Vertigo
Vertigo is a specific type of dizziness characterised by a false sense of rotational movement — a feeling that the world is spinning, or that you yourself are spinning within a stationary environment. It is not a diagnosis but a symptom, and its causes are numerous. Understanding whether vertigo originates in the peripheral vestibular system (the inner ear and vestibular nerve) or the central nervous system (the brainstem and cerebellum) is the critical first step in diagnosis.
Peripheral vertigo
The most common cause of vertigo is benign paroxysmal positional vertigo (BPPV), which occurs when tiny calcium carbonate crystals (otoliths) that normally sit in the utricle of the inner ear become dislodged and migrate into one of the semicircular canals, falsely signalling rotational movement with certain head positions. BPPV causes brief, intense episodes of vertigo (lasting less than a minute) triggered by specific movements — lying down, turning over in bed, or tilting the head back — and is highly effectively treated by the Epley manoeuvre, a series of guided head movements that repositions the crystals. Vestibular neuritis — thought to be caused by viral inflammation of the vestibular nerve — produces a single prolonged episode of severe vertigo lasting days, accompanied by nausea and vomiting, without hearing loss. Labyrinthitis is similar but also involves hearing loss. Ménière's disease causes episodic vertigo lasting 20 minutes to several hours, associated with fluctuating hearing loss, tinnitus, and a feeling of fullness in the affected ear.
Central vertigo
Vertigo of central origin is less common but more serious. It can result from a stroke or TIA affecting the cerebellum or brainstem, a demyelinating lesion in multiple sclerosis, vestibular migraine, or, rarely, a posterior fossa tumour. Central vertigo tends to be less dramatically positional than BPPV, is more often accompanied by other neurological signs (such as double vision, dysarthria, limb ataxia, or headache), and should be investigated urgently with MRI.
Symptoms and associated features
In addition to the hallmark rotational sensation, vertigo is frequently accompanied by nausea and vomiting, unsteadiness and imbalance, and a tendency to fall in a consistent direction. Nystagmus — involuntary, rhythmic eye movements — is an objective sign of vestibular dysfunction that can be observed on examination or recorded with videonystagmography.
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