Vestibular Neurology

Overview

Dizziness can mean spinning, rocking, imbalance, faintness, visual disorientation, or a vague “off” feeling. Vertigo is the illusion that you or the environment is moving. The word a patient chooses is less useful than the timing, triggers, associated symptoms, and examination.

The central safety question is whether symptoms arise from a benign vestibular disorder or a dangerous cause such as stroke, hemorrhage, cardiac arrhythmia, severe blood-pressure change, or medication toxicity.

The most important messages are:

• Use a timing-and-triggers approach. Brief position-triggered episodes, spontaneous recurrent attacks, and continuous acute vestibular syndrome have different differentials and tests.¹
• HINTS is not a general home or office dizziness test. It is intended for a patient with acute continuous vertigo and spontaneous nystagmus and should be performed by a clinician trained in the examination.¹
• CT is insensitive for many posterior-circulation strokes. MRI can also be falsely negative early, so bedside findings and evolution remain important.¹
• BPPV is treated with repositioning, not chronic vestibular suppressants. The Epley maneuver is effective for posterior-canal BPPV.²
• Vestibular migraine and PPPD are common, real disorders. They can coexist with inner-ear disease or anxiety and are not diagnoses of exclusion made solely because imaging is normal.³⁴⁵

Evidence cutoff: This article reflects publicly available evidence through August 9, 2026. Sudden dizziness with new neurological symptoms, inability to walk, severe headache, chest pain, or fainting requires emergency evaluation.

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The Modern Timing-and-Triggers Framework

A patient may have more than one pattern. For example, BPPV can trigger PPPD, and vestibular migraine can coexist with Ménière disease.

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Emergency Red Flags

Call 911 for dizziness or vertigo with:

• New weakness, numbness, facial droop, speech difficulty, double vision, or vision loss
• New inability to stand or walk
• Severe new headache or neck pain
• Loss of consciousness, chest pain, sustained palpitations, or shortness of breath
• Persistent vomiting with dehydration
• Sudden hearing loss with neurological symptoms
• Recent head/neck trauma, especially with focal symptoms

Posterior-circulation strokes may present with vertigo, imbalance, nausea, and subtle eye-movement findings without obvious one-sided weakness.

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The HINTS Examination

HINTS combines the head-impulse test, nystagmus pattern, and test of skew. In trained hands, it can help distinguish stroke from vestibular neuritis in the acute vestibular syndrome: continuous vertigo or dizziness, spontaneous nystagmus, nausea/vomiting, head-motion intolerance, and gait unsteadiness.¹

It should not be used for brief positional attacks, resolved symptoms, patients without spontaneous nystagmus, or as a self-test. Misapplication or poor technique can be falsely reassuring. GRACE-3 specifically recommends training before clinicians rely on it.¹

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Common Causes

Benign paroxysmal positional vertigo

BPPV causes brief spinning triggered by a specific head movement—commonly rolling in bed, lying back, looking up, or bending. Displaced inner-ear crystals provoke a characteristic nystagmus during Dix–Hallpike or roll testing. A canal-specific repositioning maneuver, such as the Epley maneuver for posterior-canal BPPV, is first-line.²

Routine CT/MRI and long-term meclizine are discouraged for typical BPPV. Persistent symptoms after a correct maneuver may reflect the wrong canal, incomplete repositioning, residual imbalance, vestibular migraine, or another diagnosis.

Vestibular migraine

Vestibular migraine causes recurrent vestibular symptoms lasting 5 minutes to 72 hours in a person with migraine history, with migraine features during at least half of episodes under the consensus criteria. Head pain may be absent. Motion sensitivity, visual vertigo, nausea, light/sound sensitivity, and aura can occur.³

Treatment uses migraine principles: regular sleep and meals, trigger management, acute therapy when appropriate, preventive medication for frequent disability, and vestibular rehabilitation for persistent motion sensitivity.

Vestibular neuritis and labyrinthitis

Vestibular neuritis causes acute continuous vertigo from unilateral vestibular dysfunction without hearing loss. Labyrinthitis includes cochlear involvement, such as hearing loss. Because stroke can look similar, acute assessment is essential. Vestibular suppressants may help severe symptoms briefly but should usually be tapered after the first few days so central compensation and rehabilitation can proceed.

Ménière disease

Typical episodes last 20 minutes to 12 hours and occur with fluctuating sensorineural hearing loss, tinnitus, or ear fullness. Audiometry is important. Management may include sodium moderation, selected medication, vestibular rehabilitation between attacks, and ENT/neurotology procedures for refractory disease.

Persistent postural-perceptual dizziness

PPPD causes dizziness, unsteadiness, or non-spinning vertigo on most days for at least three months, worsened by upright posture, movement, and complex or moving visual scenes. It is a functional vestibular disorder involving persistent maladaptation—not fabricated symptoms.⁴⁵

Treatment may combine education, vestibular rehabilitation with graded visual-motion exposure, cognitive behavioral therapy, and an SSRI or SNRI in selected patients. Coexisting migraine, BPPV, autonomic disease, and anxiety should also be treated.

Orthostatic and cardiovascular causes

Lightheadedness after standing may reflect dehydration, medication, orthostatic hypotension, POTS, arrhythmia, anemia, or cardiac disease. Orthostatic blood pressure/heart rate and cardiac evaluation can be more useful than vestibular imaging in the right pattern.

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Testing

• Bedside examination: eye movements, nystagmus, gait, coordination, hearing, cranial nerves, strength, sensation, orthostatic vitals, and positional testing
• Audiometry: important with hearing loss, tinnitus, or suspected Ménière disease
• MRI: selected for stroke, tumor, demyelination, or atypical/progressive patterns
• Vestibular testing: video head impulse, calorics, vestibular-evoked myogenic potentials, and posturography for specific questions
• Cardiac/autonomic testing: ECG, monitoring, tilt-table, or laboratory evaluation according to symptoms

Testing should answer a defined question. A normal MRI does not rule out vestibular migraine, PPPD, BPPV, orthostatic intolerance, or an early small posterior stroke.

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Treatment Principles

• Use the right maneuver for BPPV.
• Keep vestibular suppressants short-term. Prolonged use can worsen sedation, falls, and compensation.
• Begin vestibular rehabilitation when appropriate. Exercises are diagnosis-specific and should not be indiscriminate.
• Treat migraine biology when present.
• Address vision, neuropathy, medication burden, hearing, and fall risk.
• Avoid driving, heights, or hazardous machinery while sudden attacks remain uncontrolled.

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A Practical Framework

1. Describe timing and triggers rather than only “dizziness.”
2. Screen for stroke and cardiac emergencies.
3. Use the correct bedside test for the syndrome.
4. Limit imaging and medication to a specific purpose.
5. Treat coexisting vestibular, migraine, autonomic, and functional mechanisms.

Bottom line: dizziness is not one disease. Accurate timing, triggers, eye findings, gait, hearing, and neurological examination usually guide care more effectively than the symptom label alone.

At Los Altos Neurology, evaluation is tailored to acute, episodic, positional, or chronic patterns and may include migraine treatment, vestibular rehabilitation, autonomic assessment, imaging, and referral to ENT or neurotology.

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Already had an MRI or CT for dizziness? Our imaging review service goes through the actual images with you — not just the report.

References

1. Society for Academic Emergency Medicine. Evidence-based guideline. 2023. GRACE-3: Acute dizziness and vertigo in the emergency department.
2. Bhattacharyya N, Gubbels SP, Schwartz SR, et al. Otolaryngol Head Neck Surg. 2017;156:S1-S47. Clinical practice guideline: Benign paroxysmal positional vertigo.
3. Lempert T, Olesen J, Furman J, et al. J Vestib Res. 2022;32:1-6. Vestibular migraine diagnostic criteria: Bárány Society and IHS update.
4. Staab JP, Eckhardt-Henn A, Horii A, et al. J Vestib Res. 2017;27:191-208. Diagnostic criteria for persistent postural-perceptual dizziness.
5. Özdemir HN, Charlton J, Cortese E, et al. Eur J Neurol. 2026;33:e70494. Persistent postural-perceptual dizziness: practical approach.

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