Dizziness is one word covering three different problems, and telling them apart is most of the diagnosis. Almost everything else on this page follows from the first table.
Which kind of dizziness do you have?
| What you feel | Where it usually comes from | The clue |
|---|---|---|
| The room spins, tilts, or slides | The inner ear, occasionally the brainstem or cerebellum | Comes in episodes, often set off by a change of head position |
| Faint, woozy, about to pass out | Blood pressure, the heart, or a medication | Happens on standing or after standing a while, eases lying down |
| Head is steady but your feet are not | Sensory nerves in the legs, the cerebellum, or vision | No spinning at all, and much worse in the dark or on uneven ground |
Many people have more than one, which does not make the diagnosis harder. If unsteadiness rather than spinning is your main problem, our page on balance problems covers it in detail.
Visual guide
Describing the sensation
- Vertigo: A feeling that you or the surroundings are spinning.
- Lightheadedness: A feeling that you might faint.
- Unsteadiness: Difficulty feeling secure when standing or walking.
What causes vertigo
Three things separate one cause from another: how long an episode lasts, what sets it off, and whether your hearing changes with it. Noting those before your visit is genuinely useful.
| Cause | How long an episode lasts | The clue |
|---|---|---|
| Benign paroxysmal positional vertigo (BPPV) | Seconds to under a minute | Triggered by rolling over in bed, lying down, or looking up |
| Vestibular migraine | Minutes to days | Light and sound sensitivity or motion sickness. A headache is often absent |
| Vestibular neuritis or labyrinthitis | Constant for days, improving over weeks | Follows a viral illness. Labyrinthitis also affects hearing, neuritis does not |
| Meniere's disease | Twenty minutes to hours | Fluctuating hearing loss, ringing, and fullness in one ear |
| Multiple sclerosis | Days to weeks | Other neurological symptoms, often in a younger adult |
| Stroke in the brainstem or cerebellum | Sudden and continuous | Double vision, slurred speech, weakness, or an inability to walk |
BPPV is by far the most common of these. Tiny calcium crystals come loose in the inner ear and drift into a balance canal, where they set off a brief, intense spin whenever your head moves into a particular position. That is why the classic story is a whirling sensation when you lie down, roll over in bed, or look up at a shelf, lasting less than a minute and settling if you hold still.
Anatomy at a glanceThe balance system
How the inner ear senses movement
Small fluid-filled structures help the brain sense head movement and position.
Semicircular canals
Three canals sense head rotation in different directions.
Utricle and saccule
These small organs sense gravity and movement in a straight line.
Vestibular nerve
This nerve carries balance signals from the inner ear to the brain.
Inner-ear signals work with vision and body sensation to help you stay steady.
One part of the balance system. Dizziness can also have causes outside the inner ear.
What causes lightheadedness and unsteadiness
Faintness on standing points away from the inner ear. A blood pressure drop, dehydration, and medication are the usual explanations, most often blood pressure medications, sedatives, some antidepressants, and anticonvulsants. A medication review is part of every dizziness visit. When it is persistent and comes with a racing heart or heat intolerance, autonomic dysfunction is worth testing for.
Unsteadiness without spinning usually comes from the sensory nerves in the feet, as in peripheral neuropathy, or from the cerebellum. The giveaway is that it is much worse in the dark, when vision can no longer compensate.
Neurological causes of dizziness: when it comes from the brain
Most dizziness is peripheral, meaning it starts in the inner ear or in the nerve that connects it to the brain. A smaller share is central, meaning it starts in the brainstem or cerebellum, the parts of the brain that process balance signals. This is what people mean by neurological dizziness, and it is the part a neurologist is trained to find.
The central causes worth knowing are stroke or a transient ischemic attack in the back of the brain, vestibular migraine, which is the most common neurological cause of recurrent vertigo, multiple sclerosis, and, rarely, a tumor or a structural problem at the base of the skull.
Persistent postural-perceptual dizziness (PPPD) sits outside that list. It is a functional vestibular disorder rather than damage to the brainstem or cerebellum: a constant rocking, swaying, or unsteadiness present on most days for three months or more, usually starting after an episode of vertigo. It is made worse by upright posture, by motion whether you are moving yourself or being moved, and by busy visual environments such as supermarket aisles or scrolling screens. It is common, real, and treatable, with vestibular rehabilitation, cognitive behavioral therapy, and sometimes an SSRI or SNRI.
The clues that point to the brain are dizziness that came on suddenly and has not stopped, an inability to stand or walk unaided, any of the emergency signs below, and eye movements on examination that do not fit an inner-ear pattern. Hearing loss, in contrast, points to the ear.
How it is diagnosed
Most of the answer comes from the room rather than the scanner. The history alone usually narrows things to one or two possibilities. Then we measure blood pressure and heart rate lying and standing, check hearing, and perform a neurological examination focused on eye movements, coordination, and walking.
Two bedside tests do most of the work. The Dix-Hallpike maneuver places your head in the position that provokes BPPV, briefly reproducing the vertigo and confirming it on the spot. The head-impulse test and the direction of any nystagmus, the small involuntary eye movements we watch for, reliably separate an inner-ear cause from a brain cause. In someone with continuous vertigo, this short eye-movement examination is better at detecting a stroke in the first day or two than an early MRI, let alone a CT scan, which is why it matters that someone performs it.
Formal eye-movement recordings at a vestibular laboratory are arranged when the bedside examination is not conclusive. MRI is ordered when the examination points to the brain or other neurological symptoms are present, and most people with dizziness never need one. Because these tests are hands-on, a first evaluation for vertigo is best done in person. Follow-up works well by video.
Visual guide
The history guides the examination
- Description: Spinning, faintness, and unsteadiness are separated.
- Timing: Triggers and episode duration provide clues.
- Examination: Eye movements and other findings help identify the cause.
Treatment
Treatment follows the cause, which is why we do not prescribe a general dizziness medication before the diagnosis is clear.
- BPPV: the Epley maneuver, a sequence of head and body positions performed in the office that guides the crystals back out of the canal. It often resolves the vertigo in one or two sessions, and we teach you a home version for recurrences.
- Vestibular neuritis and labyrinthitis: medication for severe vertigo and nausea in the first few days only, because continuing it slows the brain's own recovery, then vestibular rehabilitation, which is what actually restores balance.
- Meniere's disease: reducing salt, and often caffeine and alcohol, plus medication to control attacks. We work alongside an ear, nose and throat specialist on the hearing side.
- Vestibular migraine: treated as migraine, with preventive treatment rather than vertigo medication.
- PPPD: vestibular rehabilitation that retrains the brain's response to motion, cognitive behavioral therapy, and sometimes an SSRI or SNRI.
- Medication-related dizziness: changing the drug responsible where possible, frequently the single most effective step.
When dizziness is an emergency
Call 911 or go to the nearest emergency department if dizziness comes on suddenly together with any of these: double vision, trouble speaking or swallowing, weakness or numbness on one side, a severe new headache, or an inability to stand or walk. These can be signs of a stroke in the back of the brain, and the treatment window is short.
Neurologist or ENT: who should you see for dizziness?
Both treat dizziness, and the right one depends on the pattern. Brief spinning set off by head position, or vertigo with hearing loss, ringing, or ear fullness, is usually an ear problem, and an ear, nose and throat specialist or a vestibular therapist is a good first stop. A neurologist is the right call when vertigo keeps returning without an ear explanation, when it comes with headache, visual aura, or light sensitivity, when there is unsteadiness or numbness rather than spinning, when dizziness followed a head injury, or when an ear workup has come back normal.
Book a visit if the dizziness is severe or has lasted more than a few days, if vertigo keeps returning, or if it is interfering with work or driving. An accurate name for the problem is what makes the treatment work. Dr. Achillefs Ntranos, MD, a board-certified neurologist, sees every patient himself for a 60-minute first visit, and you can request a visit in Beverly Hills or Los Angeles. We do not run a vestibular laboratory in our office; when formal testing is needed we order it nearby and review the results with you.
Frequently asked questions
References
- National Institute on Deafness and Other Communication Disorders. Balance Disorders.
- Bhattacharyya N, et al. Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update). Otolaryngology-Head and Neck Surgery, 2017.
- Kattah JC, et al. HINTS to diagnose stroke in the acute vestibular syndrome. Stroke, 2009.
- Cleveland Clinic. Dizziness.
- Staab JP, et al. Diagnostic criteria for persistent postural-perceptual dizziness (PPPD): consensus document of the Barany Society. Journal of Vestibular Research, 2017.