What Causes Vertigo?

Vertigo—a sensation of spinning or rotational dizziness—is distinct from general lightheadedness or unsteadiness. It arises when there is a mismatch between sensory inputs from the vestibular system (inner ear), visual system, and somatosensory receptors, most commonly due to pathology within the peripheral or central vestibular pathways.

The most frequent cause of vertigo is benign paroxysmal positional vertigo (BPPV), which results from dislodged otoconia—calcium carbonate crystals—from the utricle into one or more semicircular canals. These displaced particles disrupt normal endolymph flow during head movement, triggering brief but intense episodes of vertigo with characteristic nystagmus, typically provoked by changes in head position such as rolling over in bed or looking upward.

Other common peripheral causes include vestibular neuritis—an acute, often viral-induced inflammation of the vestibular nerve causing prolonged vertigo without hearing loss—and Ménière disease, characterized by recurrent vertigo attacks accompanied by fluctuating sensorineural hearing loss, tinnitus, and aural fullness due to endolymphatic hydrops.

Central causes, though less common, require urgent evaluation. These include cerebellar or brainstem ischemia or infarction, multiple sclerosis plaques affecting vestibular nuclei or pathways, and posterior fossa tumors. Central vertigo tends to be less positionally triggered, may persist for longer durations, and is often associated with neurological signs such as dysarthria, ataxia, or horizontal or vertical nystagmus that does not suppress with visual fixation.

A thorough history—including onset, duration, triggers, associated auditory or neurological symptoms—and targeted physical examination (e.g., Dix–Hallpike maneuver, head impulse test, assessment of gait and coordination) are essential for accurate diagnosis. Imaging and audiometric testing are reserved for cases with red flags suggesting central pathology or cochlear involvement.