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Vertigo: Moving from symptoms to understanding and treatment

Oct. 12, 2022
Ann-Marie C. DePalma, MEd, RDH, knows about vertigo firsthand. She explains its symptoms and treatments and explains why adding a dizziness/vertigo question to your patients’ medical history form is a good idea.

Some people love roller coasters and other motion amusement rides, but I am not one of them. What happens when everything around you feels like it’s moving, but it really isn’t? Being dizzy from a ride is one thing, but experiencing constant motion when you’re not moving is quite another.

Dizziness is a generalized phenomenon resulting from medication, motion, disease, or balance issues. Vertigo is the sensory sensation of oneself or one’s surroundings being in motion.1 Vertigo is often triggered by a change in head position with patients complaining of:

  • Spinning/tilting
  • Swaying
  • Unbalanced feeling
  • Nausea
  • Headache
  • Tinnitus

It is often associated with inner ear changes but can have other causes as well. It is estimated that 40% of adults in the United States experience vertigo at least once in their lifetime, with women experiencing it more than men.2

Causes of vertigo

The most common cause of vertigo is benign paroxysmal positional vertigo (BPPV). Patients with BPPV report vertigo sensations lasting a minute or less and occurring with body or head movements. BPPV occurs when microscopic calcium deposits (otoliths) become dislodged and trapped within the semicircular canals of the ear.

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Other ear-related causes of vertigo include Ménière’s disease (imbalance of fluid in the ear) and viral or bacterial labyrinthitis (inflammation of the inner ear). Both exhibit similar but different presentations, most notably vertigo lasting hours or days rather than the minutes seen with BPPV. Other non-ear-related causes of vertigo include:

  • Brain tumor
  • Migraines
  • Stroke or TIA
  • Multiple sclerosis
  • Diabetes
  • Heart arrythmias
  • Hyperventilation
  • Orthostatic hypotension
  • Panic attacks or anxiety
  • Multiple prescription use

Tests, treatments, and exercises

Treatments for vertigo vary depending on the diagnosis. Medications such as dimenhydrinate (Dramamine) or meclizine (Bonine) can be prescribed to reduce vertigo symptoms of BPPV, although some practitioners feel that these prolong the vertigo sensations. Patients diagnosed with BPPV often experience vertigo symptoms when rolling to a side position in bed, moving the head up or down, or bending forward. Repositioning a patient’s head during treatment may also trigger a BPPV episode.

An unexpected new case of vertigo can be frightening for patients, who will often seek treatment from their primary care provider (PCP), an urgent care center, or the emergency room of their local hospital. That was my experience. Never having suffered severe vertigo, I experienced 24-plus hours of intense spinning. After contacting my PCP, I was advised to go to a local urgent care center. Initial examination and testing were performed, and an ER visit was advised. Being seen in an ER in the COVID era was a challenge. Additional examinations and testing were performed, and all were within normal limits. A referral to an otolaryngologist (ENT) was suggested.

Dix-Hallpike test

One of the tests that was performed by both the ER physicians and ENT was a maneuver known as Dix-Hallpike. Dix-Hallpike is a diagnostic tool used to determine if the patient is experiencing nystagmus, a hallmark of BPPV. Nystagmus is the rapid, involuntary movement of the eyes either side to side (horizontal nystagmus), up and down (vertical nystagmus), or in a circle (rotary nystagmus).3

The Dix-Hallpike maneuver is performed by rapidly moving the patient from a sitting position to the supine position with the head turned 45 degrees to the right. After waiting approximately 20–30 seconds, the patient is returned to the sitting position.4 The motion is repeated on the left side and if nystagmus is present on either side, a positive finding of BPPV is considered. Clinical visual examination can be performed or specialized glasses that measure eye movement can be utilized.

My tests were inconclusive for nystagmus and, therefore, inconclusive for BPPV. Then, suddenly, several weeks after the initial symptoms appeared, the vertigo disappeared. There are several theories as to what caused the symptoms initially, but nothing has been proved definitively. During the testing and doctor visits, the vertigo was so unrelenting that I didn’t even consider driving. Many others who have suffered from symptoms of vertigo have expressed similar experiences.

Epley maneuver and vestibular rehabilitation

Some BPPV sufferers practice an exercise called the Epley maneuver. This exercise should only be performed by a physical therapist or after the patient has had training by a vestibular rehabilitation physical therapist. Vestibular rehabilitation is an exercise program to improve balance and reduce vertigo or dizziness symptoms.5 Exercises during the vestibular rehabilitation program focus on:

  • Posture training
  • Vision training
  • Stretching, strengthening, and balance exercises
  • Walking and fitness exercises
  • Neck exercises
  • Ergonomic training

A clinical hygienist who is experiencing cervical issues may benefit from an evaluation by a vestibular rehab therapist even if there are currently no symptoms of dizziness or vertigo.

The Epley maneuver is designed for patients who are diagnosed with BPPV and involves relocating the otoliths to their correct orientation in a three-step process.

The test is performed with the patient’s head rotated 45 degrees toward the right ear and the neck slightly extended so the chin is facing upward. The patient will often experience dizziness and nystagmus but once the nystagmus ceases, the head and body are rotated further until the head is tilted downward. The patient is kept in this downward rotated position for 10–15 seconds and may experience vertigo. With the head tilted to a shoulder, the patient is brought into a seated position. Once the patient is upright, the head is tilted so that the chin is facing downward. This rotation and up/down movement may be repeated up to three times.1

Patients with cervical disease, carotid issues, or unstable heart disease are not candidates for Epley. There are several other vestibular rehabilitation exercises that can be employed for those patients who cannot or will not tolerate Epley. Some patients have even reported that chewing gum helps with vertigo.

Role of the dental hygienist

Although vertigo can be a scary issue for many patients and should be evaluated for a sudden onset, it can be treated and effectively managed. For those who like the spinning sensation of motion rides, enjoy them! However, understand that patients with vertigo experience these same sensations, but they are not enjoying them. Educate yourself and your team about vertigo and consider adding a dizziness/vertigo question to your medical history. Research vestibular rehabilitation therapists in your area to serve as a resource for patients. Your patients will thank you for it. 

Editor's note: This article appeared in the October 2022 print edition of RDH magazine. Dental hygienists in North America are eligible for a complimentary print subscription. Sign up here.


  1. Furman JM, Cass SP. Benign paroxysmal positional vertigo. N Engl J Med. 1999;341(21):1590-1596. doi:10.1056/NEJM199911183412107
  2. Vertigo. University of California San Francisco. Accessed July 1, 2022. https://www.ucsfhealth.org/conditions/vertigo
  3. Boyd K. What is nystagmus? American Academy of Ophthalmology. January 11, 2022. Accessed July 1, 2022. https://www.aao.org/eye-health/diseases/what-is-nystagmus
  4. Li JC. Benign paroxysmal positional vertigo clinical presentation. Updated January 14, 2022. Accessed July 1, 2022. Medscape. https://www.medscape.com/answers/884261-46057/how-is-the-dix-hallpike-maneuver-performed-and-which-findings-indicate-benign-paroxysmal-positional-vertigo-bppv
  5. Vestibular rehabilitation. Cleveland Clinic. Updated May 4, 2018. Accessed July 1, 2022. https://my.clevelandclinic.org/health/treatments/15298-vestibular-rehabilitation
About the Author

Ann-Marie DePalma, MEd, RDH, CDA, FAADH, FADIA

Ann-Marie DePalma, MEd, RDH, CDA, FAADH, FADIA, is a technology advisor for Patterson Dental, a writer for RDH magazine, and an author in dental hygiene textbooks. She is the 2017 Massachusetts College of Pharmacy & Health Sciences Esther Wilkins Distinguished Alumni recipient. She is a continuous member of the American Dental Hygienists’ Association and an active member of the Massachusetts Dental Hygiene Association.