Help
Frequently Asked Questions
Frequently Asked Questions
No. Vertigo is the specific sensation of rotation — the environment spins or the body itself spins. Dizziness is a broader term that includes presyncope (a sensation of fainting), imbalance, and nonspecific dizziness. Vertigo indicates peripheral or central vestibular dysfunction, while other forms of dizziness have different causes. The distinction is fundamental for correct diagnosis.
The term "labyrinthitis" is frequently used incorrectly for any vertigo. True labyrinthitis — bacterial or viral inflammation of the labyrinth — is rare. The most common causes of vertigo are BPPV (30%), vestibular neuritis (10-15%), and Ménière's disease (10%). Accurate diagnosis is important because treatments are completely different.
The Epley maneuver (otoconia repositioning for posterior canal BPPV) can be learned and performed at home after confirmed diagnosis and adequate medical guidance. However, BPPV must first be confirmed by a trained professional using the Dix-Hallpike maneuver, since other types of BPPV (horizontal canal, anterior canal) require different maneuvers. Self-treatment without a diagnosis may be ineffective or inappropriate.
If vertigo worsens specifically with changes in head position — turning in bed, looking up, or lowering the head — the most likely cause is BPPV (Benign Paroxysmal Positional Vertigo). In this condition, calcium carbonate crystals (otoconia) migrate into the semicircular canals. Any movement that displaces these crystals provokes intense but brief vertigo (seconds). It is the most common and most treatable cause of vertigo.
Yes. Sudden-onset vertigo — especially with difficulty speaking, swallowing, double vision, weakness on one side of the body, severe headache, or inability to walk — may indicate posterior fossa stroke (cerebellum or brainstem). These signs require immediate emergency care. Isolated vertigo from stroke is less common but possible — hence the importance of careful neurologic examination in every patient with acute-onset vertigo.
Rest in the intense acute phase is understandable, but prolonged rest delays recovery. The central nervous system recovers from unilateral vestibular lesions through a process called "central compensation," which depends on exposure to movement stimuli. Vestibular rehabilitation — with progressive exercises of head movement and balance — significantly accelerates this compensation. Excessive use of vestibular suppressants (meclizine, dimenhydrinate) for more than 2-3 days also delays recovery.
Acupuncture may be used as complementary therapy in some vertigo presentations. Proposed mechanisms — based mainly on preclinical studies and animal models — include possible influence on vestibular nuclei, inner-ear microcirculation, and autonomic modulation, but clinical extrapolation still requires more evidence. In practice, it may be considered as adjunct in cervicogenic vertigo, residual symptoms after treated BPPV, and Ménière's disease. It does not replace repositioning maneuvers (Epley) in BPPV nor neurologic treatment of central causes. The acupuncture physician evaluates each case individually.
Yes. The BPPV recurrence rate is 15-30% in the first year and may reach 50% at 5 years. Risk factors for recurrence include advanced age, osteoporosis, prior head trauma, diabetes, and vitamin D deficiency. Vitamin D supplementation has been shown to reduce recurrences in clinical studies. The maneuver may be repeated as often as needed — each episode generally responds well to repositioning.
Vestibular rehabilitation is a program of specific exercises that promote adaptation and central compensation after vestibular dysfunction. It includes habituation exercises (progressive exposure to movements that trigger dizziness), gaze stabilization, and balance training. It is indicated for chronic residual vertigo, post-vestibular neuritis, vertigo in elderly patients, and after any unilateral vestibular lesion. Studies show significant improvement in balance, function, and quality of life.
Seek emergency care immediately if vertigo is accompanied by: difficulty speaking or swallowing, double vision, weakness or numbness on one side of the body, sudden severe headache ("the worst headache of life"), inability to walk or stand, loss of consciousness, or onset in a patient with cardiovascular risk factors (hypertension, diabetes, smoking, atrial fibrillation). These signs indicate possible posterior fossa stroke, which is a neurologic emergency.
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