The kind of vertigo physiotherapy can usually fix in one or two sessions

Most people with vertigo are given medication and told to wait. For the commonest cause, that is close to the opposite of what works.

The pattern that gives it away

Benign paroxysmal positional vertigo — BPPV — produces short, violent spinning brought on by a change in head position: rolling over in bed, lying down, sitting up, looking up at a shelf. Each attack lasts seconds to a minute. Between attacks you feel normal, perhaps a little unsteady or queasy.

If that is the pattern, the cause is mechanical. Small crystals that belong in one part of the inner ear have moved into a canal where they disturb the fluid every time the head changes position.

Why the treatment is a manoeuvre, not a tablet

Because the problem is a particle in the wrong place, it is fixed by moving the head through a sequence of positions that guides it back out. The manoeuvre takes a few minutes. Most people improve substantially after one to three treatments, and many after one.

Vestibular suppressant medication dulls the sensation without moving anything, and taken for more than a few days it can slow the brain's own compensation. It has a place in the first day or two of severe symptoms, and little place after.

What an assessment involves

Positional testing, where you are moved deliberately into the position that provokes the vertigo while your eye movements are watched. The direction and timing of those eye movements identify which canal is involved, which decides which manoeuvre is used. It is briefly unpleasant and it is the part that makes the treatment specific rather than generic.

If the manoeuvre does not fix it

Two or three treatments without meaningful change means one of a few things, and each has a different answer.

The wrong canal was treated. Three canals are involved in each ear, and each takes a different manoeuvre. Re-testing rather than repeating is the answer.

It is a variant where the crystals are stuck to the sensing structure rather than floating in the canal. It responds, but more slowly and to a different technique.

The crystals are settled and the balance system has not caught up. The spinning has stopped; what remains is unsteadiness, visual discomfort in busy places, and tiredness. That is treated with vestibular rehabilitation — graded exercises for the eyes, head and balance — over a few weeks rather than with a manoeuvre.

It was never BPPV. If the vertigo lasts hours, comes with hearing changes, or has no positional trigger, the diagnosis is the thing to revisit.

This is why the positional testing at the start matters. A manoeuvre chosen without it is a guess that works about a third of the time.

When vertigo is not BPPV

Other causes exist and are treated differently — vestibular neuritis, Meniere's disease, migraine-related dizziness, and dizziness from the neck or from blood pressure. Constant spinning lasting hours or days, hearing loss or ringing, or dizziness with no positional trigger all point elsewhere.

Go to hospital, not a clinic, if

Vertigo comes with weakness or numbness on one side, slurred speech, double vision, severe headache, difficulty swallowing, or an inability to walk. Sudden dizziness can occasionally be a stroke, and these are the signs that separate it.

What to expect afterwards

Mild unsteadiness for a few days after a successful manoeuvre is normal and settles. BPPV recurs in a proportion of people, often months or years later — which is irritating rather than worrying, and treated the same way again.