Common Causes of Vertigo in Primary Care: Part 1

This transcript has been edited for clarity.

In this three-part podcast, we're going to talk about vertigo and some of the more common causes of vertigo we see in primary care. Now, let's start with a patient who hopefully we might all identify in our own clinical practices. Flora is a 67-year-old lady who presents with a 5-day history of dizziness. She describes brief 20- to 30-second episodes of her head spinning when she rolls over in bed, looks up to reach cupboards, and bends over to pick up something. She's well in between these episodes, though occasionally does feel a little off balance.

On systemic inquiry, there is no hearing loss, tinnitus, ear fullness, headache, visual or speech disturbance, or limb weakness. Past medical history includes hypertension, for which she takes amlodipine 5 mg. Examination revealed stable observations and no evidence of a postural drop in blood pressure. Cardiovascular, respiratory, and neurologic examinations were unremarkable.

What are your thoughts? Is this vestibular neuritis or labyrinthitis? Is this benign paroxysmal positional vertigo (BPPV)? Is this vestibular migraine or the rare Ménière disease? Or are you worried about something a wee bit more serious? Could this be a posterior circulation stroke?

And what do you do next? Do you prescribe a vestibular sedative such as cyclizine or prochlorperazine? Do you undertake a Dix-Hallpike test or head impulse, nystagmus, test of skew (HINTS) examination to try and clarify the underlying diagnosis? Do you prescribe a triptan, such as rizatriptan or zolmitriptan, for presumed vestibular migraine? Do you prescribe betahistine for presumed Ménière disease? Or do you phone a friend and discuss with the stroke hotline or acute medical receiving to exclude stroke?

Flora has intermittent and recurrent true vertigo with episodes lasting less than a minute. She likely has BPPV, and diagnosis should be confirmed with a Dix-Hallpike test. I'll return to BPPV shortly, but let's start with a definition of vertigo.

Vertigo is defined as the illusion or false sensation of movement of an individual or the environment around them. Our patients, of course, will not routinely tell us this. They will often tell us that they are feeling dizzy, like Flora. So, as always, it's all in the history to elucidate any false movement, such as the impression that they or the room are spinning or tilting.

Questions we ask should include questions to qualify the sensation. Do you feel like you might pass out, or does it feel like the room is spinning? Do you feel as if you are moving when you're sitting perfectly still? Do you have a sensation of being tilted or tipped over?

We should also ask Flora about timing and triggers. How long do these episodes last? Seconds, minutes, or hours? Does a specific movement bring it on, like rolling over in bed, standing up, or tilting your head to one side? Also, ask Flora about any associated audiovestibular symptoms. Have you noticed any changes in your hearing, such as sudden hearing loss or a feeling of fullness in your ear? Do you have a ringing, buzzing, or hissing sound in your ear or tinnitus?

And finally, importantly, exclude any red flags. Are you experiencing double vision, blurred vision, or loss of vision? Do you have any new numbness, tingling, or weakness in your face, arms, or legs? Have you had sudden difficulty speaking, any slurred speech, or trouble swallowing? And do you have a sudden severe headache, especially if it was a thunderclap onset suggestive of a subarachnoid hemorrhage?

We also need to be aware of common mimics of vertigo, such as presyncope, which can often suggest an underlying cardiovascular issue, such as postural hypotension, arrhythmia, hypovolemia, or vasovagal syncope. Consider checking heart rate to check for sinus rhythm, atrial fibrillation, or another arrhythmia. Check sitting and standing blood pressures to exclude postural hypotension and consider an ECG.

Disequilibrium (unsteadiness, imbalance, or spatial disorientation) can also mimic vertigo. Disequilibrium is often multifactorial in nature, possibly related to underlying peripheral neuropathy, poor eyesight, musculoskeletal issues, electrolyte disturbance, or intercurrent infection. Or it can be iatrogenic, related to side effects of medications.

There is a wide range of medications that can cause disequilibrium, including antidepressants, anticonvulsants, and cardiovascular drugs, including diuretics, calcium channel blockers, alpha blockers, and nitrates.

Finally, don't forget about hypoglycemia in people living with or without diabetes as a potential mimic of vertigo.

Back to BPPV. BPPV is the most common cause of vertigo we will see in primary care. It is a benign and usually self-limiting condition caused by dislodgement of otoliths (or small calcium carbonate crystals) from the utricle to the semicircular canals in the inner ear. The utricle is a small, fluid-filled pouch in the inner ear, whereas the semicircular canals are three tiny fluid-filled tubes, also in the inner ear. Both are key components of the vestibular system. Specialized sensory hair cells in the utricle detect movement of these otoliths and convert them into nerve signals, which are relayed to the brain to maintain balance. In BPPV, the otoliths migrate into the semicircular canals, triggering false signals to the brain that result in sudden, brief vertigo.

Paroxysms of vertigo in BPPV usually last less than 1 minute and are typically triggered by head movement. Some individuals describe a more continuous, vague feeling of imbalance between episodes.

A diagnosis of BPPV should be confirmed with a Dix-Hallpike test to identify any torsional nystagmus. The person's head is rotated 45° to one side and then rapidly lowered in one brisk, smooth motion until the head hangs over the end of the bed, around 30° below the horizontal plane. If nystagmus is observed, this is a positive test, and a diagnosis of BPPV can be established. The Dix-Hallpike test should be done on both sides. There are plenty of great videos online demonstrating this test if you are unfamiliar with it.

Treatment is best done by completing the Epley maneuver, which is basically an extended version of the Dix-Hallpike test. The Epley maneuver uses gravity to guide the displaced otoliths out of the semicircular canals and back into the utricle to relieve vertigo. There are plenty of great videos online demonstrating the Epley maneuver. Alternatively, there are plenty of useful patient information leaflets on how patients can undertake the Epley maneuver themselves at home.

Finally, and importantly, vestibular sedatives such as cyclizine and prochlorperazine have no effect on symptom resolution and should not be prescribed.

In part two of this three-part vertigo episode, I will be covering vestibular neuritis, labyrinthitis, and how we can distinguish these diagnoses from more serious central causes of vertigo, such as a posterior circulation stroke.

Medscape Family Medicine © 2026 WebMD, LLC

Any views expressed above are the author's own and do not necessarily reflect the views of WebMD or Medscape.

Cite this: Common Causes of Vertigo in Primary Care: Part 1 - Medscape - Jul 02, 2026.