The vertigo spells you can't explain
8 min read · Uplevel editorial
It comes without warning, or it comes when you turn a certain way — roll over in bed, look up at a high shelf, turn your head quickly to the right. The room tilts. Not metaphorically. The room actually tilts, spinning or shifting in a way that has no relationship to any movement you've made, and for a few seconds or a few minutes the floor is unreliable. Sometimes there's nausea. Sometimes there's a cold sweat. Sometimes it passes in thirty seconds and you're left standing very still, waiting to be sure it's over. Sometimes it doesn't pass quickly and you end up sitting on the floor of a grocery store waiting for the world to settle. You describe this to your doctor and they say it sounds like benign positional vertigo, give you a handout about the Epley maneuver, and that's the end of it.
The Epley maneuver may or may not help. Whether it does tells you something important about what you're actually dealing with — because vertigo is a symptom, not a diagnosis, and the differential behind it is wide enough that the most common cause and the least common cause require completely different approaches.
Benign paroxysmal positional vertigo — BPPV — is the most common cause of episodic vertigo, and the name is accurate: it is benign, it is provoked by position change, and it is paroxysmal (brief episodes rather than constant). The mechanism is specific: calcium carbonate crystals called otoconia, which normally reside in the utricle of the inner ear, become dislodged and migrate into the semicircular canals. When you move your head, these crystals shift and create a fluid movement that the canal's sensors weren't expecting, sending a false signal of rotation to the brain. The Epley maneuver is a repositioning technique that moves those crystals back out of the canal, and when BPPV is the correct diagnosis, it often resolves the problem immediately or within a few sessions. If the Epley doesn't help, or if the episodes don't fit the positional pattern — brief, triggered by specific head movements, resolving quickly — then BPPV is probably not the whole story.
Vestibular migraine is substantially underdiagnosed and is probably the second most common cause of episodic vertigo in the people who end up being told their vertigo is mysterious or unexplained. Migraine is not always a headache. In vestibular migraine, the primary symptom is vertigo — sometimes with headache, sometimes without — and the episodes can last minutes to hours. If you have any history of migraine headaches or a strong family history of migraine, and your vertigo episodes last longer than BPPV would predict (longer than one to two minutes), this diagnosis deserves serious consideration. Vestibular migraine is often missed because providers aren't looking for it; it responds to the same preventive and abortive approaches as other migraine variants, which means it's treatable in ways that "unexplained vertigo" is not.
Meniere's disease is less common than BPPV or vestibular migraine but important to identify. The classic triad is episodic vertigo, tinnitus (often low-pitched and fluctuating), and hearing changes in the affected ear. Episodes tend to last twenty minutes to several hours and often include a sense of fullness in the ear. If your vertigo comes packaged with those additional features, Meniere's workup — including formal audiometry — is appropriate. Meniere's is thought to involve fluid pressure dysregulation in the inner ear (endolymphatic hydrops), and while it's not reversible, it is manageable with the right approach.
Vestibular neuritis is worth knowing about because it presents dramatically and then slowly resolves, leaving some people with residual symptoms that feel confusing and untethered from the original event. It's typically post-viral — an inflammation of the vestibular nerve that often follows or coincides with a respiratory illness — and produces sudden, severe, sustained vertigo (hours to days, not brief episodic spells) with no hearing loss. Most people recover over weeks to months, though the recovery is often incomplete without vestibular rehabilitation therapy. If you had a severe episode that gradually improved but left some residual unsteadiness or motion sensitivity, post-neuritis vestibular compensation problems may be what you're working with.
Cervicogenic vertigo is real and underappreciated. The upper cervical spine has proprioceptive connections to the vestibular system; when those signals are distorted — by cervical joint dysfunction, muscular imbalance, or injury — the brain receives conflicting information about orientation. The result can be vertigo or dizziness that's provoked by neck movement rather than head position change per se. The distinction between BPPV (inner ear, head position) and cervicogenic vertigo (neck, cervical movement) matters for treatment: manual therapy and cervical rehabilitation can be effective for the cervicogenic type while the Epley maneuver does nothing.
Early autoimmune vestibular conditions are uncommon but worth including in the picture because they're treatable and often initially attributed to something else. Autoimmune inner ear disease can cause progressive hearing loss alongside episodic vertigo, and because it's immune-mediated, it may respond to immunosuppressive treatment. If your vestibular symptoms are accompanied by bilateral hearing changes and none of the more common diagnoses fit, this is worth raising with an ENT specialist who has experience with this presentation.
The vascular contributors deserve their own honest mention. Most vertigo is not vascular — but vertebrobasilar insufficiency, which involves compromised blood flow to the posterior circulation serving the brainstem and cerebellum, can produce episodic vertigo. This is more common in older adults with cardiovascular risk factors, and it's one of the reasons that new-onset vertigo in someone over 60 with relevant risk factors warrants more urgency in evaluation. The central causes of vertigo — brainstem lesions, cerebellar pathology — are much less common than the peripheral causes but produce specific clinical signs (direction-changing nystagmus, gait ataxia, difficulty with tandem walking, any focal neurological signs) that distinguish them. If you have any of those signs alongside vertigo, that's a reason for more urgent evaluation rather than waiting to see if the Epley helps.
The conventional workup for unexplained or recurrent vertigo should include videonystagmography or other vestibular function testing, formal audiometry, and an otolaryngologist or neurotologist evaluation if the primary care assessment hasn't resolved the picture. Imaging — typically MRI of the posterior fossa and internal auditory canals — is warranted if there are central nervous system signs, if the pattern is inconsistent with peripheral causes, or if hearing loss is asymmetric and progressive. Most people with straightforward BPPV don't need imaging. People with recurrent episodes that don't fit the BPPV pattern, or episodes with additional neurological features, do.
Vestibular rehabilitation therapy — a specialized form of physical therapy targeting the vestibular system — is underutilized and effective. A trained vestibular PT can identify the specific type and location of dysfunction, guide the appropriate repositioning maneuvers, and build a habituation and compensation program that accelerates recovery. For anyone with persistent or recurrent vertigo, vestibular rehabilitation is worth seeking specifically, not just general physical therapy.
The peptide research interest in vestibular conditions is limited and not a primary focus of this conversation. The value of naming that limitation is that it redirects attention where it belongs: on diagnosis. The single most important intervention for vertigo is knowing what kind you have. BPPV treated with the Epley maneuver often resolves completely in one session. Vestibular migraine treated appropriately can go from disabling to manageable. Vestibular neuritis with rehabilitation recovers far better than without. The system is not built to give you this full picture in a routine appointment, which means you may need to advocate for a more specific workup rather than accepting the first explanation offered.
What the vertigo spells are signaling is that something in the vestibular system — inner ear, vestibular nerve, cervical proprioception, central vestibular pathways — is generating distorted information about where you are in space. That distortion has a cause. The cause is usually identifiable. The willingness to investigate it fully, rather than living with unexplained spinning as an acceptable cost of getting older, is the thing that makes the difference between manageable and unmanageable. Vertigo that's been properly diagnosed and appropriately treated is a very different experience from vertigo that's been labeled benign and sent home with a handout.
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