Home / Conditions / Dizziness and vertigo
Four quite different sensations get called dizziness, and they have different causes. Working out which one you have is most of the diagnosis — and it decides whether you need an ear specialist, a heart check, or a scan of the brain.
Dizziness with any of the following can mean a stroke affecting the balance centres at the back of the brain. It needs assessing today.
A stroke at the back of the brain can produce vertigo on its own, with little else to show for it. That is precisely why sudden vertigo with any neurological symptom is treated as a stroke until proven otherwise.
Call 995This is the question a specialist asks first, because the four types point in different directions. Describing yours accurately is worth more than any test.
"The room is spinning"
A sensation of movement — of yourself or your surroundings — when you are still. Often worse on turning the head or rolling over in bed.
Usually the inner ear or the balance nerve. Occasionally the brainstem or cerebellum, which is the group that matters clinically.
"I feel like I might faint"
Feeling faint or floaty without the world moving. Often on standing up, and often improving on sitting or lying down.
Commonly blood pressure, dehydration, blood sugar, anaemia or medication. Usually not a neurological problem.
"I'm unsteady on my feet"
Imbalance while walking or standing, without spinning and without feeling faint. Worse in the dark or on uneven ground.
The nervous system, the sensation in the feet, vision, or muscle weakness — often several together, particularly with age.
"I'm about to pass out"
Feeling close to fainting, usually with sweating, nausea, pallor or tunnel vision.
Usually circulatory — blood pressure or heart rhythm. This one points towards a cardiac assessment rather than a neurological one.
For vertigo specifically, the practical question is whether the problem is in the inner ear or in the brain. The inner ear accounts for the large majority. These are the patterns an examination looks for — not a checklist to apply yourself.
| Inner ear | Brain | |
|---|---|---|
| Onset | Often triggered by head position | Often abrupt, unrelated to position |
| Duration | Seconds to minutes, in episodes | Continuous, persisting |
| Hearing | May be affected, with tinnitus or fullness | Usually unaffected |
| Walking | Unsteady, but able to walk | Often unable to stand or walk unaided |
| Other symptoms | Nausea and vomiting | Double vision, slurred speech, weakness, numbness |
The exceptions are what make this a clinical judgement rather than a table. A stroke in the cerebellum can look convincingly like an inner ear problem, and the distinction rests on specific eye movement findings that are only apparent on examination.
Most dizziness is not neurosurgical, and it would be misleading to imply otherwise. Inner ear causes are usually managed by an ENT specialist or a vestibular physiotherapist, and both do it well.
What a neurosurgical assessment contributes is the other half: excluding or identifying the causes inside the skull. That matters when:
If your dizziness turns out to be inner ear, you will be told so and pointed to the right person. That is a useful outcome, not a wasted appointment.
The history does most of the work — what the sensation actually is, how long episodes last, what brings them on, what else happens at the same time. Then examination:
Imaging is used where a central cause is suspected rather than as a first step:
Treatment follows the cause, which is why the diagnosis matters more here than in most conditions.
BPPV often responds to a repositioning manoeuvre, sometimes in a single session. Vestibular neuritis settles with time and vestibular rehabilitation — a specific exercise programme that retrains balance, and which works considerably better than avoiding movement.
Treated as migraine rather than as a balance disorder — preventive medication, trigger management, and where those are not enough, the interventional options used for migraine. People are often relieved to learn this is what they have, having been told nothing is wrong.
An acoustic neuroma, a stroke, or pressure within the skull is treated in its own right. Some acoustic neuromas are monitored rather than treated, on the same reasoning as small unruptured aneurysms.
Vertigo is one kind of dizziness — the spinning kind. Dizziness is the umbrella term, and also covers lightheadedness, unsteadiness and feeling close to fainting. They point to different causes, which is why the distinction is the first thing asked about.
If the vertigo is brief, triggered by head position, and there are no other symptoms, ENT or a vestibular physiotherapist is usually the right starting point. If it came on suddenly, is not settling, involves other neurological symptoms, or follows a head injury, a neurological assessment comes first.
Problems in the upper neck can contribute to unsteadiness, and neck injury often accompanies the head injuries that cause dizziness. It is rarely the sole explanation, so it is worth assessing rather than assuming.
A normal scan excludes the structural causes; it does not mean nothing is wrong. Vestibular migraine, BPPV and vestibular neuritis all produce severe symptoms with entirely normal imaging. The next step is examination rather than more scans.
Rarely, and almost never on its own. Acoustic neuroma is the one most associated with balance symptoms, and it usually comes with gradual hearing loss on one side rather than dizziness alone.
No. You can book directly. Bring any scans and hearing test results, and a note of what your episodes are actually like and how long they last.
Migraine · Vestibular migraine · Headaches (all types) · Concussion · Stroke · Brain aneurysm · Neck pain
Bring a description of what the sensation is actually like. That, more than any scan, is what leads to the diagnosis.
