Vertigo: what causes it and which treatments really work?
Understanding why vertigo occurs is the first step toward finding the most appropriate treatment.
Feeling as though the room is spinning. Walking as if you were on a boat. Feeling unsteady when getting out of bed or turning your head. Many people describe these sensations as “vertigo”, although they can actually result from very different conditions.
Vertigo is a symptom, not a disease. It can have many different causes and, depending on its origin, the treatment may be completely different. While some types of vertigo can be resolved within minutes using a specific manoeuvre performed by a healthcare professional, others require vestibular rehabilitation, medical treatment or a multidisciplinary approach.
The good news is that most patients improve once the underlying cause of their symptoms has been correctly identified.
In this article, we explain the most common causes of vertigo, what the scientific evidence says about their treatment, and how a multidisciplinary team such as Aliantis can help.
What do we really mean by “vertigo”?
Although we often use the word vertigo to describe any feeling of dizziness, from a medical perspective there are important differences.
Some people feel as though the room is spinning around them. Others describe unsteadiness while walking, a sensation of “floating”, light-headedness or loss of balance.
These symptoms may seem similar, but they do not always have the same cause.
To maintain balance, the brain continuously integrates information from three different systems:
- the inner ear (vestibular system);
- vision;
- sensory information from muscles and joints about body position (proprioception).
When one of these systems is not working properly or sends conflicting information, the brain has difficulty determining where the body is in space, which may result in vertigo or balance disorders.
For this reason, a thorough clinical assessment is essential before starting any treatment.
💡 Did you know?
The inner ear is not only responsible for hearing. It also contains the vestibular system, a group of specialised structures that detect head movements and help the brain maintain balance and stabilise vision while we walk or move our head.
Vertigo, dizziness, imbalance or light-headedness? They are not the same thing
Although these terms are often used interchangeably, they describe different sensations and may point to different causes. That is why one of the first questions we ask during an assessment is: “What exactly are you feeling?”
Vertigo
A sensation that either you or your surroundings are spinning, even though no actual movement is taking place. It is usually related to a disorder of the vestibular system (inner ear) and may occur, for example, when turning over in bed or moving the head.
Unsteadiness
A feeling of difficulty maintaining balance or the sensation that you may lose your balance while walking, especially on uneven ground or in visually busy environments. Unlike vertigo, there is no spinning sensation.
Balance disorder
An objective difficulty maintaining posture or walking normally. It may result from vestibular disorders, but also from neurological, muscular, joint or even visual conditions.
Light-headedness or feeling faint
Some people describe a sensation of an “empty head”, as though they were about to faint. In these situations, the cause is usually not vestibular and may involve factors such as low blood pressure, dehydration, certain medications or cardiovascular disorders.
Although these sensations are different, they may sometimes coexist. This is why a comprehensive clinical assessment is essential to identify the underlying cause and guide the most appropriate treatment.
Benign paroxysmal positional vertigo (BPPV): the most common cause
Benign paroxysmal positional vertigo (BPPV) is by far the most common cause of vertigo of vestibular origin. Despite its name, it often causes considerable anxiety because the sensations are very intense, although fortunately it is not usually a serious condition.
The most characteristic symptom is the sudden onset of intense vertigo when changing the position of the head. Many people notice it when turning over in bed, getting up in the morning, looking upwards to reach an object or bending down to pick something up.
The episode usually lasts only a few seconds, rarely more than one minute, but during that time the spinning sensation can be very intense. It is often accompanied by nausea and a lingering feeling of unsteadiness afterwards.
Why does it occur?
Inside the inner ear are tiny calcium carbonate crystals called otoconia.
Normally, these crystals remain attached to a specific structure of the vestibular system. However, due to ageing, head trauma or sometimes for no identifiable reason, some of these crystals can become detached and move into one of the semicircular canals.
When the head changes position, these crystals move within the canal and send an incorrect movement signal to the brain. As a result, the person experiences the sensation that the surroundings are spinning, even though the body is almost motionless.
Understanding this mechanism helps explain why treatment is usually so effective.
How is it diagnosed?
Diagnosis is mainly based on the patient’s medical history and specific positional tests performed by a physiotherapist or a physician trained in vestibular disorders.
These manoeuvres identify which semicircular canal is affected and temporarily reproduce the symptoms in a controlled manner, allowing for an accurate diagnosis.
Imaging tests are usually unnecessary when the clinical examination is consistent with typical BPPV and there are no warning signs.
What is the most effective treatment?
Contrary to what many people believe, the treatment for BPPV does not consist of taking medication.
International clinical guidelines recommend repositioning manoeuvres as the first-line treatment, the best-known being the Epley manoeuvre for the most common cases.
The purpose of this manoeuvre is simple: to guide the displaced crystals back to their original position inside the inner ear through a sequence of specific head movements.
For many patients, a single treatment session is enough to completely resolve the symptoms, although some people may require repeated manoeuvres.
Anti-vertigo medications may temporarily relieve nausea in certain situations, but they do not correct the underlying cause and therefore are not considered the treatment of choice for BPPV.
What is the role of vestibular physiotherapy?
Vestibular physiotherapy plays a key role in both diagnosis and treatment.
In addition to performing positional tests and repositioning manoeuvres, the physiotherapist may prescribe specific exercises when a mild feeling of imbalance persists or when vertigo recurs.
Vestibular rehabilitation helps the brain regain confidence in movement and promotes a faster return to normal daily activities.
Current scientific evidence strongly supports these interventions and considers them the gold standard treatment for BPPV.
💡 Common myth
“If I have vertigo, I need medication.”
Not necessarily.
In BPPV, medication does not reposition the crystals responsible for the problem. Repositioning manoeuvres performed by a trained healthcare professional are far more effective because they directly address the underlying cause of the vertigo.
What is the prognosis?
The prognosis for BPPV is generally excellent.
Most patients experience rapid improvement after treatment and are able to return to their normal activities within a few days.
However, this type of vertigo may recur months or even years later. When it does, it usually responds very well to repositioning manoeuvres again, which is why early diagnosis allows symptoms to be resolved quickly and helps avoid unnecessary limitations.
Vestibular neuritis: intense vertigo that can last for several days
Vestibular neuritis occurs when one of the nerves that carries balance information from the inner ear to the brain stops functioning properly, usually as a result of an inflammatory process, often following a recent viral infection.
Unlike BPPV, where vertigo only occurs with certain head movements, vestibular neuritis typically causes severe, continuous vertigo that may last for hours or even several days.
People affected often describe an intense spinning sensation accompanied by nausea, vomiting and significant difficulty standing or walking during the acute phase.
Although symptoms usually improve gradually, it is common for some unsteadiness, walking insecurity or discomfort when moving the head quickly to persist for several weeks.
How is it treated?
During the first few days, medical treatment may be necessary to relieve the most severe symptoms, always under the guidance of a physician.
However, once the acute phase has passed, the most important part of treatment is usually vestibular rehabilitation.
The brain has a remarkable ability to adapt, known as vestibular compensation. Through this process, it learns to make more efficient use of information coming from the healthy ear, vision and proprioception to restore balance.
This adaptation does not happen through time alone: movement and appropriate exercises help make the recovery process faster and more effective.
What role does physiotherapy play?
Vestibular physiotherapy is one of the cornerstones of treatment.
Following an individual assessment, the physiotherapist designs a personalised exercise programme that may include:
- gaze stabilisation exercises during head movements;
- balance training;
- habituation exercises to gradually reduce dizziness triggered by specific movements;
- gait retraining and return to everyday activities.
International clinical guidelines consider vestibular rehabilitation to be a highly effective intervention for people with peripheral vestibular hypofunction.
Vestibular migraine: when vertigo is part of migraine
Many people associate migraine exclusively with headache. However, there is a specific type known as vestibular migraine, in which vertigo may become the predominant symptom.
In some patients, headache is very mild or even completely absent during episodes of vertigo, which can make the diagnosis more challenging.
Episodes may last from a few minutes to several hours and, in some cases, even longer.
In addition to vertigo, it is common to experience sensitivity to light or sound, a personal or family history of migraine, a tendency to motion sickness, and increased susceptibility during periods of stress, lack of sleep or hormonal changes.
How is it treated?
Treatment usually combines several different strategies.
The first step is identifying potential triggers. Too little sleep, skipping meals, inadequate hydration, or excessive caffeine or alcohol intake may trigger attacks in some people.
Depending on the frequency and severity of the episodes, a physician may recommend specific treatments to control attacks or reduce how often they occur.
Can vestibular rehabilitation help?
Yes.
When symptoms persist between attacks or the patient begins avoiding certain movements for fear of triggering another episode, vestibular rehabilitation can improve movement tolerance and balance.
Although research is still evolving, current evidence shows overall positive results, especially when physiotherapy is part of a multidisciplinary treatment approach.
💡 Did you know?
People with vestibular migraine are more likely to have experienced motion sickness in the car, on boats or on planes since childhood. This information can be particularly helpful during the clinical assessment.
Ménière’s disease: vertigo accompanied by hearing loss
Ménière’s disease is a disorder of the inner ear that causes recurrent episodes of vertigo accompanied by hearing-related symptoms.
Although it is much less common than BPPV, it can have a significant impact on quality of life when attacks become recurrent.
What distinguishes it from most other causes of vertigo is the presence of fluctuating hearing loss, tinnitus (ringing in the ears) and a sensation of fullness in the affected ear.
How does it present?
Episodes occur spontaneously and usually last between 20 minutes and several hours.
During these attacks, it is common to experience intense vertigo accompanied by nausea, vomiting and severe difficulty standing or walking.
Many people also notice reduced hearing in one ear, persistent tinnitus or a feeling of pressure or fullness in the affected ear.
Over the years, hearing may gradually deteriorate.
Why does it happen?
The exact cause is still not fully understood.
The most widely accepted theory is that an increase in the pressure of the inner ear fluid (endolymphatic hydrops) temporarily disrupts the function of both the vestibular and auditory systems.
How is it treated?
Treatment usually combines several strategies.
During attacks, a doctor may prescribe medication to relieve vertigo and nausea.
In the long term, dietary changes (such as reducing salt intake), maintaining good hydration and, in some patients, specific medications or procedures performed by an ENT specialist may be recommended.
Can vestibular rehabilitation help?
Yes. Vestibular rehabilitation can be particularly beneficial when a feeling of unsteadiness persists between attacks or when the brain needs to readapt after repeated episodes.
However, it does not prevent the characteristic attacks of Ménière’s disease. It is therefore usually included as part of a multidisciplinary treatment plan alongside medical follow-up.
💡 Did you know?
Unlike BPPV, where only the balance system is affected, Ménière’s disease affects both the vestibular and auditory systems at the same time. As a result, the combination of vertigo + hearing loss + tinnitus + a feeling of fullness in the ear is highly suggestive of this diagnosis.
Persistent postural-perceptual dizziness (PPPD): when the brain remains in “alert mode”
For some people, the problem does not completely disappear after a vestibular episode.
Even though the inner ear is functioning normally again, the brain continues to interpret certain situations as a threat to balance. This condition is known as Persistent Postural-Perceptual Dizziness (PPPD).
It is now considered one of the most common causes of chronic dizziness.
How does it present?
Unlike BPPV, PPPD usually does not cause an intense spinning sensation.
Instead, people typically experience a nearly daily feeling of unsteadiness, swaying or insecurity while walking.
Symptoms often worsen after standing for long periods, walking through shopping centres, supermarkets, train stations or other visually busy environments, using screens for extended periods, or spending time in crowded places.
Many people describe the sensation as if they were “walking on a mattress,” “on a boat,” or “as if the ground were not completely stable.”
PPPD frequently develops after a previous episode of BPPV, vestibular neuritis or vestibular migraine, although it may also appear after a prolonged period of anxiety or a particularly stressful life event.
Why does it happen?
Our brain is designed to protect us.
After a significant episode of vertigo, it may temporarily increase its level of vigilance to prevent future losses of balance.
For most people, this protective mechanism disappears once the vestibular system has recovered.
However, in some patients the brain remains in this state of heightened alertness for too long.
As a result, it becomes overly sensitive to small movements or normal visual stimuli, creating a persistent feeling of unsteadiness.
This does not mean that “it’s all in your head” or that the symptoms are imagined.
The condition is entirely real and reflects a change in the way the brain processes information related to balance.
How is it treated?
Today, the most effective approach is usually a multidisciplinary one.
Vestibular rehabilitation remains an essential part of treatment, but it is often combined with strategies aimed at reducing hypervigilance and restoring confidence in movement.
In some cases, a physician may also recommend medication.
Recent scientific evidence suggests that the best outcomes are achieved when different interventions are combined and tailored to each patient’s individual needs.
The role of physiotherapy and psychology
In PPPD, physiotherapy is not simply about “doing balance exercises.”
The goal is to expose the brain gradually and in a controlled way to the movements and situations that trigger symptoms, promoting progressive adaptation without causing excessive symptom flare-ups.
At the same time, psychology can play an important role when fear of movement, anxiety, avoidance of certain activities or a significant loss of confidence develops.
Interventions based on cognitive behavioural therapy (CBT) have shown promising results, particularly when integrated into a comprehensive rehabilitation programme alongside vestibular rehabilitation.
The goal is not to convince patients that “nothing is wrong,” but to help the brain stop interpreting situations that no longer represent a real threat to balance as dangerous.
Can neck problems cause vertigo?
This is one of the most common questions asked in clinical practice—and also one of the most misunderstood.
The short answer is: yes, but not always.
For many years, a condition known as cervicogenic dizziness has been described. It refers to a sensation of dizziness or unsteadiness associated with neck pain or cervical dysfunction.
However, the scientific community agrees that this is a complex diagnosis and, above all, a diagnosis of exclusion. In other words, before attributing symptoms to the neck, it is essential to rule out more common causes such as inner ear disorders, vestibular migraine, neurological diseases or cardiovascular conditions.
Why can the neck influence balance?
The joints, muscles and ligaments of the neck contain thousands of receptors that constantly provide the brain with information about the position of the head.
This information is integrated with signals from the inner ear and the visual system to maintain balance.
When there has been trauma, such as whiplash, marked restriction of movement or impaired cervical motor control, these signals may become less accurate.
The brain then receives information that does not fully match the signals coming from the eyes or the vestibular system, which may contribute to a sensation of unsteadiness.
However, this mechanism is still being investigated and does not explain every case of dizziness associated with neck pain.
When should a cervical origin be suspected?
Cervicogenic dizziness may be considered when several of the following features are present:
- neck pain or stiffness clearly associated with the onset of symptoms;
- a feeling of unsteadiness rather than intense spinning vertigo;
- symptoms that worsen with certain neck movements;
- a history of cervical trauma, such as a road traffic accident or a fall;
- no other findings that better explain the symptoms after a thorough medical and vestibular assessment.
None of these features alone confirms the diagnosis. This is why a comprehensive clinical assessment is so important.
💡 Common myth
“If my neck hurts, my vertigo must be coming from my neck.”
Not necessarily.
Many people experience neck pain and a vestibular disorder at the same time. In other cases, the vertigo itself causes neck stiffness because of muscle tension and fear of moving the head.
Current international guidelines consider cervicogenic dizziness to be a diagnosis of exclusion and recommend investigating more common causes first.
How can physiotherapy help?
Physiotherapy plays a key role in the management of most vestibular disorders.
The first step is a comprehensive assessment to identify the most likely cause of the symptoms. Depending on the situation, the physiotherapist may perform positional tests for BPPV, assess vestibular function, evaluate balance and gait, and examine cervical mobility.
Based on this assessment, treatment may include a range of different strategies.
In cases of BPPV, repositioning manoeuvres usually resolve the problem quickly.
For other vestibular disorders, vestibular rehabilitation uses specific exercises to improve gaze stability, restore balance, reduce sensitivity to movement and support a gradual return to everyday activities.
When a cervical impairment is also present, exercises to improve mobility, strength and motor control of the neck may also be included, always tailored to the individual patient.
The goal is not simply to eliminate symptoms, but to help the person move again with confidence and safety.
What role can osteopathy play?
Osteopathy may form part of treatment for some patients, but it is important to understand its role.
It is not intended to replace medical assessment or vestibular rehabilitation when these are indicated.
However, when vertigo or feelings of unsteadiness are accompanied by neck pain, stiffness or restricted mobility, manual therapy may help improve comfort and facilitate the active rehabilitation that follows.
At Aliantis, we view manual therapy as one component of a broader treatment plan that also includes education, therapeutic exercise and a progressive return to activity.
Current scientific recommendations encourage a cautious approach, as the quality of evidence supporting manual therapy for cervicogenic dizziness remains limited. Treatment should therefore always be individualised and based on a comprehensive clinical assessment.
What about psychology?
When symptoms persist for weeks or months, many people develop a fear that the vertigo will return. This is entirely understandable.
Some stop driving, avoid going out alone, give up travelling or gradually reduce their level of physical activity.
This cycle of fear and avoidance can keep the brain in a state of hypervigilance, particularly in PPPD.
In these situations, psychological support can be an extremely valuable part of treatment.
Interventions based on cognitive behavioural therapy (CBT) help people better understand their symptoms, reduce movement-related anxiety and gradually rebuild confidence in everyday activities.
This does not mean that the vertigo is “psychological.” It means that the brain and body function as an integrated system, and addressing both aspects can support a more complete recovery.
Can nutrition have an impact?
There is no specific diet capable of curing every type of vertigo.
However, certain lifestyle habits may influence symptoms in some people.
For people with vestibular migraine, maintaining regular mealtimes, avoiding dehydration and identifying personal triggers—such as excessive alcohol, caffeine or lack of sleep—may help reduce the frequency of attacks.
In other cases, a balanced diet supports overall health and helps prevent factors that may worsen feelings of unsteadiness, such as dehydration or low blood sugar.
Nutrition should therefore be viewed as supportive care within a personalised treatment strategy rather than as a stand-alone treatment.
When should you seek urgent medical attention?
Although most cases of vertigo have a benign cause, there are situations in which immediate medical assessment is essential.
You should attend an emergency department or call emergency services immediately if vertigo is accompanied by any of the following symptoms:
- weakness or loss of strength in an arm or leg;
- difficulty speaking or understanding language;
- double vision or sudden loss of vision;
- numbness affecting one side of the body;
- sudden and severe difficulty walking;
- an unusually severe headache that is different from previous headaches;
- loss of consciousness or fainting;
- chest pain or difficulty breathing.
These symptoms may indicate a neurological or cardiovascular condition that requires urgent medical assessment.
At Aliantis, we believe in personalised care
Not everyone experiencing vertigo requires the same treatment.
Some people improve after a simple repositioning manoeuvre. Others require several weeks of vestibular rehabilitation. In certain cases, treatment may also benefit from osteopathy, psychological support or nutritional counselling.
That is why, at Aliantis, we believe the first step is not simply to treat the symptom, but to understand its cause.
A thorough assessment allows treatment to be directed towards the underlying cause while supporting recovery through an evidence-based approach tailored to each individual’s needs.
Conclusion
Vertigo can be highly disabling and understandably worrying, but in most cases there is an explanation and effective treatments are available.
The most important step is not to look for a universal treatment, but to correctly identify the underlying cause of the symptoms. An accurate diagnosis makes it possible to choose the most appropriate management strategy, avoid unnecessary treatments and support a faster and safer recovery.
If you experience episodes of vertigo, dizziness or persistent unsteadiness that interfere with your daily life, an assessment by a healthcare professional can help determine what is happening and identify the most appropriate treatment for your situation.
Understanding the cause of vertigo is the first step towards restoring balance.
Frequently asked questions about vertigo
Why do I get vertigo when I turn over in bed?
Can stress cause vertigo?
Can neck problems cause vertigo?
How long does an episode of vertigo last?
Can I drive if I have vertigo?
Do vestibular exercises really work?
Which healthcare professional should I see if I have vertigo?
This blog article does not aim to generate new knowledge; it is based on the reading of scientific publications, blog articles and other texts.
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Smyth N, et al. Vestibular migraine treatment: a comprehensive practical review. Brain. 2022.
Geraghty AW, et al. The INVEST Trial: Psychologically Informed Vestibular Rehabilitation for Persistent Postural-Perceptual Dizziness. Journal of Neurology. 2022.
Comparative efficacy of non-pharmacological interventions for persistent postural-perceptual dizziness: a systematic review and network meta-analysis. Journal of Neurology. 2026.
Corna S, et al. Physical therapy interventions for older people with vertigo, dizziness and balance disorders. BMC Geriatrics. 2020.
Dizziness and neck pain: a perspective on cervicogenic dizziness exploring pathophysiology, diagnostic challenges, and therapeutic implications. Frontiers in Neurology. 2025.
The effects of physiotherapy on neck pain with associated symptoms, including cervicogenic dizziness and tinnitus: a systematic review. BMC Musculoskeletal Disorders. 2026.
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