The dizzy patient: a case-based guide to vertigo

The case: a spinning room on waking

Meet our illustrative patient: a woman in her fifties who wakes, rolls over in bed, and feels the room spin violently for about twenty seconds before it settles. It happens again when she tips her head back to hang out washing. There is no hearing loss, no weakness and no slurred speech. This short-lived, position-triggered spinning is the classic pattern of benign paroxysmal positional vertigo (BPPV), caused by tiny crystals drifting into the wrong part of the inner ear balance system. It is common, not dangerous, and often settles by itself, but it can be alarming and increases the risk of falls, so it is worth having assessed.

Sorting out what "dizzy" means

The first job for any clinician is to translate the word "dizzy". True vertigo — a false sense of movement or spinning — points towards the inner ear or the balance nerves and brain. Feeling faint or about to black out points more towards the heart or blood pressure. A vague unsteadiness on the feet may reflect medication, poor vision, joint problems or ageing. Asking how long each episode lasts is powerful: seconds with head movement suggests BPPV; hours with hearing changes suggests other inner-ear problems; and sudden, constant vertigo with new neurological signs raises concern about a stroke and needs urgent assessment.

The common inner-ear causes

Three inner-ear patterns account for much everyday vertigo. BPPV gives brief spinning triggered by head position and can often be fixed with a simple bedside repositioning manoeuvre performed by a trained clinician or physiotherapist. Vestibular neuritis (or labyrinthitis) causes sudden, severe, constant vertigo lasting days, often after a viral illness, sometimes with hearing change; it usually improves as the brain compensates, helped by balance exercises. Ménière's disease causes recurring attacks of vertigo lasting hours with ringing, fullness and fluctuating hearing in one ear. Recognising the pattern matters because the treatment and outlook differ for each, and because an accurate label spares people unnecessary worry and repeated tests.

When dizziness is a red flag

Most dizziness is not sinister, but some patterns need urgent action. Vertigo that comes with sudden severe headache, double vision, slurred speech, facial or limb weakness, numbness, difficulty walking or a sudden loss of hearing can signal a stroke or other serious brain problem — these are 999 emergencies. Fainting with chest pain, palpitations or breathlessness needs urgent assessment of the heart. New dizziness after a head injury, or that comes with a very stiff neck and fever, also needs prompt help. When in doubt, NHS 111 can advise on the right next step, but obvious stroke signs should never wait for a call and warrant dialling 999 straight away.

How it is assessed and managed

A clinician will ask about timing and triggers, check blood pressure lying and standing, look at eye movements, examine the ears, and test balance, coordination and the nerves of the face and limbs. Simple positional tests can confirm BPPV at the bedside. Medicines that dampen vertigo may help brief symptoms but are generally used sparingly and short-term, because long use can slow the brain's natural recovery. For many inner-ear causes, tailored balance (vestibular) rehabilitation exercises are the most effective treatment. Reviewing medicines, treating dehydration and reducing fall hazards at home all help older people who feel unsteady, and a clear explanation of the likely cause is itself reassuring.