Vertigo Causes and Treatment: BPPV and Beyond

What is the difference between vertigo and dizziness?

Dizziness is a broad term that patients use to describe lightheadedness, faintness, unsteadiness, and true spinning. Vertigo specifically refers to the illusion of rotational movement — the room appears to spin, or you feel like you are spinning when you are not.

The distinction matters because true rotational vertigo usually points to the inner ear (peripheral vertigo) or, less often, to parts of the brain that process balance signals (central vertigo). Lightheadedness without spinning has a wider differential — cardiovascular, metabolic, and medication-related causes are common.

What causes vertigo?

Benign paroxysmal positional vertigo (BPPV) is the most common cause of true vertigo. It occurs when calcium carbonate crystals (otoconia) that normally reside in one part of the inner ear displace into a semicircular canal. When the head moves, the crystals shift and send a false motion signal to the brain. Episodes are brief — seconds to less than a minute — and triggered by specific head positions (lying down, rolling over in bed, tilting the head back) 1Ref 1Bhattacharyya N, Gubbels SP, Schwartz SR, Edlow JA, El-Kashlan H, Fife T, et al. (2017).Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update).BPPV definition, canalith repositioning as primary treatment, recommendation against vestibular suppressants as first-line BPPV therapy2Ref 2Bhattacharyya N, Gubbels SP, Schwartz SR, Edlow JA, El-Kashlan H, Fife T, et al. (2017).Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update) Executive Summary.Summary of BPPV diagnostic and management recommendations.

Vestibular neuritis is inflammation of the vestibular nerve, often after a viral infection. It causes severe, constant vertigo lasting days, sometimes with nausea and vomiting, but typically no hearing loss.

Meniere's disease is a disorder of fluid pressure in the inner ear that causes episodes of severe spinning vertigo lasting 20 minutes to several hours, along with fluctuating hearing loss, tinnitus, and ear fullness 3Ref 3Basura GJ, Adams ME, Monfared A, Schwartz SR, Antonelli PJ, Burkard R, et al. (2020).Clinical Practice Guideline: Ménière's Disease.Meniere's disease — episodic vertigo with hearing loss, tinnitus, and aural fullness; long-term management approach.

Labyrinthitis is similar to vestibular neuritis but also involves the cochlea, causing hearing changes alongside vertigo.

Central causes — brainstem or cerebellar strokes or tumors — are less common but important to recognize. Central vertigo tends to be accompanied by other neurological signs and does not follow the positional pattern of BPPV.

How is BPPV treated?

BPPV is treated with canalith repositioning maneuvers — a series of guided head movements designed to move the displaced crystals back to where they belong.

The Epley maneuver is the most studied and most effective for the most common type (posterior canal BPPV). A clinician guides the patient through a sequence of head positions held for about 30 seconds each. A Cochrane review found that the Epley maneuver is effective at resolving BPPV and improving symptoms 4Ref 4Hilton MP, Pinder DK (2014).The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo.Effectiveness of the Epley maneuver for BPPV. Many people experience significant relief after one to three sessions.

The AAO-HNS clinical practice guideline on BPPV recommends the canalith repositioning procedure as the primary treatment and advises against routine initial use of vestibular suppressant medications for BPPV 1Ref 1Bhattacharyya N, Gubbels SP, Schwartz SR, Edlow JA, El-Kashlan H, Fife T, et al. (2017).Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update).BPPV definition, canalith repositioning as primary treatment, recommendation against vestibular suppressants as first-line BPPV therapy.

A home version of the Epley maneuver can be performed once a clinician has confirmed the diagnosis and identified the affected canal — the steps for the wrong canal or wrong side can worsen symptoms. Video-guided home exercises exist and can be effective for recurrent, confirmed posterior canal BPPV.

What about medications for vertigo?

Vestibular suppressants (such as meclizine) can reduce the intensity of spinning during acute episodes and help with nausea. They are reasonable for short-term comfort during severe vertigo from vestibular neuritis or acute Meniere's episodes.

However, the AAO-HNS guideline explicitly cautions against relying on vestibular suppressants for BPPV — these medications can actually slow the brain's natural process of adapting to and compensating for the inner ear problem 1Ref 1Bhattacharyya N, Gubbels SP, Schwartz SR, Edlow JA, El-Kashlan H, Fife T, et al. (2017).Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update).BPPV definition, canalith repositioning as primary treatment, recommendation against vestibular suppressants as first-line BPPV therapy. The repositioning maneuver, not medication, is the right treatment for BPPV.

Meniere's disease management typically involves dietary sodium restriction to reduce fluid fluctuations, diuretics, and in more severe or refractory cases, procedural interventions. An ENT or vestibular specialist manages Meniere's 3Ref 3Basura GJ, Adams ME, Monfared A, Schwartz SR, Antonelli PJ, Burkard R, et al. (2020).Clinical Practice Guideline: Ménière's Disease.Meniere's disease — episodic vertigo with hearing loss, tinnitus, and aural fullness; long-term management approach.

What kind of specialist treats vertigo?

For BPPV: a primary care clinician can perform canalith repositioning. If uncertain about the diagnosis or if the standard maneuver does not work, an ENT (otolaryngologist) or vestibular physical therapist is appropriate.

For Meniere's disease: an ENT with experience in vestibular disorders.

For vertigo with neurological signs (sudden onset with headache, double vision, facial numbness, slurred speech, or difficulty walking): emergency evaluation for a possible central cause.

A Gale clinician can assess your symptoms, discuss the most likely cause based on your history, and guide you to the right next step — whether that is an in-office repositioning procedure, a specialist referral, or emergency care.

Will vertigo come back?

BPPV recurs in a meaningful proportion of people over subsequent months and years. Recurrence is not a sign of treatment failure — it reflects the natural behavior of the condition. When it recurs, the repositioning maneuver works again.

Meniere's disease is a chronic condition with unpredictable episodic flares. Long-term management with lifestyle modifications and medical therapy reduces frequency and severity for many patients.

Vestibular neuritis typically resolves fully over weeks, though some people have residual unsteadiness that responds to vestibular rehabilitation therapy.