Treatment of Vertigo Dizziness and Balance Disorders in Turkey

Feeling dizzy or unsteady is one of the most common reasons patients see a doctor. It can strike suddenly when getting out of bed, or it can linger for days and disrupt work and daily life. In most cases the cause is simple and treatable, but some cases require an accurate diagnosis to rule out serious causes. In this guide, we explain what vertigo is, its causes and symptoms, and how it is diagnosed and treated in Turkey, where a number of hospitals and specialized centers offer ear, nose and throat (ENT) and neurology departments equipped with balance-testing devices.

What Are Vertigo and Dizziness?

"Dizziness" is a broad term people use to describe different sensations, such as feeling faint, lightheaded, mentally foggy, weak, or unsteady while standing and walking.

Vertigo is a specific type of dizziness. It is a false sensation that you are spinning, or that the objects around you are spinning or moving, even though your body is still. It often results from a disorder of the vestibular system, the part of the inner ear, the associated nerves and the brain that is responsible for balance.

Dizziness is one of the most common complaints among adults. Episodes may recur or persist for a period of time, affecting quality of life and increasing the risk of falls and injuries. Even so, it rarely indicates a life-threatening condition, and in most cases it can be controlled once the cause is identified.

Treatment depends on the cause and the accompanying symptoms, and may include medication, rehabilitation exercises, or special head-positioning maneuvers. Most cases improve with appropriate treatment, but symptoms may sometimes return, so follow-up with a specialist doctor is recommended.

Symptoms of Vertigo and Balance Disorders

Symptoms vary from person to person. It is helpful for patients to describe to their doctor exactly what they feel, because this description alone largely guides the diagnosis. People experiencing dizziness may describe the following:

• A false sensation of spinning or movement (vertigo), as if the room is spinning around you.
• Lightheadedness or a feeling that you are about to faint.
• Loss of balance or a feeling of unsteadiness while standing and walking.
• A floating sensation, mental fogginess, or a heavy head.
• Nausea or vomiting during an episode.
• Sweating and pale skin in some cases.

When Do Symptoms Appear and How Long Do They Last?

Symptoms often appear or worsen when walking, standing, moving the head, or changing position, such as rolling over in bed. An episode may come on suddenly and so severely that you have to sit or lie down to avoid falling.

The duration of an episode varies widely, which is useful for diagnosis. If an episode is very brief, lasting seconds to less than a minute, and occurs when the head position changes, the cause is most often benign paroxysmal positional vertigo (BPPV). Episodes lasting from minutes to hours may point to vestibular migraine or Ménière's disease. If vertigo lasts continuously for several days, the cause may be vestibular neuritis or labyrinthitis. These durations are only a guide and do not replace a medical examination.

When Should You See a Doctor?

See a specialist doctor (ENT or neurology) if the vertigo is:

• Recurrent, sudden, or severe.
• Long-lasting with no clear cause.
• Affecting your work, driving, or sleep.
• Accompanied by hearing loss or ringing in the ear (tinnitus).

When Should You Go to the Emergency Room Immediately?

Seek emergency medical care (in Turkey, you can call 112) if you develop new, severe vertigo or dizziness together with any of the following symptoms:

• Sudden, severe headache, or chest pain.
• A rapid or irregular heartbeat.
• Numbness or weakness in the face, arms, or legs.
• Difficulty walking, obvious stumbling, or inability to stand.
• Difficulty breathing.
• Fainting or seizures.
• Double vision or loss of vision, or a sudden change in speech.
• Confusion or slurred speech.
• Persistent vomiting.

Why do these symptoms matter? Vertigo accompanied by neurological symptoms may be a sign of a stroke in the posterior circulation of the brain. This is a condition that requires urgent intervention and must not be treated as ordinary vertigo.

Causes of Vertigo and Dizziness

Vertigo has many possible causes, including inner ear disorders, circulatory problems, side effects of certain medications, and motion sickness. Less commonly, the cause may be an infection, an injury, or a neurological disease. The nature of the sensation, the factors that trigger it, how long it lasts, and the accompanying symptoms provide important clues that help the doctor identify the cause accurately.

How Does the Inner Ear Maintain Balance?

Our sense of balance depends on the integration of information from three sources:

• The eyes: determine the body's position in space and its direction of movement.
• Sensory receptors in the muscles and joints: send the brain information about body position and movement.
• The inner ear (vestibular system): detects gravity and head movement.

The vestibular system consists of the three fluid-filled semicircular canals, which sense rotational head movements, and two small organs in the vestibule, the utricle and the saccule. These two organs contain vestibular hair cells topped with tiny crystals of calcium carbonate called otoconia, which help detect head position relative to gravity and linear motion, such as going up and down in an elevator or moving forward and backward in a car. It is worth noting that they have nothing to do with earwax.

When the inner ear malfunctions, the brain receives signals that do not match what the eyes and sensory receptors are reporting. The sensation of vertigo results as the brain tries to resolve this conflict.

Inner Ear Disorders That Cause Vertigo

1. Benign paroxysmal positional vertigo (BPPV)

This is the most common cause of vertigo. It occurs when some of the otoconia become detached from their normal location and enter one of the semicircular canals, causing a strong, brief sensation of spinning. Episodes are triggered by a sudden change in head position, such as rolling over in bed, sitting up, or looking upward. A head injury may be a cause of the condition, while the direct trigger of an episode is head movement.

2. Vestibular neuritis and labyrinthitis

Both conditions usually occur after a viral infection. The difference between them lies in the location of the inflammation:

• Vestibular neuritis: affects the nerve that carries balance signals from the inner ear to the brain. It causes severe, continuous vertigo that may last for days, usually without affecting hearing.
• Labyrinthitis: affects the inner ear itself. It causes vertigo along with hearing loss or tinnitus.

3. Vestibular migraine

People with migraine may experience episodes of vertigo, even without a severe headache. An episode lasts from minutes to hours and may be accompanied by sensitivity to light and noise.

4. Ménière's disease

An inner ear disorder believed to be related to an excess of fluid in the inner ear. It causes sudden episodes of vertigo that usually last from about 20 minutes to 12 hours, along with hearing loss that may fluctuate, tinnitus, and a feeling of fullness in the ear. It is less common than the other conditions, and treatments aim to reduce the number of episodes rather than to cure the disease completely.

Circulatory Problems

You may feel dizzy or faint if not enough blood reaches the brain. Causes include:

• Orthostatic hypotension: a temporary drop in blood pressure when standing or getting up quickly after sitting or lying down, causing a brief feeling of faintness.
• Poor blood flow: for example cardiomyopathy, heart attack, heart rhythm disorders, or transient ischemic attack (TIA), all of which can reduce blood flow to the brain or inner ear.

Other Causes of Vertigo

• Neurological diseases: such as Parkinson's disease and multiple sclerosis, which can lead to a gradual loss of balance.
• Medications: drugs that may cause dizziness include anti-seizure medications, antidepressants, sedatives, and some pain relievers. Blood pressure medications may also cause fainting if they lower blood pressure too sharply. Do not stop any medication on your own before consulting your doctor.
• Anxiety disorders: such as panic attacks and agoraphobia.
• Anemia: which may be accompanied by fatigue, weakness, and pale skin.
• Low blood sugar: usually affects people with diabetes who use insulin or certain glucose-lowering medications, and may be accompanied by anxiety and sweating. Hunger after a missed meal can cause unpleasant symptoms without necessarily meaning that blood sugar is low.
• Carbon monoxide poisoning: its symptoms resemble the flu and include headache, dizziness, weakness, nausea, vomiting, chest pain, and confusion. It is an emergency, especially in winter with the use of heaters and water heaters. If you suspect it, go outside into fresh air and call emergency services.
• Overheating or dehydration: may occur with activity in hot weather or insufficient fluid intake, and the risk is higher with some heart medications.

Factors That Increase the Risk of Dizziness

• Age: older adults are more prone to balance problems and to taking medications that may cause dizziness.
• Previous episodes: people who have had dizziness before are more likely to experience it again.

Complications of Vertigo

Vertigo can increase the risk of falls and physical injuries, especially in older adults. It also raises the likelihood of accidents while driving or operating machinery. Longer-term complications may appear if the condition causing the vertigo is not treated.

Methods of Diagnosing Vertigo and Balance Disorders in Turkey

Diagnosis of vertigo begins with an attempt to determine the type and cause of the dizziness. In most cases, this process relies more on conversation with the patient and the clinical examination than on devices. In Turkey, the evaluation is usually carried out by an ENT specialist or a neurologist, and the patient may be referred to an audiology and balance specialist, a cardiologist, or a physiotherapist, depending on the case.

Clinical Examination and Medical History

The doctor first asks about the nature and timing of the symptoms: When did they start? How long does an episode last? What triggers it? Is it accompanied by hearing symptoms, headache, or neurological symptoms? The doctor also asks about the medications you take, chronic illnesses, and previous head injuries.

The doctor then performs a physical examination to assess how you walk and your ability to maintain balance, and examines the cranial nerves, muscle strength, sensation, and reflexes to confirm that the nervous system is intact. Blood pressure is also measured while lying down and standing to detect orthostatic hypotension.

Eye and Balance Tests

• Eye movement test (nystagmus): the doctor observes your eye movements while you follow a moving object, because certain patterns of involuntary eye movement indicate the source of the problem. Special goggles with a camera that records the movement may be used, known as videonystagmography (VNG).
• Caloric test: water or air at a specific temperature is introduced into the ear canal to stimulate the vestibular system and compare the response of the two ears.
• Video head impulse test (vHIT): a modern test that measures the function of the semicircular canals during rapid, controlled head movements.
• HINTS exam: a set of brief clinical eye-movement tests performed by the doctor in acute cases to distinguish between vertigo of peripheral origin (the inner ear) and vertigo of central origin (the brain), such as a posterior-circulation stroke. It is best performed by a doctor trained in it.
• Dix-Hallpike maneuver: a simple test in which your head and body are moved quickly from a sitting position to lying down with the head turned. It confirms BPPV when vertigo and the characteristic eye movement appear.
• Posturography: you stand barefoot on a platform and try to maintain your balance under different conditions, to determine which parts of the balance system you rely on most and which may be causing the problem.
• Rotary chair test: you sit in a computer-controlled chair that moves slowly in a full circle, then at higher speeds in a small arc back and forth, to measure the function of the vestibular system.

Hearing Tests

An audiogram (hearing test) may be requested to detect any hearing loss. This is particularly important when Ménière's disease or labyrinthitis is suspected.

Imaging and Laboratory Tests

• Magnetic resonance imaging (MRI) or computed tomography (CT): requested immediately when a stroke is suspected, after a blow to the head, or when neurological symptoms appear, and they may also be requested for older adults. MRI is more accurate for imaging the back of the brain, as a CT scan may not show some small strokes.
• Blood tests: to detect infection, anemia, low blood sugar, or other disorders.
• Heart and vascular tests: such as an electrocardiogram (ECG) and blood pressure measurement, when a cardiac or circulatory cause is suspected.

An Important Note

Do not try vertigo treatment maneuvers on yourself before a doctor confirms the diagnosis. Choosing the wrong maneuver, or performing one when there is another cause for the vertigo, may not help and may cause harm.

Methods of Treating Vertigo and Dizziness in Turkey

In many cases, vertigo improves on its own, as the body usually adapts to the cause of the problem within a few weeks. However, if symptoms persist, recur, or affect your daily life, the doctor will determine the appropriate treatment based on the cause and symptoms. Treatment may include medication, head-positioning maneuvers, balance exercises, psychotherapy, and, in rare cases, surgery or delicate procedures.

Medication

The doctor chooses the medication according to the diagnosis, and these medications should not be used without medical supervision:

• Diuretics: used in Ménière's disease. Together with a low-salt diet, they help reduce the number of vertigo episodes, but they do not cure the disease permanently.
• Medications to relieve vertigo and nausea: given to quickly relieve acute symptoms, such as certain antihistamines and anticholinergics, many of which cause drowsiness. They are usually used for a short period during an acute episode only, because prolonged use may slow the recovery of the vestibular system.
• Benzodiazepines (such as diazepam): not a routine treatment for vertigo. The doctor may occasionally prescribe them for a very short period during severe episodes or when there is severe anxiety, but they cause drowsiness and may lead to dependence and addiction. Long-term use also impairs natural vestibular compensation, so it is not recommended.
• Migraine prevention medications: used for vertigo associated with vestibular migraine, and they help reduce the frequency of episodes.
• Anti-anxiety medications and antidepressants: may be used in some cases of anxiety-related vertigo, at the doctor's discretion.

Most of these medications are dispensed in Turkey by prescription, so do not rely on non-specialist advice in choosing a medication or its dosage.

Treatment With Maneuvers and Exercises

1. Epley maneuver (canalith repositioning)

A series of carefully performed head movements that return the displaced otoconia to their normal position, used to treat BPPV. It usually improves the condition faster than waiting for it to resolve on its own, and it often succeeds after one or two sessions. It is performed by a doctor, an audiology and balance specialist, or a physiotherapist.

The maneuver is performed after the diagnosis is confirmed (often with the Dix-Hallpike maneuver), and the patient should tell the doctor beforehand if they have:

• Neck or back problems.
• Retinal detachment.
• A condition affecting the safety of blood vessels.

2. Vestibular rehabilitation

A specialized exercise program supervised by a physiotherapist, aimed at reducing the balance system's sensitivity to motion and training the brain to adapt. It is especially helpful in inner ear disorders such as vestibular neuritis, and for people whose unsteadiness continues after the initial cause has resolved.

3. Talk therapy (psychotherapy)

Based on sessions with a psychiatrist or mental health professional, it helps people with anxiety-related vertigo by helping them manage symptoms and break the cycle of fear of vertigo episodes.

Medical and Surgical Procedures

These options are used in limited cases, when other treatments have not worked:

• Intratympanic gentamicin injection: the antibiotic gentamicin is injected into the middle ear on the affected side (most often in Ménière's disease) to weaken balance function in that ear, so that the healthy ear takes over that function and episodes become less frequent. Patients should know that this treatment may affect hearing, and the effect may be permanent in a percentage of cases, so the doctor discusses the benefits and risks with the patient before resorting to it.
• Labyrinthectomy: a rare surgical procedure in which the part of the inner ear causing the vertigo is removed, resulting in complete hearing loss in that ear while the other ear takes over balance function. It is used only in cases of severe hearing loss, and when symptoms have not improved despite trying other treatments.

When Is Treatment in Turkey a Suitable Option?

Turkey has hospitals and centers that offer a comprehensive balance evaluation (ENT, neurology, audiology, and vestibular rehabilitation) in one place, which saves the patient from moving between several facilities. The quality of service and the availability of equipment and technologies vary from one center to another, so ask the center in advance about the available tests and the specialist staff before booking.

Tips for Preventing Vertigo Episodes

Not every type of vertigo can be prevented, but following a few daily measures reduces the frequency of episodes and the risk of falls and injuries when they occur.

Protecting Yourself From Falls

• Be aware of the risk of losing your balance and avoid quick or sudden movements, such as getting up quickly from bed or a chair. Get up gradually: sit for a moment before you stand.
• Use a walking cane when needed, especially if unsteadiness is persistent.
• Prepare your home: remove small rugs and exposed cords that could cause tripping, place non-slip mats in the bathroom and shower area, and make sure hallways and stairs are well lit, especially at night.

When an Episode Occurs

• Sit or lie down immediately when you feel dizzy to avoid falling.
• During a severe episode, lie down with your eyes closed in a quiet, dark room until the symptoms subside.
• Avoid driving or operating machinery if episodes are frequent or come without warning, until your doctor allows you to do so.

Lifestyle

• Reduce caffeine, alcohol, salt, and tobacco, as excessive intake may worsen symptoms. Salt in particular is important in Ménière's disease.
• Drink enough fluids, eat regular healthy meals, and do not skip meals, especially if you have diabetes.
• Get enough sleep and manage stress, as stress and lack of sleep are triggers for vertigo episodes, especially vestibular migraine.
• Do light physical activity regularly, such as walking, after your doctor's approval, as it supports balance and fitness.

Medications That Relieve Nausea and Vertigo

If the vertigo is accompanied by stomach upset, your doctor or pharmacist may recommend a medication from the antihistamine class (such as dimenhydrinate or meclizine). These may cause drowsiness, so do not drive after taking them. They are used for a short period during an episode only, because prolonged use may slow the recovery of balance. Some of these substances are available in Turkey under different brand names, and it is advisable to consult a pharmacist or doctor before using them, especially for older adults or people taking other medications.

If You Know the Cause of the Vertigo

• If the cause is a particular medication: consult your doctor about reducing the dose, stopping it, or replacing it safely. Do not stop the medication on your own.
• If the cause is overheating or dehydration: rest in a cool place and drink water or a drink that replaces electrolytes (oral rehydration solution or a sports drink). If symptoms do not improve or severe symptoms appear, go to the emergency room.
• If the cause is low blood pressure on standing: get up slowly, drink fluids regularly, and consult your doctor about adjusting your blood pressure medications.