Vertigo or just dizzy? Why the difference matters (and what fixes each)

Patients walk into our OPD all the time saying 'doctor, I have vertigo.' Half the time they mean lightheadedness. The rest of the time they mean a real spinning sensation. These are different problems with different causes and very different treatments, and the most common cause of true vertigo is something we can usually fix in a single ten-minute manoeuvre, no medicine required.

What true vertigo actually feels like

True vertigo is a sensation that the room is spinning, or that you are spinning while still. It's almost always triggered or worsened by changes in head position, turning over in bed, looking up at the ceiling fan, bending down to tie a shoelace. Episodes typically last seconds to minutes, occasionally longer. Many patients vomit during a bad episode.

Most true vertigo comes from the inner ear, not the brain. The most common single cause, by a wide margin, is something called BPPV (Benign Paroxysmal Positional Vertigo). Tiny calcium crystals that normally sit in one part of the inner ear get displaced and float into a part where they don't belong. Every time you move your head, they slosh around and trigger a spinning sensation.

What 'lightheadedness' actually is

Lightheadedness, feeling about to faint, woozy, off-balance, is usually NOT an ear problem. Common causes include low blood pressure (especially when standing up quickly), low blood sugar, dehydration, anaemia, anxiety, side effects of blood-pressure medication, and heart rhythm issues.

If a patient describes 'I feel I might fall' or 'I feel light' rather than 'the room is spinning', I refer them straight to a physician for a blood pressure check, ECG, basic blood work and a review of their medications. Vertigo tablets won't help.

Why the difference matters

Take a typical scenario. A 50-year-old patient develops a few episodes of room-spinning when turning over in bed. They go to a general physician who prescribes a vertigo medicine (most commonly betahistine or one of the calcium-channel blockers used 'off-label' for vertigo).

The episodes settle for a few weeks, then come back. The medicine is restarted, often increased. After two years on continuous vertigo medication, the patient comes to us. We do a 60-second Dix-Hallpike test, confirms BPPV, perform the Epley repositioning manoeuvre once, and the spinning is gone.

Two years of unnecessary medication. One ten-minute manoeuvre.

What an ENT vertigo evaluation looks like

• Detailed history, what triggers the episodes, how long they last, any hearing changes
• Bedside vestibular tests including the Dix-Hallpike (for BPPV)
• Audiometry, to rule out conditions like Meniere's disease that affect both vertigo and hearing
• Neurological screening, quick, just to confirm the problem is from the ear and not the brain
• MRI only when the pattern suggests something central

When vertigo IS a more serious problem

Most vertigo is benign. But certain warning signs need urgent evaluation:

• Sudden severe vertigo with sudden hearing loss in one ear
• Vertigo with double vision, difficulty speaking or weakness on one side
• Severe headache with vertigo
• Vertigo in a patient with significant cardiovascular risk factors
• Vertigo after a head injury

These deserve same-day evaluation, often combined with neurology.

The bottom line

If you've been on long-term 'vertigo tablets' and never had a proper bedside vestibular examination, please get one. The most common cause of true vertigo has a physical cure, not a medicinal one.