Vertigo: only 8% of patients get the treatment that works

How many people are affected

The symptom is ordinary, the disorder is not. That gap is the first thing to understand: almost everyone has felt the room move, and a minority has a defined vestibular disorder.

One figure from the same German survey deserves to stand alone: in 80% of people with genuine vestibular vertigo, the symptom led to a medical consultation, an interrupted activity or sick leave. And more than half of them left with a diagnosis that was not vestibular.

The commonest cause is also the least well treated

Benign paroxysmal positional vertigo, BPPV, is a displacement of microscopic crystals inside the inner ear. It causes brief attacks triggered by head movement, classically on turning over in bed. It is diagnosed by one manoeuvre, the Dix-Hallpike, and treated by another, the Epley. Neither requires equipment.

This is where the figures become uncomfortable.

That audit of 458 records, across 26 sites of one health system between 2018 and 2022, compares real practice against the 2017 American guideline. The gap is not a methodological detail: a sedating vestibular suppressant dulls the sensation for a few hours and moves no crystal. The manoeuvre treats the cause in a single session.

What the Epley manoeuvre actually achieves

The 2014 Cochrane review pooled 11 randomised trials and 745 participants comparing the Epley manoeuvre with a sham manoeuvre.

An odds ratio of 9.62 for a three-minute procedure, with no drug and no imaging, is a benefit-to-burden ratio few treatments reach. The honest counterpart sits in the same review: the manoeuvre is unpleasant, and roughly one patient in four feels sick while it is performed.

The scan sees less than the examination

This is the most counterintuitive result in the file, and it is a solid one. The diagnostic accuracy meta-analysis carried out for the GRACE-3 guideline compared imaging with what it is supposed to detect in acute vertigo.

A scan that misses seven central causes in ten is not a screening test, it is false reassurance. That is precisely why the 2023 GRACE-3 guideline advises against non-contrast head CT as a first-line test in acute vertigo, and against routine MRI when a clinician trained in HINTS is available.

Two American figures show what the opposite habit costs. In 2004, 94.1% of emergency visits for dizziness that involved a CT scan produced no central neurological diagnosis, and the scan added 40 to 77 minutes to the visit (Kerber, Am J Emerg Med, 2010). In 2011, 39.9% of the 3.9 million annual emergency visits for dizziness involved imaging, for an estimated total of 3.9 billion dollars a year (Saber Tehrani, Acad Emerg Med, 2013).

When it is not benign

The question that matters is not whether it is serious, it is how anyone knows it is not. Two orders of magnitude frame the answer.

The 12% false-negative MRI figure matters and is rarely stated: in the earliest hours, a normal MRI does not exclude a posterior fossa stroke. That result is what founded the HINTS test, whose 2009 landmark study reported 100% sensitivity and 96% specificity across 101 consecutive patients. The broader and more cautious 2023 Cochrane meta-analysis brings those figures down to 94.0% and 86.9%, with an explicit caveat: the test performs only in trained hands. Performed by someone untrained, it is worth nothing.

Sudden vertigo together with difficulty speaking, seeing or swallowing, weakness or numbness on one side of the body, or inability to stand, means calling emergency services immediately. The planned work-up described here concerns vertigo that lasts, recurs, or has never been explained.

Vertigo is not just an inconvenience, it is a fall risk

In the 2009 NHANES analysis, measurable vestibular dysfunction with symptoms multiplied the odds of falling by 12. Worldwide, the World Health Organization counts 684,000 fall-related deaths a year and 37.3 million falls severe enough to require medical care, with people over 60 bearing the heaviest share.

That changes how vertigo reads in an older person: the immediate risk is not neurological, it is mechanical. A treatable vestibular cause left undiagnosed is a fall risk left in place.

What delay adds

In England, 594,546 people were waiting for ENT care in June 2026, and only 59.0% were treated within 18 weeks against a 92% target. In Ireland, on 30 July 2026, 46,124 patients were waiting for a first ENT outpatient appointment, 5,277 of them for more than twelve months.

For BPPV that delay is not neutral: the median untreated episode lasts two weeks, but the condition recurs, and every episode is a fall risk. Waiting months for a three-minute manoeuvre is a poor exchange.

What the studies do not allow anyone to claim

Three limits should be stated plainly.

There is no good European data on how many doctors are seen before the correct diagnosis, nor on the average time to that diagnosis. The figures circulating on this point come from single-centre studies outside Europe and do not transfer. What is established is the gap from guideline, not the length of the wandering.

The 8% of BPPV patients effectively treated comes from a 2007 German population survey. The American guideline dates from 2017, and a 2025 French study shows that targeted emergency department training raises guideline-consistent diagnosis from 16.9% to 38.0%. The picture is moving, slowly.

Finally, none of the figures above predicts what will happen to any one person. A prevalence, an odds ratio and a sensitivity describe groups. They help choose a test, they do not announce a result.

In practice, if this concerns you

Vertigo that lasts, recurs, or has never been explained deserves a vestibular examination by someone who performs the manoeuvres, before any imaging. The question to ask in consultation is short and discriminating: have you done a Dix-Hallpike manoeuvre. If the answer is no and a vestibular suppressant was prescribed, the diagnosis was not looked for.

Noria Health arranges a full ENT work-up in Brussels within 24 to 48 hours, with a vestibular examination, an audiogram and, where the examination justifies it, the appropriate imaging. The report is issued within 24 hours and follow-up is structured at D14, D30 and D90. What Noria Health does not do: manage a neurological emergency. Sudden vertigo with an associated neurological sign belongs to your country’s emergency services, immediately.

Further reading

• Hearing: 430 million people need hearing care
• Snoring and sleep apnoea, a cardiovascular risk worth testing for
• Neurology, 1 migraine in 4 may go unrecognised

Sources

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2. Neuhauser HK, Radtke A, von Brevern M, et al. Burden of dizziness and vertigo in the community. Archives of Internal Medicine, 2008;168:2118-2124. https://doi.org/10.1001/archinte.168.19.2118
3. Jönsson R, Sixt E, Landahl S, Rosenhall U. Prevalence of dizziness and vertigo in an urban elderly population. Journal of Vestibular Research, 2004;14:47-52. https://doi.org/10.3233/VES-2004-14105
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7. Hilton MP, Pinder DK. The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo. Cochrane Database of Systematic Reviews, 2014, CD003162. https://doi.org/10.1002/14651858.CD003162.pub3
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19. National Treatment Purchase Fund. Outpatient waiting list by specialty, 30 July 2026. https://www.ntpf.ie/waiting-list-data/open-data/

See also: all our articles on ENT.

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