Vertigo and dizziness: causes, BPPV, and when to see a GP

What vertigo is

Vertigo is the illusion that you or the world around you is spinning or moving when nothing is actually moving. It is a symptom — not a diagnosis — and it points the doctor toward the body’s balance pathways: the inner ear, the nerve that connects the inner ear to the brain, and the brain regions (the brainstem and cerebellum) that integrate balance information with vision and body-position sense.

In Australian general practice, sorting vertigo means answering one question first: is the cause peripheral (the inner ear or its nerve — usually not dangerous, often very treatable) or central (the brain — sometimes a stroke or other serious problem that needs urgent assessment)? Most vertigo is peripheral. But getting the small minority of central causes right matters, because a posterior-circulation stroke can present with vertigo and very little else in its first hours.

This article walks through the common causes of vertigo, how a GP works out which one is present, what treatment looks like, and the red flags that mean it cannot wait until morning. For the consumer-facing Australian primary-source overview, see HealthDirect and Better Health Channel.

Orienting: peripheral versus central

The most useful modern approach, endorsed by the Barany Society and reflected in RACGP and Therapeutic Guidelines, focuses less on what the dizziness “feels like” — patients describe the same symptom in different ways from day to day — and more on:

• Timing. Is the vertigo continuous over days, or are there discrete episodes lasting seconds, minutes, or hours?
• Triggers. Is each episode brought on by a specific head position or by standing up, or does it happen out of the blue?
• Examination findings. What do the eyes, the gait, and the cranial nerves show?

That framework collapses the differential into a few well-defined patterns, each pointing to a likely cause and a sensible next step.

The common peripheral causes

Benign paroxysmal positional vertigo (BPPV)

BPPV is by far the commonest cause of vertigo in Australian general practice. Tiny calcium-carbonate crystals (otoconia) that normally sit on a sensor inside the inner ear become dislodged and tumble into one of the semicircular canals. Head movement now sends them sliding, briefly tricking the brain into perceiving rotation.

Classic features:

• Short bursts of intense spinning, usually 10–60 seconds long.
• Triggered by rolling over in bed, looking up to a high shelf, bending down to tie a shoelace, or lying flat at the hairdresser.
• No hearing loss, no ringing, no headache, no neurological symptoms between episodes.

Diagnosis is bedside: the Dix-Hallpike manoeuvre. The patient sits on the examination couch, the GP turns the head 45 degrees to one side, then guides the patient quickly back to a supine position with the head hanging just below the edge of the couch. If posterior-canal BPPV is present, a characteristic upbeat-torsional flicker of the eyes (nystagmus) starts after a 5–10 second pause, lasts under a minute, and gets less intense with repeated testing.

Treatment is the Epley manoeuvre — a sequence of head and body positions that uses gravity to roll the crystals out of the affected canal and back into a part of the inner ear where they no longer cause symptoms. The Cochrane review found about 80% of patients are cured in a single session. Recurrence happens in roughly half within five years, and recurrent BPPV is sometimes linked to vitamin D deficiency — worth checking with bloods if BPPV keeps coming back.

Vestibular neuritis

Vestibular neuritis is sudden severe vertigo, lasting continuously for days, caused by inflammation of the vestibular nerve (often viral). It is the second most common peripheral cause after BPPV.

Typical features:

• Vertigo starts abruptly and persists hour after hour for several days, settling gradually over one to two weeks.
• Nausea and vomiting are often severe.
• No hearing loss (which distinguishes it from labyrinthitis, where hearing is also affected).
• Walking is unsteady but possible — the patient can typically stand with support, unlike central causes where balance often collapses completely.

Treatment is supportive: anti-nausea medicine for the first 48–72 hours only (longer use slows the brain’s compensation), early walking and head movement once acute nausea settles, and referral to a vestibular physiotherapist for graded rehabilitation. Steroids have been tried but the Cochrane review found the evidence too thin to support routine use.

Meniere’s disease

Meniere’s disease is a chronic inner-ear condition causing episodes of vertigo that last 20 minutes to several hours, accompanied by:

• Hearing loss, often fluctuating in early disease and becoming permanent over years.
• Ringing in the ear (tinnitus) on the affected side.
• A sense of fullness or pressure in the ear before or during an attack.

It tends to come in clusters of attacks with quiet months in between. The cause is thought to involve a build-up of fluid (endolymph) inside the inner ear. Treatment is layered:

• Salt restriction below about 1500 mg sodium per day.
• A low-dose diuretic.
• Trigger moderation: caffeine, alcohol, and dehydration.
• Betahistine — PBS-authority listed specifically for Meniere’s, though the evidence on whether it actually works is mixed.

ENT referral is usual to confirm the diagnosis and to consider second-line treatments such as intratympanic steroid injections if attacks remain frequent and disabling. Australian Prescriber and Therapeutic Guidelines cover the AU prescribing detail.

Vestibular migraine

Vestibular migraine is now recognised as one of the commonest causes of recurrent spontaneous vertigo. The episodes last minutes to hours, often without the classic headache that other migraines bring. Light sensitivity, sound sensitivity, and a personal or family history of migraine point toward it. Treatment overlaps with general migraine prevention — lifestyle triggers, magnesium, and where needed prophylactic medicines such as propranolol, amitriptyline, topiramate, or candesartan, prescribed per AMH and Therapeutic Guidelines.

Central causes — what we must not miss

Central vertigo arises from the brainstem or the cerebellum. The most important cause to detect is a posterior-circulation stroke — particularly a cerebellar stroke, which can present with vertigo and very little else in its first hours, and which is often missed because the rest of the neurological examination seems normal.

Other central causes include:

• Vertebral or carotid artery dissection — a tear in the lining of a neck artery, sometimes after neck trauma, vigorous neck manipulation, or even just sustained extension. The hallmark is vertigo with new severe neck pain or head pain.
• Multiple sclerosis — a plaque in the brainstem can cause vertigo as an isolated symptom, particularly in younger adults.
• Cerebellar haemorrhage — sudden severe headache, vomiting, ataxia, and progressive drowsiness.
• Vestibular schwannoma — a slow-growing benign tumour of the vestibular nerve, presenting with gradually progressive one-sided hearing loss and mild unsteadiness, not acute vertigo.

How the GP works out which one it is

The history

• When did it start?
• How long does each episode last?
• What triggers it?
• Any associated symptoms: headache, neck pain, hearing change, ringing in the ear, weakness, numbness, slurred speech, double vision, loss of consciousness?
• Vascular risk: age over 60, blood pressure, diabetes, smoking, atrial fibrillation, previous stroke or TIA, the contraceptive pill, recent neck trauma or manipulation?
• Medicines that can affect balance: blood pressure tablets, sedatives, antiepileptics, some antibiotics.
• Alcohol and recreational drug use.

The examination

• Blood pressure lying and standing.
• Hearing screen.
• Eye movements at rest and with gaze tested in different directions.
• Coordination tests: finger to nose, heel down the shin, walking heel-to-toe.
• A careful gait assessment — central causes often produce truncal ataxia (the body sways and falls) that is much worse than the vertigo itself would explain.
• The Dix-Hallpike manoeuvre if positional BPPV is suspected.
• The HINTS examination if there is ongoing continuous vertigo with spontaneous eye movement: Head Impulse test, Nystagmus pattern, Test of Skew. In expert hands, HINTS performs better than an early MRI for detecting posterior-circulation stroke in the right scenario, per Kattah et al. Important caveat: HINTS is only valid in the specific setting of ongoing continuous vertigo. It is not used for positional BPPV or for someone whose vertigo has already settled.

Investigations

Most vertigo does not need scans. Investigations are reserved for specific situations:

• Audiometry if there is hearing loss or suspected Meniere’s disease or vestibular schwannoma.
• MRI brain if a central cause is suspected, if there is asymmetric hearing loss, or if vertigo persists without a clear diagnosis. CT brain is not reliable for ruling out a stroke in the back of the brain — it misses most of them in the first 24 hours.
• ECG and lying-standing blood pressure if presyncope features dominate.
• Bloods — selective: thyroid function, vitamin B12, vitamin D (especially in recurrent BPPV), iron studies, glucose.

Treatment in summary

Cause	Treatment
BPPV	Epley manoeuvre in clinic; review in one week; consider vitamin D check if recurrent
Vestibular neuritis	Anti-nausea medicine for 48–72 hours only; early head movement; vestibular physiotherapy
Meniere’s disease	Low-salt diet, diuretic, lifestyle triggers, betahistine; ENT referral
Vestibular migraine	Migraine trigger management; prophylactic medicines per AMH
Central cause	Emergency department transfer for MRI and stroke pathway

A few principles cut across all peripheral causes:

• Anti-vertigo medicines for the first 72 hours only. Drugs such as prochlorperazine reduce acute symptoms but slow the brain’s natural compensation if used longer. They also increase falls risk in older adults.
• Early movement, not bed rest. The brain rewires faster when the balance system is challenged.
• Vestibular rehabilitation by a trained physiotherapist drives recovery in persistent peripheral dysfunction — the Cochrane review supports moderate benefit. Australian vestibular physiotherapists can be accessed via private referral or, where chronic dizziness affects function long-term, through a GP Chronic Condition Management Plan (GPCCMP).

When to see your GP

Book a GP appointment if:

• Vertigo is recurrent — episodes of spinning triggered by head movement.
• Vertigo settled but balance still feels off days or weeks later.
• There is one-sided hearing change, ringing in the ear, or a sense of ear fullness.
• Past episodes of vertigo have been diagnosed as migraine or Meniere’s and the pattern is changing.
• Medicines you are on may be contributing (blood pressure medicines, sedatives, antiepileptics).

Red flags — go to hospital

Call an ambulance or go straight to an emergency department if vertigo comes with any of the following:

• A new severe headache or new neck pain.
• Difficulty walking that seems much worse than the spinning would explain.
• Double vision, slurred speech, numbness or weakness in the face, arm, or leg.
• Sudden new hearing loss in one ear.
• A recent neck injury, whiplash, or vigorous neck manipulation before the vertigo started.
• Sudden loss of consciousness or near-fainting.
• Chest pain or palpitations.

These features can signal a stroke in the back of the brain, a tear in a neck artery, or a circulation problem affecting the inner ear — all of which are time-critical.

Driving and vertigo

Austroads Assessing Fitness to Drive 2022 sets the national driving standards. Recurrent unprovoked vertigo, untreated Meniere’s disease, and persistent balance dysfunction can require a conditional licence assessment. Anyone in this situation should talk to their GP, who can document the advice and where needed help arrange the formal medical review with the licensing authority.

What this article is and is not

This is general health information drawn from current Australian clinical guidelines — RACGP, Therapeutic Guidelines, Australian Prescriber, and the Australian Medicines Handbook — alongside international evidence such as the Barany Society classification, Kattah HINTS study, and Cochrane reviews on Epley and vestibular rehabilitation. It is not personal medical advice and does not create a doctor–patient relationship. Decisions about diagnosis, investigations, and treatment are made with your own GP and any specialists involved in your care.

For Australian consumer-friendly summaries: HealthDirect — Vertigo and dizziness · Better Health Channel — Dizziness and vertigo.

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Sources cited

1. RACGP — AJGP: Vertigo in general practice
2. Therapeutic Guidelines — Neurology and ENT: dizziness and vertigo
3. Australian Prescriber — Dealing with dizziness
4. Australian Medicines Handbook
5. HealthDirect — Vertigo and dizziness
6. Better Health Channel — Dizziness and vertigo
7. Barany Society — International Classification of Vestibular Disorders
8. Kattah et al — Stroke 2009: HINTS for vestibular neuritis vs stroke
9. Hilton and Pinder — Cochrane 2014: Epley for posterior canal BPPV
10. Hillier and McDonnell — Cochrane 2015: vestibular rehabilitation
11. Austroads — Assessing Fitness to Drive 2022