Vertigo vs. Dizziness: What’s Really Going On in Your Brain and Inner Ear

People say they feel "dizzy" all the time. But if you’ve ever had vertigo, you know it’s not the same thing. One feels like the room is spinning. The other feels like you’re about to pass out. They’re not interchangeable. And mistaking one for the other can delay real treatment-sometimes for years.

Vertigo Isn’t Just Dizziness

Vertigo isn’t a vague feeling of unsteadiness. It’s a specific illusion: you or the world around you is moving, usually spinning. You’re sitting still, but your brain says you’re on a merry-go-round. That’s not anxiety. That’s your vestibular system sending false signals. It’s like your inner ear is screaming, "We’re turning!"-even when you’re not.

Dizziness? That’s different. It’s lightheadedness. A foggy head. A sense you might faint. You don’t feel rotation. You just feel off. It’s what happens when your blood pressure drops too fast standing up, when you’re low on iron, or when meds mess with your balance. It’s not a spinning sensation. It’s a sinking one.

That distinction matters because the causes are worlds apart. And so are the treatments.

Why Your Inner Ear Is the Key

Your inner ear isn’t just for hearing. It’s your body’s gyroscope. Three fluid-filled semicircular canals detect head rotation. Tiny crystals (otoconia) in the utricle and saccule sense gravity and straight-line movement. Together, they send data to your brain 100 to 200 milliseconds after you move. That’s faster than you can blink.

When those crystals get loose-like in Benign Paroxysmal Positional Vertigo (BPPV)-they float into the wrong canal. Every time you roll over or look up, they jiggle the fluid, tricking your brain into thinking you’re spinning. BPPV is the #1 cause of vertigo. It affects 2.4% of people every year. Half of those are over 50.

That’s why the Epley maneuver works. It’s not magic. It’s physics. A series of controlled head movements, done right, guides those loose crystals back where they belong. Success rate? 80-90%. Most people feel better after one or two sessions. Yet, many go months-or years-misdiagnosed as having "anxiety" or "aging."

Neurological Vertigo: When the Brain Lies

Not all vertigo comes from the ear. Sometimes, it comes from the brain.

When a stroke hits the brainstem or cerebellum, it can disrupt how vestibular signals are processed. That’s central vertigo. It’s rare-only 5-10% of cases-but dangerous. Unlike BPPV, it doesn’t just happen when you turn your head. It’s constant. And it often comes with other red flags: double vision, slurred speech, numbness on one side, or trouble walking in a straight line.

Multiple sclerosis can do the same. So can vestibular migraine. That’s right-migraines don’t always mean headaches. Some people get vertigo as their only symptom. They feel like they’re on a boat, nauseated, sensitive to light, and then it fades. Doctors often mistake this for inner ear infections. But if you’ve had migraines before, or if your vertigo episodes last hours and come with nausea, it’s likely vestibular migraine. It makes up 7-10% of all vertigo cases.

Here’s the catch: central vertigo doesn’t usually cause hearing loss. Peripheral vertigo (from the ear) often does. If you suddenly lose hearing on one side with vertigo, that’s not BPPV. That’s something more serious.

Dizziness: The Broad Category With Many Faces

Dizziness isn’t one condition. It’s a symptom with dozens of causes.

Cardiovascular issues are the biggest culprit-about 20-30% of cases. Orthostatic hypotension: your blood pressure drops too much when you stand. You feel faint. Your vision tunnels. You might even black out. It’s common in older adults, especially if they’re on blood pressure meds.

Anemia and low blood sugar? They’re next. When your brain doesn’t get enough oxygen or glucose, it doesn’t function right. You feel dizzy, tired, confused. Easy to fix-once you know the cause.

Then there’s medication. Antibiotics like gentamicin can damage your inner ear. Blood pressure pills, antidepressants, even some allergy meds can throw off your balance. If your dizziness started after a new prescription, talk to your doctor. Don’t assume it’s just "getting older."

And then there’s psychological dizziness. Anxiety doesn’t cause vertigo, but it can make you hypersensitive to normal balance signals. That’s Persistent Postural-Perceptual Dizziness (PPPD). It often follows a real vestibular event-like an infection or BPPV-that never fully resolved. Your brain gets stuck in "alarm mode." You feel off even when you’re calm. It’s real. It’s not "all in your head." It’s your nervous system overreacting.

How Doctors Tell the Difference

There’s no single blood test for vertigo or dizziness. Diagnosis is all about clues.

Doctors start with history: When did it start? What triggers it? How long does it last? Do you hear ringing? Lose hearing? Have headaches? Numbness?

Then comes the physical exam. The head impulse test checks if your inner ear reflexes work. If your eyes jerk when you quickly turn your head, it points to vestibular neuritis. If your eyes move involuntarily in a rhythmic pattern (nystagmus), the direction and timing tell you if it’s peripheral or central.

Videonystagmography (VNG) is the gold standard. You wear special goggles while your eyes are tracked as you follow lights and get cold/warm air blown into your ears. It shows exactly how well your vestibular system is firing. It’s 95% accurate for peripheral problems.

But here’s the problem: only 12% of primary care doctors feel confident diagnosing vertigo. Most rely on guesswork. That’s why delays are so common. People wait 8 months on average before getting the right diagnosis. BPPV patients get answers faster-around 3 months. Those with Ménière’s disease? Nearly 15 months.

What Actually Helps

Treatment depends entirely on the cause.

For BPPV: Epley maneuver. Done in a clinic or at home with guidance. Takes 10-15 minutes. Works in most cases.

For vestibular neuritis: Short-term steroids to reduce inflammation, then vestibular rehabilitation. That’s physical therapy for your balance system. Exercises to retrain your brain to trust signals from your inner ear again. It takes 6-8 weeks. But 89% of people who stick with it see major improvement.

For vestibular migraine: Avoid triggers-stress, caffeine, skipped meals. Some people take daily migraine preventatives like beta-blockers or topiramate. New FDA-approved protocols for transtympanic gentamicin can help severe, frequent attacks.

For cardiovascular dizziness: Adjust meds, increase salt and water intake, rise slowly. For anemia: iron supplements. For PPPD: cognitive behavioral therapy (CBT) combined with balance retraining. It’s not about fixing your inner ear-it’s about calming your nervous system.

And for stroke-related vertigo? That’s an emergency. If you have vertigo with new weakness, slurred speech, or double vision-call 911. Don’t wait. Don’t assume it’s just a bad ear infection.

What Doesn’t Work

Antibiotics for "ear infection" when there’s no infection. Anti-nausea meds alone for BPPV. SSRIs for dizziness without anxiety. And the worst: telling someone their vertigo is "just stress."

Over 30% of vestibular migraine cases are misdiagnosed as sinusitis or anxiety. One patient spent two years on antidepressants before a specialist found the real cause: migraines triggered by sleep loss and screen glare.

And here’s the hard truth: if you have PPPD and no one tells you what it is, you’ll keep cycling through doctors, tests, and meds that don’t touch the root problem. You’ll feel dismissed. You’re not crazy. Your brain just got stuck in a loop.

The Bigger Picture

The global market for vertigo treatments is growing fast-$2.8 billion in 2022 and climbing. Why? Because more people are being diagnosed. More hospitals are offering vestibular rehab. Medicare now pays $235 per VNG test-up from $185 in 2020.

But access is uneven. Only 42% of community hospitals have specialized vestibular programs. Academic centers? 78%. That means if you live outside a big city, you might need to travel for the right care.

And the population is aging. One in three adults over 65 has dizziness. By 2030, demand for vestibular services will jump 25%. We’re not ready.

Research is moving fast too. Stanford is testing hair cell regeneration. Johns Hopkins has AI that can read eye movements and tell if vertigo is from the ear or the brain-with 85% accuracy. That could change ER diagnostics overnight.

What You Can Do Now

If you’re dizzy or spinning:

• Write down your symptoms: When? How long? What triggers it? Any hearing loss? Headache? Numbness?
• Don’t assume it’s stress. Don’t self-diagnose with Google.
• Ask your doctor for a head impulse test or VNG. If they don’t know what that is, ask for a referral to an ENT or neurotologist.
• If you have vertigo with new neurological symptoms-go to the ER.
• If you have BPPV, ask for the Epley maneuver. Don’t wait.
• If you’ve had dizziness for months with no diagnosis, seek out a vestibular therapist. They’re certified. They know what they’re doing.

You don’t have to live with this. The right diagnosis isn’t magic. It’s science. And it’s available-if you know what to ask for.