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

Ever felt like the room was spinning? Or just plain lightheaded, like you might pass out? These feel similar - but they’re not the same thing. Vertigo and dizziness are often used interchangeably, but they point to very different problems in your body. Mixing them up can lead to months of wrong treatments, unnecessary meds, and growing frustration. If you’ve been told it’s just stress or aging, but nothing helps, you’re not alone. And you’re not imagining it.

What Exactly Is Vertigo?

Vertigo isn’t just feeling unsteady. It’s the false sensation that you - or everything around you - is spinning, tilting, or moving when you’re completely still. Imagine lying in bed, closing your eyes, and suddenly feeling like you’re on a merry-go-round. That’s vertigo. It’s not anxiety. It’s not fatigue. It’s your brain receiving conflicting signals from your inner ear and your eyes.

This sensation comes from the vestibular system - a network of fluid-filled tubes and tiny crystals in your inner ear. These structures detect head movement and send data to your brain at lightning speed (in under 200 milliseconds). When something goes wrong here - like crystals getting loose or nerves getting inflamed - your brain gets confused. That’s when you feel the spin.

The most common cause? Benign Paroxysmal Positional Vertigo, or BPPV. It happens when tiny calcium crystals (otoconia) break free from their normal spot and float into the wrong canal. When you turn your head, these loose crystals push on fluid in the canal, tricking your brain into thinking you’re spinning. BPPV accounts for 20-30% of all vertigo cases, and it’s especially common after age 50. The good news? It’s treatable. A simple maneuver called the Epley maneuver repositions those crystals. In 80-90% of cases, one or two sessions clear it up completely.

What Exactly Is Dizziness?

Dizziness is the broader term - and it’s not about spinning. It’s that heavy, foggy, floating, or faint feeling. You might feel like you’re going to pass out, or that your feet aren’t connected to the ground. You don’t see the room move. You just feel off.

This kind of dizziness often comes from systems outside your inner ear. Low blood pressure when you stand up (orthostatic hypotension) is a big one. If your systolic pressure drops more than 20 mmHg when you rise, your brain doesn’t get enough blood fast enough. That’s why you get lightheaded. Anemia, low blood sugar, dehydration, or even certain medications can trigger this. It’s not a neurological problem - it’s a systems problem.

Psychological factors also play a role. Chronic stress, anxiety, or depression can cause persistent dizziness that feels real but doesn’t involve the inner ear. This is called non-vestibular dizziness. It’s not "all in your head" - it’s your nervous system stuck in overdrive. But it responds differently to treatment than vertigo does.

Neurological Causes of Vertigo: When Your Brain Is the Problem

Not all vertigo comes from the inner ear. Sometimes, it’s the brain itself. Central vertigo means the problem is in the brainstem, cerebellum, or thalamus - areas that process balance signals. These are less common but far more serious.

Stroke is the biggest red flag. If vertigo comes with slurred speech, double vision, trouble walking, numbness on one side, or sudden severe headache, it could be a stroke. Only 2-3% of vertigo cases are stroke-related, but they make up 25% of emergency room vertigo visits because they’re so dangerous. A 2023 Johns Hopkins study found that only 12% of ER doctors correctly spot stroke-related vertigo using standard tools. That’s why timing matters.

Multiple sclerosis can also cause vertigo. If you’re young and have a history of vision problems or muscle weakness, and now you’re getting spinning spells, it could be MS. Vestibular migraine is another sneaky one - it’s not just a headache. You get vertigo without a headache, or with a headache that comes later. It affects 7-10% of vertigo patients and is often misdiagnosed as Ménière’s disease or anxiety.

Here’s how to tell neurological vertigo apart from inner ear vertigo: neurological cases often come with other brain symptoms. Numbness, trouble swallowing, double vision, or loss of coordination aren’t typical in BPPV or vestibular neuritis. If you have those, you need imaging - not just a head turn.

Vestibular Causes: The Inner Ear’s Role

The inner ear is where most vertigo starts. The semicircular canals detect rotation. The otolith organs detect up-and-down movement. When these are damaged, the brain gets false motion signals.

BPPV is the MVP here - the most common vestibular disorder. But there are others. Vestibular neuritis is an inflammation of the nerve connecting the inner ear to the brain. It usually hits suddenly, with intense spinning that lasts days, followed by weeks of imbalance. It’s often after a cold or flu. Labyrinthitis is similar but includes hearing loss or ringing in the ear.

Ménière’s disease is rarer - affecting about 615,000 Americans - but it’s brutal. You get spinning attacks lasting 20 minutes to several hours, along with roaring tinnitus, ear pressure, and hearing loss that gets worse over time. It’s caused by fluid buildup in the inner ear. Treatment includes salt restriction, diuretics, and in severe cases, gentamicin injections into the ear to disable the bad side.

These conditions show up clearly on diagnostic tests. Videonystagmography (VNG) records eye movements during head movements. Nystagmus - involuntary eye jerking - is the telltale sign. In peripheral vertigo (inner ear), the nystagmus has a specific pattern and fades when you fix your gaze. In central vertigo (brain), the pattern is irregular and doesn’t fade. That’s how experts tell them apart.

Diagnosis: What Doctors Actually Do

Most primary care doctors aren’t trained to spot the difference. Only 12% say they feel "very confident" diagnosing vertigo. That’s why so many people wait months - or years - for answers.

Here’s what a proper evaluation looks like:

1. History: When did it start? What triggers it? Does it spin or just feel faint? Any hearing loss? Headache? Numbness?
2. Physical exam: The head impulse test checks if your inner ear reflexes work. The Dix-Hallpike maneuver checks for BPPV. If you get spinning and nystagmus during this, it’s BPPV.
3. VNG testing: Goggles with cameras track your eye movements as you follow lights and as cold/warm air is blown in your ears. This picks up 95% of inner ear problems.
4. Imaging: Only needed if there are red flags - like new weakness, vision changes, or difficulty walking. MRI rules out stroke or MS.

Don’t settle for "it’s stress" or "you’re getting older." If your dizziness or vertigo is persistent, get referred to a neurotologist or vestibular specialist. The Vestibular Disorders Association (VEDA) has a directory of certified providers.

Treatment: What Actually Works

Wrong diagnosis = wrong treatment. Here’s what works for each:

• BPPV: Epley maneuver - done in-office or at home. 90% effective in 1-3 sessions.
• Vestibular neuritis: Short-term steroids, then vestibular rehab. No pills fix the spinning - your brain has to relearn balance.
• Ménière’s disease: Low-salt diet, diuretics, stress control. Injections of gentamicin can stop attacks by disabling the affected ear.
• Vestibular migraine: Preventive meds like beta-blockers or topiramate, avoiding triggers (stress, caffeine, sleep loss), and vestibular rehab.
• Orthostatic dizziness: Increase fluids, salt, compression stockings. Stand up slowly.
• Chronic dizziness from anxiety: Cognitive behavioral therapy (CBT) and graded exposure to movement. Medications like SSRIs help, but only when paired with movement therapy.

Vestibular rehabilitation therapy (VRT) is the unsung hero. It’s not just exercises - it’s a personalized program to retrain your brain. You start with simple balance tasks (standing with eyes closed), then move to walking with head turns, then navigating busy spaces. Most people see big improvement in 6-8 weeks. But 35% of patients quit because it feels hard at first. Stick with it. It works.

Real Stories, Real Delays

On Reddit’s r/vertigo community, people report waiting an average of 8.2 months for a correct diagnosis. BPPV patients get answers faster - around 3 months. But those with Ménière’s or vestibular migraine wait over a year. One person spent two years on antidepressants for "anxiety dizziness" - until a VNG test showed vestibular migraine. Another spent 18 months being told it was stress, until a canalith repositioning maneuver fixed her spinning in 15 minutes.

But it’s not all bad. UCHealth reports 89% success with VRT. Medicare now pays $235 per vestibular test - up from $185 in 2020 - because providers finally see the value. Hospitals are adding vestibular clinics: 42% now, up from 18% in 2015.

What’s Next?

The future is getting better. The FDA approved a new home-based vestibular rehab device in May 2023. Johns Hopkins is using AI to analyze eye movements and spot stroke-related vertigo with 85% accuracy. Stanford is testing hair cell regeneration - the first step toward actually repairing damaged inner ears.

But right now, the biggest gap isn’t technology - it’s awareness. Dizziness affects 15-20% of adults every year. Vertigo affects 1 in 5 of those. Yet most people don’t know the difference. And doctors still miss the signs.

If you’re dizzy or spinning, don’t wait. Track your symptoms: When? How long? What makes it better or worse? Do you hear ringing? Feel numb? See double? Bring that list to a specialist. Don’t let another month go by thinking it’s just stress. Your brain and inner ear are trying to tell you something. Listen.