What causes vertigo and dizziness upon waking?

Vertigo Upon Waking: Causes and Clinical Approach

The most common cause of vertigo upon waking in the morning is benign paroxysmal positional vertigo (BPPV), triggered by rolling over in bed or sitting up from a lying position. 1

Primary Diagnostic Considerations

Benign Paroxysmal Positional Vertigo (BPPV)

• BPPV is the most frequent cause of positional vertigo, accounting for 20-30% of vestibular clinic referrals and is particularly common in morning presentations. 2
• Symptoms are triggered by specific head movements such as rolling over in bed, sitting up, or looking up—movements that commonly occur upon waking 1
• The vertigo lasts seconds to minutes with each position change, often accompanied by nausea and severe disorientation 1
• Diagnosis requires bedside testing with the Dix-Hallpike maneuver or supine roll test; imaging is unnecessary when typical nystagmus is present 1
• BPPV results from displaced otoconia (crystals) in the semicircular canals that settle when lying still during sleep and move with morning position changes 1

Vestibular Migraine

• The American Academy of Otolaryngology-Head and Neck Surgery recommends assessing for vestibular migraine when evaluating vertigo, as it commonly mimics other vestibular disorders 1
• Patients may experience vertigo upon waking if migraine attacks occur during sleep or upon awakening 1
• Associated features include photophobia, phonophobia, motion intolerance, and headache (though headache may be absent) 1
• Hearing loss is typically mild or absent and stable over time, distinguishing it from Ménière's disease 1

Ménière's Disease

• Characterized by episodic vertigo with fluctuating hearing loss, tinnitus, and aural fullness 3
• Attacks can occur at any time, including upon waking 1
• The presence of auditory symptoms (tinnitus, hearing loss, aural fullness) strongly suggests peripheral vestibular pathology 3

Critical Red Flags Requiring Urgent Evaluation

Do not assume normal neurologic examination excludes stroke—up to 75-80% of patients with posterior circulation stroke may lack focal neurologic deficits. 3, 4

High-Risk Features for Central Causes

• Age over 50 years with vascular risk factors warrants consideration of imaging 3
• Pure vertical or direction-changing nystagmus suggests central pathology 3
• Cranial nerve deficits (diplopia, dysphagia, dysarthria) indicate urgent neuroimaging 3
• Severe imbalance out of proportion to vertigo suggests cerebellar involvement 3
• Failure to respond to standard vestibular treatments may indicate stroke 4

HINTS Examination Findings Suggesting Stroke

• Absent head impulse test (normal corrective saccade) 3, 4
• Direction-changing nystagmus 3, 4
• Vertical skew deviation 3, 4
• The HINTS examination has 100% sensitivity for stroke when performed by trained practitioners, superior to early MRI at 46% 4

Diagnostic Algorithm

Step 1: Characterize the Vertigo Pattern

• Triggered by specific head movements (rolling over, sitting up): Strongly suggests BPPV 1
• Spontaneous vertigo lasting minutes to hours: Consider vestibular migraine or Ménière's disease 1, 5
• Continuous vertigo with neurologic symptoms: Urgent evaluation for central causes 3, 4

Step 2: Assess for Auditory Symptoms

• Presence of tinnitus, hearing loss, or aural fullness strongly favors peripheral causes (Ménière's disease or labyrinthitis) 3
• Absence of auditory symptoms points toward BPPV or vestibular migraine 1, 3

Step 3: Perform Bedside Testing

• Dix-Hallpike maneuver for posterior canal BPPV 1
• Supine roll test for horizontal canal BPPV 1
• Typical nystagmus on provocative testing confirms BPPV and eliminates need for imaging 1
• Atypical or absent nystagmus with positional symptoms increases risk of central pathology and warrants imaging 1

Step 4: Risk Stratification for Imaging

• Imaging is NOT required for typical BPPV with positive Dix-Hallpike testing 1
• Consider MRI (not CT) for: atypical features, negative provocative testing with ongoing symptoms, age >50 with vascular risk factors, or positive HINTS examination 1, 3, 4
• CT frequently misses posterior circulation strokes and should not be relied upon 4

Treatment Approach

For Confirmed BPPV

• Canalith repositioning procedures (Epley maneuver) have approximately 80% success rates with 1-3 treatments 1
• 91% of posterior canal BPPV resolves within 2 maneuvers 2
• Repeated testing and treatment within the same session is safe and effective 2
• Meclizine 25-100 mg daily in divided doses is FDA-approved for vertigo associated with vestibular system diseases 6
• Vestibular suppressants (meclizine, diazepam) should be used only for acute symptom relief, not long-term 7

Common Pitfalls

• 19% of patients experience post-treatment downbeating nystagmus or "otolithic crisis" after repositioning maneuvers—monitor for fall risk 2
• Elderly patients have a 12-fold increased risk for falls and require special precautions 4
• Presence of nystagmus and vertigo during the Epley maneuver does NOT predict treatment success 2
• BPPV can resolve spontaneously within weeks, but untreated patients face increased fall risk, particularly seniors 1

For Vestibular Migraine

• Dietary modifications, tricyclic antidepressants, beta blockers, or calcium channel blockers are effective 8
• Imaging is not required for diagnosis when clinical criteria are met 1

For Acute Vestibular Neuronitis

• Initial vestibular suppressants followed by vestibular rehabilitation exercises 8
• Gabapentin 300 mg two to three times daily may help stabilize visual field 7