Vertigo and dizziness: causes, red flags and when to see a GP

The NHS dizziness page defines dizziness as feeling off-balance, giddy, light-headed or faint, or as if you or things around you are spinning, which is vertigo. Each version points in a different direction. True spinning suggests the balance organs or the brain pathways that serve them. A faint or light-headed feeling suggests a drop in blood pressure or blood flow. Unsteadiness, especially when walking, may come from the inner ear, the nerves in the feet or the brain.

NICE CKS stresses that vertigo is a symptom rather than a diagnosis, and that most balance problems seen in primary care are not true rotatory vertigo. That is why a clinician starts by asking you to describe the sensation in your own words, and whether it comes on when you move your head, stand up or at random.

The table follows the NHS and NICE CKS lists. Peripheral causes sit in the inner ear and its nerve; central causes sit in the brain.

The NHS vertigo page tiers the warning signs. For 999 or A&E: double vision or loss of vision, hearing loss, trouble speaking, and leg or arm weakness, numbness or tingling. It also says always to take someone who cannot be woken to A&E or call 999.

For an urgent GP appointment or NHS 111, the NHS lists vertigo with a severe headache, with being sick or feeling very sick, or with a very high temperature or shivering. The NHS dizziness page adds reasons to see a GP in less urgent terms: finding it harder to hear or speak, ringing in the ears, changes in eyesight, numbness or weakness of the face, arms or legs, changes in pulse, fainting or collapsing, and headaches.

NICE CKS describes features that raise suspicion of a central cause: prolonged severe vertigo, new-onset headache or recent trauma, focal neurological signs, central-type nystagmus (abnormal eye movements), an abnormal response to the Dix-Hallpike test, and inability to stand or walk even with the eyes open.

• Vertigo with double vision, loss of vision, slurred speech or weakness of face, arm or leg.

• Severe, sudden headache or a head injury.

• Being unable to stand or walk with eyes open.

• Fainting, collapse or a racing or irregular pulse.

• Fever, stiff neck, or vomiting that does not settle.

The NHS says a GP will ask about symptoms to find the cause and may do a simple test that involves moving quickly from sitting to lying, which can bring on symptoms. CKS describes the clinical examination: looking for facial asymmetry, examining the ears, testing cranial nerves and cerebellar function, examining the eyes and checking gait. Tests named include Romberg's test, the Dix-Hallpike manoeuvre, the head impulse test and the Unterberger test.

Questions include how long episodes last, what triggers them, whether hearing changes or tinnitus accompany them, what medicines are being taken, and whether there is headache, sickness or recent illness. When light-headedness is the main complaint, blood pressure, pulse and blood sugar may also be checked.

CKS says imaging such as MRI or CT is not needed to confirm BPPV unless another condition has to be excluded, for example when nystagmus is atypical or there are additional neurological symptoms. BPPV can be treated with a repositioning manoeuvre such as the Epley manoeuvre, and Brandt-Daroff exercises may be considered; CKS says drug treatment is not usually helpful for BPPV. Watchful waiting is an option because it can settle on its own.

The NHS says most people with vertigo get better without treatment, that treatment depends on the cause, that antibiotics may be given for an infection, that exercises can retrain balance, and that antihistamines can sometimes help symptoms. Referral to an ear, nose and throat or balance specialist is considered if symptoms are atypical, repeated manoeuvres have not worked or symptoms have not resolved within 4 weeks.

The NHS suggests lying still in a quiet, dark room to reduce the spinning feeling, moving the head slowly, sitting straight down when you feel dizzy, turning on the lights if you get up at night, using a stick if at risk of falling, sleeping with your head raised on two or more pillows, getting out of bed slowly and relaxing, since anxiety can make vertigo worse.

It says not to bend over to pick things up (squat instead) and not to stretch the neck, for example to reach a high shelf. The NHS also advises not to do anything dangerous, such as driving, climbing a ladder or using heavy machinery, while dizzy, and to avoid coffee, cigarettes, alcohol and drugs.

A GP can assess vertigo that will not go away or keeps coming back, as the NHS says, and can arrange balance or hearing tests and specialist referral. An audiologist or balance clinic assesses inner-ear function. On driving, the NHS says that if you drive you must tell the DVLA about your vertigo.

Sudden vertigo with any neurological sign should not wait for a routine appointment; it is dealt with through 999 or A&E.