Vertigo Explained: What to Do When the World Is Spinning

Vertigo’s often sudden onset and its seismic effect on balance and literal world view can be terrifying and surreal, not to mention temporarily debilitating. Yet Justin S. Golub, MD,  an ear, nose, and throat specialist at Columbia University, says vertigo is often due to a benign, transient condition that can be diagnosed and treated non-invasively.  

Vertigo is like the feeling you get when you’re at an amusement park—but the world keeps whirling around long after the ride has stopped.  

“ENTs use ‘vertigo’ to mean the feeling of motion,” Golub says. “The most extreme form of vertigo involves the feeling of spinning, tilting, and sudden loss of balance. It is different from dizziness, which is a more general feeling of imbalance and lightheadness.”  

About one in 15 adults will experience vertigo at least once in their life. Each year, an estimated 200,000 people, typically in their 50s, 60s, and 70s, seek medical attention for the most common type due to inner ear dysfunction, benign paroxysmal positional vertigo (BPPV). Golub says he typically sees two patients a day with BPPV, though many people don’t bother to seek medical attention, suggesting far higher numbers.  

"BPPV seems both absurd and magical because it is such an odd phenomenon,” says Golub. “But for patients, it’s a major nuisance that can be frightening when it happens.” 

A disruption in the ‘sixth sense’  

Most cases of BPPV are caused by wayward crystals in the inner ear. 

The inner ear contains five small structures, fully developed at birth, that allow you to sense where you are in space. “We have an underappreciated sixth sense that allows us to perceive—and take pleasure in—movement, just as we do with taste, vision, smell, or hearing, for example,” Golub says. 

Three of the structures are semicircular canals (think hula hoops), which contain liquid that allows us to perceive rotational motion, such as when you pick up your head from the pillow after lying on your side. When you rotate your head, the liquid moves around for a split second and sends a signal to your brain that you are moving. The fluid stops rotating once you stop moving. 

The other two structures help us perceive vertical and horizontal movement. These organs, the utricle and saccule, contain thousands of tiny calcium carbonate crystals suspended in a gelatin-like substance. When you move your head vertically or horizontally—such jumping off a diving board—the crystals move and push against tiny hairs lining the inside of these structures. The movement of the hairs tells the brain which way you are moving. 

Occasionally, some of these crystals break away from the confines of the utricle or saccule and float into one of semicircular canals. “When that happens and you turn your head, these crystals start to spin in a continuous loop that keeps the inner ear fluids moving long after your head has stopped moving,” Golub says. “Your brain thinks your head is still moving, though that conflicts with the messages your brain gets from your eyes and the rest of your body. The fact that you know you’re not spinning even though you see spinning is very uncomfortable for people.”  

In some instances, BPPV can be triggered by physical trauma, such as banging your head in a car accident, says Golub, though most of the time patients can’t recall any trauma. In cases without trauma, scientists don’t know what causes the crystals to get loose and run amok. 

When to seek medical help 

Many patients experience BPPV symptoms once, and the symptoms subside within a few days on their own.  

"Still, it's important for patients who are experiencing symptoms for the first time to see a doctor, because it could also be a sign of something worse, like an impending stroke,” Golub says. 

For those with persistent symptoms, BPPV can be terrifying and extreme. Simply turning your head in the direction of the affected ear can trigger an intense episode of vertigo lasting a minute or two, occasionally accompanied by nausea and vomiting.  

Physicians diagnose BPPV by taking a patient history and performing a physical exam. “If the patient says that they suddenly feel like the world is spinning when they are lying in bed and turn to the right, that is a huge tipoff that they have right-sided BPPV,” Golub says. 

BPPV is confirmed with a physical maneuver called the Dix-Hallpike test. In this test, a doctor or physical therapist turns the patient’s head 45 degrees to the right while the patient is seated on an exam table. Then the patient suddenly lies flat. If the patient has BPPV, the liquid in one of the semicircular canals will move around and the patient will feel extremely dizzy for about a minute after lying down. A direct connection between the inner ear and the eyes via the brain causes the patient’s eyes to jerk back and forth, which is the smoking gun for the doctor making the diagnosis.  

Non-invasive treatment 

Once diagnosed, the treatment for BPPV is non-invasive. BPPV is treated with a two-part procedure called the Epley maneuver. First, the clinician performs the Dix-Hallpike maneuver to consolidate the loose crystals into the affected canal. Then the patient is rolled on their side 180 degrees to encourage the crystals to drift back into the utricle or saccule.  

The maneuver may need to be repeated two or three times over the course of a few weeks or days until the crystals are firmly lodged in the right place and the patient no longer feels symptoms. The maneuvers are typically performed by an ENT or a physical therapist trained in vestibular disturbances, though some neurologists also perform the procedure.   

Unfortunately, both the diagnosis and treatment temporarily invoke symptoms. 

"We know these maneuvers can make patients feel worse temporarily, but the good news is that most patients will feel better for a long period of time afterward,” Golub says.