Part of Dizziness and BPPV
Vertigo causes: BPPV vs vestibular migraine, Meniere's or something else
Warning signs, and when to get help
What causes vertigo?
The NHS puts inner ear problems at the top of its list and calls them the most common causes of vertigo. It names four: BPPV, labyrinthitis, vestibular neuritis and Meniere's disease. Migraine and certain medicines follow. Then comes the entry most comparison pages leave off, and it is the honest one: sometimes the cause is unknown.
BPPV, which stands for benign paroxysmal positional vertigo, is short-lived spinning triggered by a change in head position, and the BPPV and dizziness program covers what it is, how it is diagnosed and how it is treated. That page is where BPPV lives on this site. This one exists for everything else on the list, and for the reader who has been given the BPPV label and does not recognize themselves in it.
A word about what vertigo means, because the list above only applies to some of what people call dizziness. Vertigo is the sense that you or the room is moving when neither is. Feeling faint, swimmy, lightheaded or weak-legged is a different symptom with a different set of causes, and sorting that out early saves a lot of wasted reading. The NHS keeps the two on separate pages for exactly that reason, and the section further down on dizziness that is not coming from the ear covers the second group.
How long a spell lasts, and what sets it off
If you take one thing from this page, take this. The two questions a clinician will come back to are how long an episode lasts, start to finish, and what you were doing in the moment it began. Those are also the two things you can record accurately without any equipment, which makes them worth more than any name you arrive with.
Here is the rough territory each condition occupies, with the source for each. Note how much they overlap.
BPPV has diagnostic criteria of its own, and they are specific about the timing. The Barany Society criteria ask for repeated attacks of positional vertigo or positional dizziness brought on by lying down or turning over, each attack lasting less than a minute, with a particular flicker of the eyes provoked by a positional test, and nothing else that accounts for it better (von Brevern and colleagues, 2015). St George's NHS puts the same thing in a sentence written for patients: the spinning is usually brief, lasting less than a minute, and it comes on when you change your head position, such as rolling over in bed, looking up or down, or tilting your head. The NHS vertigo page, speaking about vertigo of any cause, says an episode can last from seconds to several hours and that severe cases can go on for days or even months.
The other three sit in different parts of the clock. The vestibular migraine criteria set their window at 5 minutes to 72 hours (Lempert and colleagues, 2022). For Meniere's disease, the NHS says attacks start suddenly and can last anywhere between a few minutes and 24 hours, while the international criteria are tighter and ask for 20 minutes to 12 hours for a definite diagnosis, up to 24 hours for a probable one (Lopez-Escamez and colleagues, 2015). The criteria limit the window at both ends, so a spell of a few minutes does not meet either category, which is worth knowing if Meniere's is the name you have arrived with.
Labyrinthitis and vestibular neuritis sit outside all of this: one long bout, with symptoms often easing after a few days and balance usually returning within about 2 to 6 weeks, though it can take longer (NHS).
The list is the easy part. Where it breaks down matters more.
The ranges share borders, and the borders are blurrier than the numbers look. The criteria time an attack of BPPV from the head movement to the end of the spinning, and that is under a minute. What a person times at home is usually longer than that, because it includes the nausea and the wobble afterward, and the criteria themselves note that mild unsteadiness can hang on between attacks and even after successful treatment (von Brevern and colleagues, 2015). In the less common variants, where the particles are thought to be stuck to the sensor rather than floating free, the same document puts the eye movement at longer than a minute and notes that an attack lasts longer if you keep your head in the position that provoked it. None of that makes a quarter of an hour of spinning into BPPV, and all of it is why there is no timing rule on this page that you can apply to yourself, and why the next sections are about patterns across many episodes rather than about one.
And the trigger is a weaker signal than it looks. Positional spinning is characteristic of BPPV, but the vestibular migraine document describes positional nystagmus, the flicker of the eyes a clinician watches for, occurring in vestibular migraine as well, usually steadier and slower than in BPPV, and names that difference as something which helps separate the two during an acute attack (Lempert and colleagues, 2022). The distinction is made by someone watching your eyes, not by you watching the ceiling.
If your spells are worst first thing, why vertigo is worse in the morning works through why that is, and the question of where the positional trigger comes from in the first place is covered in what causes BPPV and the loose crystals.
Is it BPPV or vestibular migraine?
This is the comparison that brings most people here, and almost everything written about it is written for clinicians. Vestibular migraine has no page of its own on this site, so here is what the criteria actually say, in plain words.
The Barany Society, with the International Headache Society, requires four things for a diagnosis of vestibular migraine (Lempert and colleagues, 2022). At least 5 episodes of vestibular symptoms of moderate or severe intensity, each lasting between 5 minutes and 72 hours. A history of migraine, with or without aura, now or in the past, meeting the international headache classification. At least one migraine feature during at least half of the episodes, which means headache with at least two of its four usual traits, one-sided, pulsating, moderate to severe, or worse with ordinary physical activity, or sensitivity to light and sound together, or a visual aura. And the episodes are not better explained by another vestibular or headache diagnosis.
There is a second category for the people who nearly fit. Probable vestibular migraine takes the same episode requirement but needs only one of the other two, so either the migraine history or the migraine features during the attacks, not both (Lempert and colleagues, 2022).
Read those criteria again and notice what the deciding evidence is. It is not any single spell. It is the pattern across at least five of them, and the company the spinning keeps: headache, light and sound sensitivity, visual aura. Nobody can reconstruct that from memory six months later, which is the practical argument for writing episodes down starting today.
Aura is where this gets muddled. Dizziness turns up in the NHS list of migraine aura symptoms, alongside visual disturbance, pins and needles and difficulty speaking, and the NHS says aura should not last longer than an hour, while a migraine attack itself usually lasts between 4 hours and 3 days. So a brief dizzy patch before a headache is well-described territory, and it is not the same thing as vestibular migraine, where the vestibular symptoms are the attack. The NHS migraine pages do not use the term vestibular migraine at all, which is one reason people searching for it end up on research sites.
Then there is the hinge between this page and the program page. If BPPV has been diagnosed and treated and you are no better, that is specifically addressed in the BPPV guideline, which tells clinicians to go back and check both for BPPV that has not cleared and for another inner ear or brain cause (Bhattacharyya and colleagues, 2017). A second appointment after unsuccessful treatment is the expected next step, not a nuisance. If the spells are clearing and then returning, that is a different pattern again, and why BPPV keeps coming back covers it.
Is it Meniere's disease?
Meniere's disease is the diagnosis people fear most from this list, partly because it involves hearing and partly because the NHS is blunt that there is no cure, although it adds that symptoms can be managed with treatment.
The NHS symptom list is where to start. It gives spinning, losing your balance, ringing or buzzing in one or both ears, hearing loss, a feeling of pressure, discomfort or pain deep inside the ear, and feeling or being sick. Attacks start suddenly. Over time the hearing can gradually get worse and the ringing can become constant.
The ear symptoms are what make this one recognizable. BPPV does not affect your hearing. A spell of spinning that comes with your ear feeling full or blocked, with ringing that rises as the attack builds, and with hearing that dips and then partly recovers, is a very different story to tell. The international criteria are built around that combination: the definite category pairs episodic vertigo lasting 20 minutes to 12 hours with hearing loss in the low to middle frequencies in the affected ear, which is a hearing test result rather than a description of how your hearing feels, and fluctuating ear symptoms on that side, and the probable category allows a broader picture with episodes from 20 minutes to 24 hours (Lopez-Escamez and colleagues, 2015).
Hearing is also where Meniere's disease and vestibular migraine part company. Both can bring ringing, pressure and hearing that comes and goes, and it is the long-term pattern of hearing loss, measured on a hearing test, that separates the two (Lempert and colleagues, 2022). The FAQ at the foot of the page goes through how.
What all of that means for you is narrow. Any change in your hearing belongs at an appointment, and sudden hearing loss has its own same-day line in the warning list at the foot of this page. Do not wait to see whether it comes back. Treatment for Meniere's disease is a specialist matter and it starts with the diagnosis, so nothing on this page is a management plan for it.
Labyrinthitis and vestibular neuritis: the spell that lasts days, not seconds
These two are the reason some people reading about BPPV cannot make the timings fit at all. Their vertigo did not come in spells. It arrived one morning and stayed.
The NHS separates the pair by where the inflammation is. Labyrinthitis affects the labyrinth, the fluid-filled channels of the inner ear, while vestibular neuritis affects the vestibular nerve, which carries balance signals to the brain. Both bring dizziness or vertigo, unsteadiness, and feeling or being sick, and both can start suddenly and feel worse later in the day.
Hearing is the divider. Labyrinthitis can cause hearing loss and ringing in the ear, and vestibular neuritis does not, so if hearing is affected the NHS says the cause is labyrinthitis.
The usual trigger is a virus, a cold or flu, which is why so many people date the onset to the week after an infection. The NHS says symptoms often ease after a few days, and that balance usually comes back within about 2 to 6 weeks, although it can take longer and some people have balance problems for months or years.
That last group is where physiotherapy enters, and the NHS names it: where balance problems last many months or even years, vestibular rehabilitation is a set of exercises that can help balance, dizziness, sickness and anxiety, and it says to do them only with a specialist supervising you, for example a physiotherapist or an audiologist, and never on your own. A GP can put in the referral, and in many areas you can refer yourself directly rather than wait. The program on this site is on the BPPV and dizziness page. Start these exercises only after a doctor or vestibular physio has found the cause of your dizziness. New dizziness, or dizziness that has changed, needs checking first.
One warning belongs in this section as well as in the list at the foot of the page, because it comes straight out of this story. Vertigo arriving with vomiting, a high temperature, or feeling hot, cold or shivery is not something to manage at home as a bad bout of labyrinthitis. The NHS routes that combination to urgent advice, and it has a same-day line in the warning list below.
Can both be going on at once?
More than one of these can be true of the same person, and it is common enough that assuming otherwise causes real delays.
The clearest statement comes from the vestibular migraine document, which records that typical BPPV occurs more often in people with migraine, and says openly that the reason is unclear (Lempert and colleagues, 2022). The same source sets out how a double diagnosis is made when vestibular migraine and Meniere's disease are both in play: not by splitting the difference, but by identifying two distinct attack types, each meeting its own criteria.
The Barany criteria for persistent dizziness make the same move. They describe BPPV as something that can come before persistent dizziness or run alongside it, and say each active disorder should be identified by its own characteristic symptoms, short-lived positional vertigo being the one that marks BPPV (Staab and colleagues, 2017).
So the useful habit is to stop trying to force everything into one explanation. If you have brief spinning when you roll over in bed and also a heavy, swimmy feeling that lasts all afternoon, those may well be two separate things, and a clinician would rather hear them described separately than hear an average of the two.
Can the neck cause vertigo?
A stiff, painful neck and a spinning head often turn up in the same person, and the internet is confident about what that means. The evidence is not.
The Barany Society looked at this directly in a position paper on cervical dizziness and found the evidence for a mechanistic link between neck problems or neck pain and the illusion of self-motion to be lacking (Seemungal and colleagues, 2022). The mechanisms that get proposed, including disturbed position sense from the neck, remain theoretical. There is no validated test, and the committee specifically declined to propose even preliminary diagnostic criteria for use outside research. It treats one older theory in this area, the Barre-Lieou hypothesis, as discredited.
What the committee does accept is more useful than what it rejects. Migraine, including vestibular migraine, is the commonest cause of neck pain and vestibular symptoms appearing together. Common vestibular conditions such as BPPV can produce spinning that a head or neck movement sets off, which is how a neck gets blamed for an inner ear. And a short list of serious causes can present with both, including a tear in an artery of the neck with a stroke in the back of the brain, which is the reason the two neck pain warning lines on this page are as long and as specific as they are. The committee also notes that if there is no neck pain, or the dizziness comes on spontaneously or is purely positional, a neck explanation can be set aside.
None of that makes your neck irrelevant to how you feel. It means the neck is not where the diagnosis of your vertigo gets made. If neck pain is a real part of your problem, neck pain is the page for it, headache coming from the neck is covered on cervicogenic headache, pain running into the arm with pins and needles sits on cervical radiculopathy, and a neck hurt in a car accident belongs on whiplash.
One practical rule, and it is the reason this section exists at all. Do not let anyone thrust-manipulate or crack your neck for dizziness without being examined first. The international framework for examining the neck asks physiotherapists to assess you and check for blood vessel risk factors before any thrust technique (Rushton and colleagues, 2023). If your neck pain is new, sudden, or unlike your ordinary neck pain, read the two neck lines in the warning list below before you book anything.
Dizziness that never quite goes away
A good number of people reading this page do not have episodes at all. They have a background of unsteadiness that has been there for months, worse when they are upright, worse in a supermarket aisle, and nobody has given it a name.
That picture has a name and a set of criteria. Persistent postural-perceptual dizziness, usually shortened to PPPD, is defined by the Barany Society as dizziness, unsteadiness or non-spinning vertigo present on most days for 3 months or more, which the document puts at more than 15 days in every 30, lasting hours at a time and varying in severity through the day (Staab and colleagues, 2017). It is made worse by three things in particular: being upright, moving or being moved whichever way, and busy or moving visual surroundings.
The part that makes sense of a lot of stories is what the criteria say about how it starts. PPPD follows something else that caused vertigo, unsteadiness or a balance problem. The document lists peripheral and central vestibular disorders, vestibular migraine attacks, panic attacks and anxiety with prominent dizziness, concussion and whiplash, and autonomic problems among the events that precede it. It also puts rough proportions on them, drawn from published series rather than from new measurements of its own: an inner ear or brain balance disorder comes first in 25 to 30 percent of cases, a vestibular migraine attack in 15 to 20 percent, panic attacks and anxiety with prominent dizziness in 15 percent each, concussion or a whiplash injury in 10 to 15 percent, and an autonomic problem in about 7 percent (Staab and colleagues, 2017). In other words a settled BPPV, a labyrinthitis that cleared, or a migraine attack can leave this behind, which is why a reader can be told their original problem is fixed and still be unwell.
The document is firm on two points, and both get misreported anyway. The criteria require significant distress or difficulty with daily life, and they require that the symptoms are not better explained by another condition, so it is diagnosed on its own features rather than by eliminating everything else. And although anxiety can precede it and can go along with it, the document states that PPPD is not a psychiatric condition.
If anxiety is the word you have been given for your dizziness, vertigo, stress and anxiety goes through what the evidence supports and what it does not. If exhaustion and a foggy head are the dominant problem, vertigo, tiredness and brain fog covers that.
When dizziness is not coming from the ear at all
Everything above assumes the problem is in the balance system. Often it is not, and this is the section to read if your symptom is feeling faint or swimmy rather than the room turning.
The NHS splits this group in two. Where you are already unwell with something else, it names an ear infection, migraine, dehydration or heat exhaustion, stress or anxiety, low blood sugar because of diabetes, iron deficiency anemia, and motion sickness. Where there is no obvious reason, it pairs the symptom with the likely cause: dizziness on standing or sitting up suddenly points to a sudden drop in blood pressure, feeling off balance with some hearing loss or ringing in the ears points to the inner ear, feeling off balance or as though things are spinning with sickness and sometimes after a cold or flu points to labyrinthitis, and dizziness that started after a new prescription points at the medicine.
Tiredness runs alongside several of those, and it has its own line in the warning list at the foot of this page. Tiredness that has gone on for weeks, that you cannot account for, or that is getting in the way of your daily life is a question for your doctor in its own right, because it is not an ear symptom and the ear is not where it gets answered.
That last one deserves a sentence of its own. Medicines are a genuinely common cause and a genuinely common fix, and the fix is not yours to make. Do not stop or change a prescription because of something you read here. Take the list to your doctor or pharmacist and ask them.
Then there are the causes that are not inner ear problems and are not benign either, and they are the reason this page carries the warning list it does. A sudden loss of balance can be a stroke, and recovery from one is covered on stroke rehabilitation. Dizziness with a racing, pounding or irregular heartbeat can be a heart rhythm problem, and blacking out is its own event with its own route.
Dizziness that follows a knock to the head is common and well recognized, and it has both an emergency and a same-day line below, so read those before you decide it will settle. Ongoing unsteadiness is also part of several neurological conditions, which is why multiple sclerosis has its own program here.
Whatever the cause turns out to be, unsteadiness raises your risk of a fall while you wait to find out. Do not drive, climb ladders or use machinery while you feel dizzy (NHS dizziness), and that holds for every condition on this page, named or not. Balance and falls prevention is the page for that side of it, and the balance pages list what else is covered here.
How a clinician tells them apart, and what to take to your appointment
The most useful evidence in a vertigo assessment is the one piece you cannot collect yourself: your eyes. During a positional test the clinician watches for a particular flicker of the eyes while your head is held in a particular place, and that flicker, its direction and how long it lasts, is the most informative minute of the whole assessment. Nobody can see their own. The tests themselves, the Dix-Hallpike and the roll test, are described on the BPPV and dizziness page, along with what each one is looking for.
Alongside that, the NHS describes what a first appointment often involves. For vertigo in general, a GP asks about your symptoms and may carry out a test that moves you quickly from sitting to lying, and may refer you on to a specialist. For suspected Meniere's disease, the GP asks about symptoms, looks inside your ears and examines your head and neck, may ask you to do some balance exercises, and refers you to a specialist for further tests where the diagnosis is suspected. Hearing tests carry real weight in that process, for the reasons set out above.
There are no repositioning instructions anywhere on this page, and that is on purpose. The right maneuver depends on which ear and which canal are involved, the wrong one achieves nothing, and the spinning it provokes can put somebody on the floor. The reasoning is set out in full under why this site publishes no maneuver steps on the program page. Nothing you have read here tells you which treatment you need, and it is not meant to.
What you can bring is the history, and this is the part worth ten minutes of preparation. For each episode you can remember, and for every new one from now on, note:
- The date and the time of day.
- What you were doing in the exact moment it started, and in particular whether your head had just moved.
- How long it went on, from the start to the point where you felt normal again.
- Whether the room spun, or you felt faint, or you simply felt unsteady.
- Anything your ears did, so ringing, fullness, pressure or muffled hearing, and which ear.
- Any headache, or sensitivity to light or sound, before, during or after.
- How many episodes in total, and over how many weeks or months.
- Any medicine you started in that period, and any knock to the head or neck injury, however minor it seemed.
The program page asks for one more thing: which movement sets the spinning off, and which side you roll onto when it happens, because that is what the positional tests are built from. Take both lists with you. An accurate account of five episodes is worth considerably more at an appointment than a name you found online, including the one you found here.
When vertigo needs emergency help
A name for your spells can wait for the appointment. This section cannot. Dizziness is one of the symptoms through which genuinely dangerous things first announce themselves, and they seldom announce themselves as dangerous.
Call emergency services straight away for any sign of a stroke, even if it goes away: sudden dizziness with unsteadiness or falling over, a face that droops on one side, an arm you cannot lift or keep up, slurred or muddled speech, weakness or numbness on one side of your body or face, sudden blurred vision, double vision or loss of sight, trouble swallowing, a sudden severe headache, or a sudden fall where your legs give way but you do not black out (a drop attack).
The NHS puts the same message in its own words on the vertigo page, listing double vision or loss of vision, hearing loss, difficulty speaking, and weakness, numbness or tingling in an arm or leg as reasons to call for an ambulance or get to an emergency department when they come with vertigo. The Meniere's page adds a drooping face, being unable to lift both arms, difficulty speaking, sudden vision problems in one eye and feeling very off balance to that list, naming them as possible signs of a stroke. Both of those appear in the warning list below in our own fuller form.
One line matters more than any other on this page, because every reader here has already decided their problem is positional. Same day: dizziness or spinning that has been there all the time for a day or more, rather than coming in short spells when you move your head, without any of the emergency signs above. Get medical advice the same day. If you cannot stand or walk steadily, call emergency services.
And one line is the route out of the uncertainty this whole page is about. Within a few days: short spells of spinning when you lie down, roll over in bed or look up, or dizziness that keeps coming back, without any of the signs above. See your GP or a physio within a few days so the cause can be confirmed and treated.
The full list below carries every warning sign for this subject, including new or sudden neck pain, palpitations, fainting, a knock to the head, sudden hearing loss and vertigo with a fever. It is long because the subject is, and it is sorted by how fast each line needs acting on: the emergency group comes first, then the lines for today, then the ones to book an appointment for. Read it once now, while nothing is happening, rather than during an episode.
Related exercise programs
Warning signs
Get emergency help now
- Emergency: call emergency services straight away for any sign of a stroke, even if it goes away: sudden dizziness with unsteadiness or falling over, a face that droops on one side, an arm you cannot lift or keep up, slurred or muddled speech, weakness or numbness on one side of your body or face, sudden blurred vision, double vision or loss of sight, trouble swallowing, a sudden severe headache, or a sudden fall where your legs give way but you do not black out (a drop attack).
- Emergency: vertigo or dizziness together with new hearing loss, double vision or loss of vision, trouble speaking, or weakness, numbness or tingling in an arm or leg. Call emergency services or go to an emergency department straight away.
- Emergency: dizziness with a new, severe headache, or a sudden, severe headache that feels unlike anything you have had before. Call emergency services straight away.
- Emergency: a new headache or neck pain, or both, that does not feel like ordinary neck pain. If this is your first bout, judge it by how it behaves rather than by how it compares. Either of the next two is enough on its own. One, it came on suddenly, in a single moment, even if it is not severe and even if it has eased since. Sudden onset counts on its own. Two, nothing you do changes it much: no position or rest makes a real difference, and after the first day or two it has not started to settle. It counts even if you have none of the other emergency signs above, and it matters more if it started after a neck injury or strain, even a minor one, a bout of heavy coughing, or having your neck manipulated. Go to an emergency department straight away, or call emergency services if you cannot get there safely, and do not drive yourself. Do not start these exercises, and do not have any hands-on treatment to your neck, until your neck has been checked. A tear in an artery in the neck can start as pain alone, often on one side, with nothing else to find. If you can find a position that eases it, follow the same day warning sign for this below instead.
- If chest pain, pressure or tightness does not ease quickly when you rest, spreads to your arm, neck, jaw, stomach or back, or comes with sweating, feeling sick, feeling light-headed or being short of breath, call emergency services straight away, as this can be a heart attack. If it eases quickly and none of these happen, get medical advice the same day, and do not exercise again until you have been checked.
- Emergency: a racing, pounding, fluttering or irregular heartbeat that does not settle when you rest, or that comes with dizziness, feeling faint or fainting, chest pain or shortness of breath. Call emergency services straight away. If it has already stopped, get medical advice the same day.
- Emergency: after a knock to the head, being very drowsy or finding it hard to keep your eyes open, confusion, a fit (seizure), new weakness or numbness anywhere in your body, new trouble understanding, speaking, walking or keeping your balance, new problems seeing or hearing, clear fluid coming from your ears or nose, bleeding from your ears or bruising behind them, a black eye when your eye was not hit, a dent in your head or a wound with something stuck in it, or a change in behavior. Call emergency services straight away. These can be signs of an injury to the brain.
- Emergency: after a knock to the head, you were knocked out, even for a moment, you cannot remember what happened just before or after, you have had a headache ever since, or you are being sick (vomiting). The same applies, even if you feel fine, if you take medicine that thins your blood, other than aspirin on its own, have a bleeding or clotting condition, have had brain surgery in the past, or had been drinking alcohol or taking drugs when it happened. Go to an emergency department straight away, and do not drive yourself.
- Emergency: you have just fallen and cannot get up, or you think you may have hurt your head, neck, back or hip. Stay where you are, keep warm and call emergency services, or get someone to call for you. If you got up and walked without trouble and only notice pain later, use the same-day lines in this list instead.
- Emergency: you fell and cannot remember the fall or how it happened. Go to an emergency department straight away, and do not drive yourself. You may have blacked out or hit your head without knowing it.
Get help today
- Same day: a new headache or neck pain, or both, that does not feel like ordinary neck pain, that started after a neck injury or strain, even a minor one, a bout of heavy coughing, or having your neck manipulated, but that does ease when you change position or rest. Get checked the same day before you start these exercises or have any hands-on treatment to your neck. If nothing you do changes it much any more, or it has not started to settle after a day or two, follow the emergency warning sign for this above.
- Same day: you blacked out or fainted, even for a moment. Get medical advice the same day. Call emergency services instead if the person is not breathing, cannot be woken within 1 minute, has not fully recovered or has trouble speaking or moving, has chest pain or a pounding, fluttering or irregular heartbeat, fainted while exercising or lying down, is shaking or jerking, or was badly hurt.
- Same day: dizziness, lightheadedness, blurred vision or feeling faint when you stand up that is new for you, does not pass within a minute or two, keeps happening, or has made you fall. Sit or lie down, and get medical advice the same day. This can be a drop in blood pressure on standing (postural hypotension), a type of low blood pressure, which the NHS lists among the causes of falls, and your doctor can check it. Tell them about your medicines, because some can cause it. If it does not settle within a few minutes of sitting or lying still, call emergency services. If you faint, use the fainting line above.
- Same day: sudden new dizziness, or feeling faint or unsteady, without any of the stroke signs above. Stop, sit down and get medical advice the same day. If you faint, it does not settle within a few minutes of sitting still, or you cannot stand or walk steadily, call emergency services.
- Same day: dizziness or spinning that has been there all the time for a day or more, rather than coming in short spells when you move your head, without any of the emergency signs above. Get medical advice the same day. If you cannot stand or walk steadily, call emergency services.
- Same day: after a fall, you are in pain, have hurt yourself or feel unwell, or you were on the floor for an hour or more, without any of the emergency signs above. Get medical advice the same day, even if you managed to get up.
- Same day: you feel dizzy after a knock to the head, without any of the emergency signs above. Get medical advice the same day.
- Same day: vertigo with being sick or feeling very sick, a very high temperature, or feeling hot, cold or shivery, without any of the emergency signs above. Get medical advice the same day.
- Same day: you are more short of breath than usual, or short of breath while you are resting or lying down, without any of the emergency signs above. Get medical advice the same day. Call emergency services if you have severe difficulty breathing, are gasping, choking or cannot get your words out, or your lips or skin turn very pale, blue or gray. Breathlessness is not a symptom of the inner ear: the NHS names heart failure and lung conditions among the causes, and it is easy to put down to being run down.
- Same day: sudden hearing loss in one or both ears, or hearing that has got worse over a few days, without dizziness or any of the emergency signs above. Get medical advice the same day, as it may need treating quickly.
Book an appointment
- Within a few days: short spells of spinning when you lie down, roll over in bed or look up, or dizziness that keeps coming back, without any of the signs above. See your GP or a physio within a few days so the cause can be confirmed and treated.
- Within a few days: you have had a fall, even if you were not hurt, or you keep tripping, stumbling or feeling that your legs might give way. Book an appointment with your doctor within a few days and ask about a falls assessment. Tell them about every fall, even the ones where you were not hurt.
- Routine: you have been tired for a few weeks and you are not sure why, your tiredness is getting in the way of your daily life, or you are tired along with other symptoms such as losing weight without meaning to or a change in your mood. Book an appointment with your doctor about the tiredness itself, say how long it has been there and what else has changed, and let them decide what to test. Tiredness is not a symptom of the inner ear: the NHS names sleep apnea, iron deficiency anemia, diabetes, an overactive thyroid and ME or chronic fatigue syndrome among the conditions behind it, and a blood test settles several of them. Tell your doctor as well if anyone has said you gasp, snort or choke in your sleep. If the tiredness comes with chest pain, feeling faint, or being short of breath while you are resting, use the emergency and same day lines above instead.
Common questions
Can you have BPPV and vestibular migraine together?
Yes, and the vestibular migraine criteria address it directly. That document notes that typical BPPV is more common in people with migraine, for reasons that are not yet clear (Lempert and colleagues, 2022). So a positional spell that behaves like BPPV, in somebody with a long migraine history, is not a contradiction to be resolved. Two conditions in one head are handled by describing each attack type separately rather than averaging them, which is the same approach the Barany criteria take to vestibular migraine alongside Meniere's disease: a dual diagnosis is made when a person has two distinct kinds of attack, one meeting each set of criteria (Lempert and colleagues, 2022). Practically, keep two accounts rather than one. If repositioning treatment has settled the positional spells and a different kind of dizziness is still there, say exactly that at your review appointment, because it changes what gets looked at next.
What is the difference between vestibular migraine and Meniere's disease?
Hearing is where the two diverge, and the criteria are specific about it. Fluctuating hearing loss, ringing and a feeling of pressure in the ear can all happen in vestibular migraine, but the hearing loss does not progress to profound levels, and when it becomes long-standing it is usually on both sides and affects the higher frequencies more. In long-standing Meniere's disease it is usually one-sided or clearly worse on one side, and flatter across the frequencies (Lempert and colleagues, 2022). The same document gives the rule for a head that could fit either: where the Meniere's criteria are met, particularly one-sided hearing loss on a hearing test, Meniere's is diagnosed even if migraine symptoms occur during the attacks. That is why a hearing test does more here than any amount of reading, and it is not something you can estimate at home.
What causes vertigo in women?
Nothing in the sources read for this page gives a separate list of causes for women. The NHS causes list is the same one for everybody: BPPV, labyrinthitis, vestibular neuritis, Meniere's disease, migraine, some medicines, and sometimes no identified cause at all. Migraine is commoner in women than in men, which means the migraine-related entries on that list come up more often, but it does not create a different condition. The question that usually sits behind this search is whether hormones or the menopause are involved, and that has its own page: vertigo in menopause sets out what the evidence does and does not support. Treat any page that offers you a women's list of vertigo causes with suspicion unless it names its source.
Will a scan tell me which one it is?
Usually not, and a normal scan is a common and frustrating result. Most of these conditions are diagnosed from the history and the examination rather than from a picture. The BPPV guideline advises against scans and inner ear balance testing when the signs fit BPPV and nothing points elsewhere (Bhattacharyya and colleagues, 2017). For Meniere's disease the NHS says a GP asks about your symptoms, looks in your ears and examines your head and neck, and refers you to a specialist for further tests if Meniere's is suspected, which may include blood tests and an MRI scan. Imaging earns its place when something in your story or your examination does not fit, which is a decision for the clinician in front of you. Hearing tests are a different matter and often do carry real weight, because the pattern of hearing loss is one of the few measurable things that separates these conditions.
References
- von Brevern M, Bertholon P, Brandt T, et al. Benign paroxysmal positional vertigo: Diagnostic criteria. Journal of Vestibular Research. 2015;25(3-4):105-117. https://doi.org/10.3233/VES-150553
- Lempert T, Olesen J, Furman J, et al. Vestibular migraine: Diagnostic criteria (Update). Journal of Vestibular Research. 2022;32(1):1-6. https://doi.org/10.3233/VES-201644
- Lopez-Escamez JA, Carey J, Chung WH, et al. Diagnostic criteria for Meniere's disease. Journal of Vestibular Research. 2015;25(1):1-7. https://doi.org/10.3233/VES-150549
- Staab JP, Eckhardt-Henn A, Horii A, et al. Diagnostic criteria for persistent postural-perceptual dizziness (PPPD): Consensus document of the Committee for the Classification of Vestibular Disorders of the Barany Society. Journal of Vestibular Research. 2017;27(4):191-208. https://doi.org/10.3233/VES-170622
- Seemungal BM, Agrawal Y, Bisdorff A, et al. The Barany Society position on 'Cervical Dizziness'. Journal of Vestibular Research. 2022;32(6):487-499. https://doi.org/10.3233/VES-220202
- Bhattacharyya N, Gubbels SP, Schwartz SR, et al. Clinical practice guideline: benign paroxysmal positional vertigo (update). Otolaryngology-Head and Neck Surgery. 2017;156(3 Suppl):S1-S47. https://doi.org/10.1177/0194599816689667
- Rushton A, Carlesso LC, Flynn T, et al. International framework for examination of the cervical region for potential of vascular pathologies of the neck prior to musculoskeletal intervention: International IFOMPT Cervical Framework. Journal of Orthopaedic and Sports Physical Therapy. 2023;53(1):7-22. https://doi.org/10.2519/jospt.2022.11147
- NHS. Vertigo. https://www.nhs.uk/conditions/vertigo/
- NHS. Dizziness. https://www.nhs.uk/symptoms/dizziness/
- NHS. Labyrinthitis and vestibular neuritis. https://www.nhs.uk/conditions/labyrinthitis/
- NHS. Meniere's disease. https://www.nhs.uk/conditions/menieres-disease/
- NHS. Migraine symptoms. https://www.nhs.uk/conditions/migraine/symptoms/
- NHS. Symptoms of a stroke. https://www.nhs.uk/conditions/stroke/symptoms/
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- St George's University Hospitals NHS Foundation Trust. Benign paroxysmal positional vertigo (BPPV). https://www.stgeorges.nhs.uk/service/therapies/neurology-vestibular-physiotherapy-outpatients/benign-paroxysmal-positional-vertigo-bppv/
- NHS. Chest pain. https://www.nhs.uk/symptoms/chest-pain/
- NHS. Falls. Page last reviewed 06 March 2025. https://www.nhs.uk/conditions/falls/
- NHS. Low blood pressure (hypotension). https://www.nhs.uk/conditions/low-blood-pressure-hypotension/
- NHS. Shortness of breath. Page last reviewed 30 January 2024. https://www.nhs.uk/symptoms/shortness-of-breath/
Written and checked by the PocketPhysio editorial team. Last updated 2026-10-18.
This page is general education, not a diagnosis or a personal treatment plan. See a physiotherapist or doctor for advice about your own situation.