Vertigo is the sensation of spinning or whirling, where a person feels as though they are moving or their surroundings are moving when neither is true. This symptom is distinct from general lightheadedness or feeling faint and signifies an issue within the balance system. Since vertigo is a symptom, not a diagnosis, its cause can range from a benign inner ear disturbance to a problem originating in the brain.
Starting the Diagnostic Journey
For most people experiencing a new episode of vertigo, the first point of contact is the Primary Care Physician (PCP), General Practitioner, or Internist. The PCP’s initial function is triage, determining the urgency and potential origin of the symptom by differentiating true vertigo from other types of dizziness, such as lightheadedness (presyncope) or unsteadiness (disequilibrium).
The evaluation includes a patient history regarding the timing, duration, and triggers of the spinning sensation. A physical examination focuses on neurological and balance checks, including observing the patient’s gait and coordination. The physician may perform the Dix-Hallpike maneuver, which helps diagnose Benign Paroxysmal Positional Vertigo (BPPV) by provoking a temporary eye movement called nystagmus.
This initial assessment is designed to rule out common, non-vestibular causes of dizziness, such as medication side effects, dehydration, or blood pressure fluctuations. If the PCP suspects a peripheral cause (inner ear) that is not BPPV, or if the symptoms are complex or suggest a central origin, they will refer the patient to a medical specialist for definitive diagnosis and treatment.
Specialists Focused on Inner Ear and Brain
The two main medical specialties that treat the underlying causes of vertigo are Otolaryngologists and Neurologists, each focusing on different parts of the balance system. Otolaryngologists, often called Ear, Nose, and Throat (ENT) doctors, or Neurotologists, primarily address peripheral vertigo. This type of vertigo originates in the inner ear’s vestibular labyrinth or the vestibular nerve.
They manage conditions like Meniere’s disease, labyrinthitis, and Benign Paroxysmal Positional Vertigo (BPPV). To diagnose these conditions, they often use Videonystagmography (VNG), which uses infrared cameras to record eye movements during various head positions. For BPPV, the ENT or Neurotologist performs the Epley maneuver, a sequence of rotations designed to move the dislodged inner ear crystals back into place.
Neurologists focus on central vertigo, which stems from issues within the brain or brainstem. Conditions such as stroke, multiple sclerosis, or vestibular migraine fall under their expertise. Their diagnostic approach involves ordering imaging, such as Magnetic Resonance Imaging (MRI) or Computed Tomography (CT) scans, to visualize the central nervous system.
The presence of specific neurological signs, like vertical nystagmus (involuntary eye movements) or gait instability so severe that the patient cannot walk, strongly suggests a central cause. Neurologists manage these conditions medically, often utilizing preventative medications for conditions like migraine-associated vertigo.
Rehabilitation and Physical Therapy Approaches
Once a diagnosis is established, Physical Therapists specializing in Vestibular Rehabilitation Therapy (VRT) become part of the treatment plan. VRT is an exercise-based approach aimed at helping the brain compensate for inner ear deficits or central balance issues. This therapy helps patients habituate to dizzying movements, reducing the severity of symptoms over time. The therapist designs an individualized program that includes gaze stabilization exercises to improve visual focus during head movements.
Balance retraining exercises are also incorporated to enhance stability and reduce the risk of falls during daily activities. This rehabilitation process encourages the brain to rely more on vision and proprioception (sense of body position) to compensate for the faulty input from the inner ear.
Audiologists play a role, particularly in cases of inner ear-related vertigo, such as Meniere’s disease. They conduct hearing evaluations, including pure-tone audiometry, to assess for hearing loss or tinnitus, which frequently accompany vestibular disorders. Their findings provide specialists with additional diagnostic information about the extent of the inner ear involvement.
When Vertigo Requires Emergency Care
While most vertigo episodes are caused by benign inner ear problems, certain associated symptoms indicate a central cause, such as a stroke, and require emergency evaluation. These “red flag” symptoms demand a trip to the Emergency Department, bypassing the need for a specialist referral.
Acute vertigo accompanied by severe headache, double vision, or slurred speech is concerning. Other urgent signs include weakness or numbness on one side of the body, facial droop, or an inability to walk or stand without assistance. These combined symptoms suggest a possible compromise of the brainstem or cerebellum and must be assessed by an emergency physician.