What Are the Causes of Vertigo — and How Is It Diagnosed?

Vertigo is more than “just feeling dizzy.” It’s the unsettling, often terrifying sensation that you or the world around you is spinning, tilting, or moving when nothing is. While a single dizzy spell can be harmless, repeated or severe vertigo disrupts life—making walking, driving, or even getting out of bed stressful. In this post Dr. Chirag Gupta breaks down the common causes of vertigo, how clinicians figure out what’s behind it, and what you can expect during a diagnostic work-up.

A quick map: peripheral vs central vertigo

Doctors usually separate vertigo into two broad groups:

• Peripheral vertigo: caused by problems in the inner ear or vestibular nerve (the system that senses motion and head position). These causes are the most common and often treatable.
   
• Central vertigo: caused by issues in the brain — for example, in the brainstem or cerebellum. These are less common but may signal a more serious problem.
   

Understanding which side of that divide a patient falls on is the first step toward the right test and treatment.

Common causes — explained simply

1. Benign paroxysmal positional vertigo (BPPV)

BPPV is the most frequently diagnosed cause of true vertigo. Tiny calcium crystals (called otoconia) that usually sit in the utricle of the inner ear can become dislodged and shift into the semicircular canals. When you change head position, those crystals move and send incorrect signals to your brain — and you experience brief, intense spinning. BPPV is classically triggered by rolling over in bed, sitting up, or looking upward. 

2. Vestibular neuritis / labyrinthitis

These conditions are inflammatory — often post-viral — problems affecting the vestibular nerve (vestibular neuritis) or both the nerve and hearing apparatus (labyrinthitis). They typically cause a sudden, prolonged attack of vertigo with nausea and imbalance. Recovery can take days to weeks, and some people benefit from vestibular rehabilitation exercises. 

3. Menière’s disease

Menière’s involves abnormal fluid dynamics in the inner ear and is characterized by episodes of vertigo combined with hearing loss, a feeling of fullness in the ear, and tinnitus (ringing). Attacks can last hours and may recur over months or years. 

4. Vestibular migraine

Migraine-related vertigo can mimic other causes and may occur with or without headache. Patients may describe a spinning sensation, visual sensitivity, or imbalance that comes and goes. A history of migraine helps clue clinicians in.

5. Less common or more serious causes

Stroke or transient ischemic attacks (especially involving brainstem/cerebellum), brain tumors, head trauma, certain medications, and systemic conditions (like low blood pressure or dehydration) can also present with dizziness or vertigo. It’s crucial to distinguish these because they require different, often urgent, care. 

How doctors diagnose vertigo — what to expect

Diagnosing vertigo is mostly about careful history and physical exam. The pattern of symptoms (when they start, how long they last, what triggers them) gives large clues.

1. The history — the most powerful test

Your clinician will ask questions like: Is the sensation spinning or lightheadedness? How long does an episode last (seconds, minutes, hours)? What brings it on (head movements, standing up, loud sounds)? Are you nauseated or vomiting? Any hearing changes or headache? Those answers often point strongly toward BPPV, Menière’s, vestibular neuritis, or central causes. 

2. Bedside maneuvers and eye exams

• Dix-Hallpike maneuver: a classic test for BPPV. The clinician moves you quickly from sitting to lying while observing your eyes for a characteristic, brief, rotatory nystagmus (involuntary eye movement). A positive test supports BPPV.
   
• Head impulse test, observation of spontaneous or gaze-evoked nystagmus, and balance testing help distinguish peripheral from central causes.
   

3. Instrumented vestibular testing (if needed)

If the bedside exam is inconclusive, tests such as videonystagmography (VNG) or electronystagmography (ENG), rotary chair testing, posturography, or vestibular-evoked myogenic potentials (VEMPs) can quantify inner-ear function. These are usually performed by specialists. 

4. Imaging and labs

If a central cause is suspected — for instance if the pattern is atypical, there are neurological deficits, or the history suggests stroke — the doctor may order MRI or CT scans. Blood tests or ECGs may be used to check for systemic causes. 

Red flags — when to seek immediate care

Seek urgent evaluation if vertigo comes on suddenly with weakness, slurred speech, double vision, difficulty walking, or fainting — these can be signs of a stroke. Persistent high fever, severe headache, or progressive hearing loss also merit prompt assessment. 

A patient-friendly takeaway

Vertigo isn’t a single disease — it’s a symptom with many possible causes. The good news: the most common causes (like BPPV and many cases of vestibular neuritis) are diagnosable at the bedside and often respond well to maneuvers, rehabilitation, or short-term symptom control. If you or a loved one are experiencing spinning sensations, note the exact pattern and triggers, get a timely evaluation, and tell your clinician about any hearing loss, headaches, or neurological symptoms.

If you’d like, my team and I can prepare a simple one-page checklist you can bring to your appointment (what to note about episodes, medication list, and a symptom timeline) — it often makes the doctor’s job easier and speeds diagnosis.
— Dr. Chirag Gupta