About dizziness, vertigo and blackouts
Vertigo most often comes from the balance organ of the inner ear. Benign paroxysmal positional vertigo (BPPV) causes brief spinning on turning in bed or looking up and is cured by a simple repositioning manoeuvre. Vestibular neuritis causes days of severe vertigo after a viral illness. Vestibular migraine is a common and under-recognised cause of recurrent dizziness. Less often, vertigo comes from the brain itself.
Blackouts are most often faints (syncope), caused by a temporary drop in blood flow to the brain, but they can also be seizures or, importantly, heart rhythm problems. Sorting these out quickly matters because the treatments, and the risks, are different. Dr Raga Qasem has a specialist interest in vertigo and stroke medicine and leads this clinic.
Symptoms we assess
Reasons for referral include:
- A spinning sensation, particularly when moving the head or turning in bed
- Recurrent dizziness lasting minutes to hours, with or without headache
- Persistent unsteadiness or a fear of falling
- Light-headedness on standing, or a blackout with warning
- A blackout without warning, or with injury, or while sitting or lying
- Dizziness with double vision, slurred speech, weakness or numbness (seek urgent care)
- Hearing loss or ringing in the ear alongside vertigo
How we diagnose it
The history usually gives the diagnosis: what the sensation is, how long it lasts, what brings it on and what comes with it. The examination includes specific tests of eye movements and positional manoeuvres that identify BPPV and distinguish inner-ear from brain causes, along with checks of blood pressure lying and standing, gait and balance, and the heart.
Tests are chosen to the question. MRI of the brain is arranged where a central cause is possible. Hearing tests and vestibular function testing are used for inner-ear disease. For blackouts, an ECG is essential and prolonged heart monitoring, an echocardiogram or a tilt-table test may follow, in liaison with cardiology. An EEG is arranged where a seizure is suspected.
Treatment and follow-up
BPPV is treated in the clinic with a repositioning manoeuvre, often with immediate relief. Vestibular neuritis is treated with a short course of medication and then vestibular rehabilitation exercises, which retrain balance and are the most effective treatment for persistent unsteadiness of inner-ear origin. Vestibular migraine responds to migraine preventive treatment and trigger management.
Simple faints are managed with advice on fluids, salt, posture and recognising warning signs, and with specific measures where needed. Where a heart cause is found it is treated with cardiology. Seizures are treated as described on our epilepsy page. Where dizziness is part of anxiety or a persistent postural-perceptual dizziness, a combined approach of explanation, rehabilitation and, sometimes, medication works well.
The consultant sets out the diagnosis and plan in a letter to your GP, and reviews you until symptoms are controlled.
When to see a GP, and when to see a consultant
See your GP first for dizziness; many causes are diagnosed and treated there. Ask for a consultant referral for recurrent or persistent vertigo, unexplained blackouts, imbalance that is affecting your safety, or dizziness with neurological symptoms. Sudden dizziness with weakness, double vision, difficulty speaking or a severe headache is a stroke warning and needs emergency care.
