VERTIGO: THE DIZZY IMPOSTOR

“My head is spinning, the whole world is spinning!”

Chances are, you’ve heard a family member say something like this. Of course, their heads aren’t literally spinning; that’s impossible. But the strange sensation they describe is very real. It’s what many people call vertigo.

The tricky part is this: not everyone who feels dizzy or lightheaded actually has vertigo. Still, they often get that diagnostic label and a prescription for tablets like Vertin.

So here’s the question: Is it really vertigo, or is it just being misdiagnosed as vertigo? This article is here to clear up that confusion, so the “common diagnosis” doesn’t turn into “common mistake.”

Vertigo means “to spin,” nothing more.

The word “vertigo” is just a fancy way to say you have dizziness.

But dizziness can happen for many reasons — like BPPV, neck (cervicogenic) problems, vestibular migraines, stroke, certain nerve diseases, Meniere’s disease, vestibular neuritis, or a condition called superior canal dehiscence (SCD).

Saying ‘vertigo’ simply doesn’t do any justice. We can follow a simple guideline to broadly categorise it into three things:

An ear problem (peripheral ) or
A neural problem (central) or
A systemic/side effects of a previous condition

Cutting through the Noise

Imagine you’re sitting in the living room and hear your mother drop a utensil in the kitchen. You can’t see it, but from the sound, you can guess what fell — its size and even its shape. That’s because you didn’t just hear the sound, but you listened and compared it with past experiences. You know that even a plate and a spoon have similar sounds but are slightly different, and that helps you figure it out.

In the same way, different types of vertigo may look similar, but if you know what to look for, you can tell them apart. By identifying the right patterns, you can filter out the “noise” and find the real cause of vertigo, just like finding the plate.

Diagnostic approach to Vertigo:

The priority is to look for the dangerous central causes. If central pathology is excluded, proceed to evaluate for peripheral vertigo.

If BPPV is also excluded, then consider non-BPPV causes such as Meniere’s disease, vestibular neuritis, labyrinthitis, perilymph fistula, or third-window syndromes(SCD), guided by history. Then we move on to others ( cervicogenic headache, PPPD)

By doing this simple thing, we are halfway to a more accurate diagnosis. The guide below uses a 2-step process: a questionnaire and a test to help you do that.

STEP 1: QUESTIONNAIRES

This stage will help us narrow down to the key conditions.

Questionnaires

S.No	Factors	Interpretation
1	Onset	Sudden & continuous: Stroke? Vestibular neuritis
2	Duration of Episodes	Seconds: BPPV Minutes-hours: Meniere’s / Vestibular Migraine Days: Vestibular neuritis / Stroke
3	Triggers	Head movement/position: BPPV Standing up: Postural hypotension Loud sound/pressure: Superior canal dehiscence, fistula No trigger: Central (stroke, MS, migraine)
4	Hearing Symptoms	Yes (hearing loss, tinnitus, fullness): Meniere’s, Labyrinthitis, Fistula No: BPPV, Vestibular neuritis, Central
5	Associated Symptoms	Headache/Visual aura: Migraine, Central lesion Neurological signs (speech, weakness, vision issues): Stroke, MS Syncope / Blackout: Cardiac/Systemic cause Neck pain/stiffness: Cervicogenic
6	History	Recent trauma: Post-traumatic vertigo, Fistula Recent infection: Vestibular neuritis, Labyrinthitis Chronic illness (DM, vascular, osteoporosis): Ischemic/recurrent BPPV Medications (antiepileptics, sedatives, antihypertensives): Drug-induced dizziness

STEP 2: TEST

Once the questionnaire gives us an idea of the possible condition, we confirm it with tests. These tests help us rule out other causes and identify a single pathology.

A. To identify central causes:

HINTS test
Neurological check

B. To identify peripheral and other causes:

Dix-Hallpike test
Supine roll test

A. Assessing central vertigo

HINTS test

The HINTS test is a bedside clinical exam used in patients with acute continuous vertigo (Acute Vestibular Syndrome, AVS) to help differentiate between a peripheral cause (like vestibular neuritis) and a central cause (like stroke in the brainstem/cerebellum).

As indicated by the research, HINTS stands for Head-Impulse, Nystagmus, Test-of-Skew.

Head Impulse Test (HIT)

The patient fixes eyes on the examiner’s nose; the examiner quickly turns the head 10–20° to each side.

Normal: eyes stay locked on target.
Abnormal: eyes “slip off target,” then a catch-up saccade happens – suggestive of peripheral cause (vestibular neuritis).
If the test is normal but vertigo is present, it is more likely due to a central cause (stroke).

Nystagmus

Nystagmus is an involuntary, repetitive eye movement.

Peripheral: Unidirectional, horizontal-torsional (worse when looking toward the fast phase).
Central: Direction-changing (right when looking right, left when looking left), vertical or torsional nystagmus.

Test of Skew

It is used to detect vertical misalignment of the eyes, which can indicate a central cause of vertigo (like a brainstem stroke).

Cover-uncover test: examiner alternately covers each eye while the patient looks straight. Look for any vertical realignment (up or down movement) of the eye.
Positive (vertical realignment of eyes): Suggests a central lesion.
Negative (no vertical shift): Suggests a peripheral lesion.

Central (stroke or other):	Peripheral AVS (vestibular neuritis):
• Normal head impulse	• Abnormal head impulse
• Direction-changing or vertical nystagmus	• Unidirectional nystagmus
• Positive skew deviation	• No skew deviation

Neurological Screening:

Neurological screening checks for central causes of vertigo, like stroke, multiple sclerosis. It analyses cranial nerves, muscle strength, sensation, coordination, reflexes, and gait. Abnormal findings like weakness, ataxia, or abnormal reflexes suggest a brain or brainstem problem. Normal findings with vertigo make peripheral causes more likely.

B. Assessing peripheral vertigo

Dix–Hallpike Maneuver (posterior canal for BPPV)

The patient sits, the head is turned 45 degrees, and then they are quickly laid back with the head hanging off the table.
A positive result is brief spinning vertigo with rotatory nystagmus, usually toward the affected ear and is suggestive of posterior canal BPPV.

Supine Roll Test (for horizontal canal BPPV)

The patient lies flat while the head is quickly rotated left and right.
A positive result is horizontal nystagmus when the head is turned to one side.
If positive, this is highly suggestive of horizontal canal BPPV

Orthostatic Hypotension Test

Measure BP & HR lying, sitting, standing. A drop in systolic ≥20 mmHg or symptomatic dizziness suggests orthostatic hypotension, not inner ear disease.

“The questionnaire acts like a lighthouse, guiding us toward the broad category, and the tests help us decide in which direction to sail.”

Treatment

FOR BPPV:

Canalith Repositioning Procedure or Epley manoeuvre

Canalith Repositioning Procedure (CRP), also called the Epley manoeuvre, for posterior canal BPPV, uses gravity to move loose inner ear crystals back to a safe spot, stopping vertigo.
It is 4–10 times more effective than sham or Brandt-Daroff exercises, with 80–90% of patients improving after just one or two sessions. Anti-nausea medicine may be given if symptoms are severe during the procedure.

Procedure:

Sit, head 45° to the affected ear.
Lie back, head 20–30° down, wait.
Turn your head 90° opposite side, wait.
Roll to the same side, nose down toward the floor, wait.
Sit up slowly, head slightly down

Semont Manoeuvre:

In a randomised control trial of 195 patients with posterior canal BPPV, both Epley and Semont-plus were safe and effective, but Semont-plus gave faster recovery (2 vs 3.3 days). Mild nausea was the only side effect.

Procedure:

Sit, head 45° away from the affected ear.
Drop quickly to the affected side, face up, and wait.
Move rapidly to the opposite side, face down, wait.
Sit up slowly.

For Non-BPPV (Vestibular Neuritis and Meniere’s)

A systematic review suggests that for vestibular neuronitis, doing rehabilitation exercises together with anti-vertigo drugs helps them recover faster and better than using either one alone, as recommended by the research evidence.

Medications: Steroids (reduce inflammation), antihistamines/betahistine (control vertigo), Vitamin B12 & sodium bicarbonate (nerve support).

Rehab: Vestibular exercises (habituation, adaptation, substitution, reconditioning).

Central vertigo is not treated with a single drug; instead, management focuses on treating the underlying cause and providing disease-specific treatment.

Other treatment approaches:

Tele-rehabilitation:

Doing vestibular rehab online (through video calls, apps, or remote monitoring) can reduce dizziness, disability, and anxiety. The results were similar to traditional in-person rehab, as shown by a 2024 Systematic Review with Meta-Analysis.

Patient education for vertigo, Lifestyle change, and Prevention

Be cautious with head movements during mild dizziness.
Manage underlying conditions like migraines or blood pressure.
Maintain good hydration and a Low salt diet, especially in Meniere’s.

Vitamin D supplement:

A study done by Chua, Kenneth W De et al. shows that Vitamin D supplementation reduces BPPV recurrence in older adults with low vitamin D and may lower dizziness and fall risk.

In this blog, I’ll go through a case of BPPV, a type of peripheral vertigo, showing how to differentiate it, confirm the diagnosis, and rule out other causes.

The charts above are just guidelines to help cut through the noise and narrow down the possibilities. Now, let’s put the guideline chart to the test and see how it works in practice.

Case study:

A 31-year-old female presented with a history of dizziness after her labour.

She states that she can’t lie on her back or bend forward, or move her neck freely, which seems to aggravate her dizziness, and the dizziness seems to extend for several seconds. In addition to that, she stated that she felt the room was spinning whenever she got up from lying to an upright position.

If we decode the history using a guideline questionnaire, we can clearly point towards “BPPV”

Onset: Not sudden and continuous- rules out stroke / vestibular neuritis.
Duration: several seconds- BPPV.
Triggers: head movement/position change (lying, bending, neck movements, getting up)- classic BPPV.
Hearing Symptoms: No hearing loss/tinnitus- rules out Meniere’s, labyrinthitis, fistula; Supports BPPV.
Associated Symptoms: No neuro signs, no migraine features, no fainting- again supports peripheral cause (BPPV).
History: Post-labour (stressful physiological event, but not trauma/infection). It could be linked with fatigue, positional habit, or even calcium/vitamin D shifts post-pregnancy, which increases BPPV risk.

What we understood from the questionnaire:

Her history checks almost every pivot for posterior canal BPPV:

Episodic, seconds of dizziness, triggered by lying down, bending, and standing up, spinning sensation (vertigo), no hearing or neuro symptoms.

The next step is to do a test, but the problem is that if we assume she has BPPV and perform the test, it could give a false positive. So the better approach is to check for other possible causes first, rule them out, and then work back to confirm BPPV.

In this case, Dix-Hallpike was positive: BPPV (Benign Paroxysmal Positional Vertigo)

Conclusion:

Vertigo isn’t the villain; our lazy diagnosis is. Every spin has a story, and unless you know the pivot point, you’re just guessing in the dark. So stop calling everything vertigo, start asking the right questions, and maybe next time you’ll actually treat the patient, not just the symptom.

Reference Article

Bhattacharyya, Neil et al. “Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update).” Otolaryngology–head and neck surgery: official journal of American Academy of Otolaryngology-Head and Neck Surgery vol. 156,3_suppl (2017): S1-S47. doi:10.1177/0194599816689667
Argaet, E C et al. “Benign positional vertigo, its diagnosis, treatment and mimics.” Clinical neurophysiology practice vol. 4 97-111. 6 Apr. 2019, doi:10.1016/j.cnp.2019.03.001
Yetiser, Sertac. “Review of the pathology underlying benign paroxysmal positional vertigo.” Journal of International Medical Research 48.4 (2020): 0300060519892370.
Strupp, Michael, et al. “Vestibular disorders: diagnosis, new classification and treatment.” Deutsches Ärzteblatt International 117.17 (2020): 300.
Ohle, Robert, et al. “Can emergency physicians accurately rule out a central cause of vertigo using the HINTS examination? A systematic review and meta‐analysis.” Academic Emergency Medicine 27.9 (2020): 887-896.
Burak, Kundakci, et al. “The effectiveness of exercise-based vestibular rehabilitation in adult patients with chronic dizziness: A systematic review.” F1000Research 7 (2018).
Grillo, Davide, et al. “Effectiveness of telerehabilitation in dizziness: a systematic review with meta-analysis.” Sensors 24.10 (2024): 3028.
Strupp, Michael, et al. “The Semont-plus manoeuvre or the Epley manoeuvre in posterior canal benign paroxysmal positional vertigo: a randomised clinical study.” JAMA Neurology 80.8 (2023): 798-804.
Chua, Kenneth W De et al. “Randomised Controlled Trial Assessing Vitamin D’s Role in Reducing BPPV Recurrence in Older Adults.” Otolaryngology–head and neck surgery: official journal of American Academy of Otolaryngology-Head and Neck Surgery vol. 172,1 (2025): 127-136. doi:10.1002/oohn 54
Chen, Jia, et al. “Effects of vestibular rehabilitation training combined with anti-vertigo drugs on vertigo and balance function in patients with vestibular neuronitis: a systematic review and meta-analysis.” Frontiers in Neurology 14 (2023): 1278307.

Azarudheen

Azarudheen is a passionate physiotherapist and exercise prescriptor with a deeply rooted belief in the transformative power of movement and education. His journey began in 2013 as a first-year physiotherapy student, balancing academics with part-time work to support his ambitions. Early in his career, he sought practical experience and began working at a fitness center, eventually transitioning into roles that expanded his knowledge and skill set in both clinical practice and teaching.

Driven by a relentless curiosity and desire for growth, Azarudheen took on an anatomy tutor position, believing in the value of continuous learning. A pivotal turning point came with his experience in cardiopulmonary rehabilitation at PSG Hospitals, where he worked closely with lung transplant patients. This experience emphasized the life-changing impact of functional movement and patient education, inspiring him to dive deeper into respiratory and cardiovascular physiology.

With strong support and belief in his vision, Azarudheen pursued a Master’s in Exercise and Sports Science at Manipal University—choosing it over conventional MPT programs to focus more on biomechanics, exercise physiology, strength and conditioning, and lifestyle health. His dedication was evident as he spent late nights at the library, worked part-time in gyms and cricket academies, and honed his craft through practical application.

In 2022, despite initial doubts, he opened his first clinic in his hometown—an act of courage and self-belief supported by his family and mentors. Built from the ground up, this clinic marked the start of a new era. Today, Azarudheen leads a growing team of 21 physiotherapists across two thriving clinics in Chennai and Coimbatore. His philosophy centers on patient education, movement optimization, and professional growth, and he continues to evolve both as a clinician and a leader.

Azarudheen’s journey reflects the power of perseverance, vision, and lifelong learning. He is not only a practitioner but also a mentor and advocate for a more thoughtful, movement-centered approach to healthcare.