Dizziness and vertigo in MS

Dizziness and vertigo are common in multiple sclerosis (MS). MS can directly cause these sensations if MS damage (lesions) or MS symptoms disrupt your body’s balance system. Research suggests over half of people with MS experience dizziness, whilst vertigo affects around 1 in 5 people.

On this page we explain the difference between dizziness and vertigo, and how they are linked to balance. We also look at what can cause these symptoms and how they are assessed and treated.

People often use the terms dizziness and vertigo interchangeably, but they are different.

Dizziness (NHS.UK) is the overarching term used to describe general feelings of wooziness, being slightly unsteady or off-balance. Dizziness can also make you feel light-headed or faint. It can happen when you are standing, sitting or lying down. Common triggers are when you move from sitting to standing, or when moving your head. Some people find dizziness also makes them feel tired, sick (nauseous) or causes them to vomit. Dizziness can be caused by a range of conditions that are unrelated to MS.

Vertigo (NHS.UK) is more than just feeling dizzy. With vertigo it feels as if you, or everything around you, is spinning, tilting or swaying. It feels like there is movement even though you, or your surroundings, are not actually moving. Like dizziness, vertigo can also make you feel sick or vomit. Maintaining your balance can be difficult when you experience vertigo and people often find they need to hold on to something to reduce the risk of falling.

Balance is the term used to describe your ability to keep your body stable and upright. Staying balanced relies on the complex processing of messages from several systems in your body. Balance is closely connected with dizziness and vertigo as they all involve the same systems.

• Vestibular system – the sensory system in your inner ear which sends information about your head movements to your brain. 
• Visual system – your eyes send information about where you are in relation to your environment to help orientate you. This is known as spatial orientation. 
• Proprioceptive system – movement sensors in your skin, muscles and joints send information to your brain so you know where the different parts of your body are, and how it is moving, without having to look. This is known as proprioception.

If the brain is having difficulty receiving or processing the information from one or more of these systems, it can cause issues with balance, dizziness or vertigo.

While MS can directly cause dizziness and vertigo, there are other factors that can also trigger these sensations. So, it is important to establish whether symptoms are related to MS or not. This will ensure the most appropriate treatment approach to help with symptoms.

MS itself can directly affect all the parts of the balance system. This can impact how information about balance is sent to the brain.

The brain and spinal cord (central nervous system) process messages from the sensory systems involved in balance to keep you stable. The main areas of the brain that do this are the brainstem and the cerebellum. The brainstem contains lots of connections between the inner ear and brain, and the cerebellum is involved in the coordination of movement.

If there are lesions in these parts of the brain, nerve messages sent from the sensory systems can be interrupted. The brain can struggle to correctly interpret the information it’s receiving. This can affect your balance and spatial orientation as the body is unable to make sense of its position in space. Likewise, if there is damage to the vestibular nerve pathway from the inner ear to the brain, then information about your head and body position may be misinterpreted. Both these situations can leave you feeling dizzy, unbalanced or with vertigo.

Some MS symptoms can also make you more likely to experience dizziness and vertigo. If you have visual problems such as blurred vision, double vision (diplopia) or involuntary movement of the eyes (nystagmus), the information that your brain receives from the visual system can get confused and result in these sensations. 

Similarly, if you have issues with altered sensations, weakness, spasticity or muscle stiffness, these symptoms can affect the sensory information sent by the skin, muscles or joints. This may mean your brain does not recognise if your body is tilting or swaying, or where your limbs are in relation to the ground. This mismatch in information can lead to dizziness and vertigo and can also put you at increased risk of falling.

Dizziness and vertigo can be experienced as part of an MS relapse if there is new inflammation in parts of the central nervous system involved in balance.

Some medicines that are commonly used in MS, for example antimuscarinic drugs used to treat an overactive bladder and other lower urinary tract symptoms, can cause dizziness as a side effect.

People with MS are just as likely to experience dizziness or vertigo because of issues that are not related to MS as the general population. Some of the most common general causes of dizziness and vertigo are problems with the inner ear (vestibular system). This can be due to infection, injury or age-related changes. Examples of inner ear problems that can cause vertigo are:

• labyrinthitis (NHS.UK) – an inner ear infection caused by the cold or flu virus.
• benign paroxysmal positional vertigo (BPPV) (Ménière’s & Vestibular UK) – where certain head movements cause vertigo. BPPV can co-exist with MS-related vertigo.

Find out more about inner ear problems that can cause vertigo (NHS.UK).

Other common causes of dizziness and vertigo are:

• dehydration or heat exhaustion
• low blood pressure, or a sudden drop in blood pressure when you stand, sit up or move position suddenly (postural hypotension (ENT.UK))
• migraine (NHS.UK).

Find out more about other common causes of dizziness (NHS.UK).

It is important to rule out other potential causes of dizziness and vertigo first to make sure you get the right treatment.

Symptoms can vary from person to person. The following are the most common things you might notice.

• Dizziness brought on by movement – particularly head movement.
• Blurred vision when you move your head.
• Feeling anxious or overwhelmed in busy environments.
• Feeling unsteady on your feet.
• Finding it difficult to stand up straight or walk in a straight line. People often find they lean or veer to one side
• Feeling sick (nausea) (NHS.UK) or vomiting.
• Feeling like you, or your surroundings, are spinning, tilting or swaying (vertigo).

Everyday head movements like watching TV, reading, scrolling on your phone or turning over in bed can be triggers. Busy visual environments like the supermarket or watching an action film at the cinema can also lead to dizziness or vertigo. Other triggers may include:

• fatigue
• dehydration or overheating
• infection or fever
• illness, poor sleep, stress or anxiety
• some medications.

As with any new symptoms of MS, you should consider speaking to your GP or a member of your MS team in the first instance. Especially if you have dizziness or vertigo that does not go away or keeps coming back. They may suggest you have tests to identify the cause of your dizziness or vertigo. They may prescribe medication to help with symptoms in the short term. 

An assessment may be carried out by your GP or MS team. In some areas you may be referred to a specialist physiotherapist or vestibular rehabilitation clinic. 

Many of the tests will initially be looking to see if there is a non-MS related cause for your dizziness or vertigo, such as an inner ear problem or low blood pressure. Other tests will help establish whether your MS might be causing these symptoms. Sometimes dizziness and vertigo can happen due to a combination of MS and non-MS related causes. 

It is important to diagnose the exact cause of any dizziness or vertigo so it can be treated appropriately. 

The first step of the assessment will be to have your clinical history taken. This is to build a picture of how the symptoms are affecting you and what the cause may be. This will include talking through your symptoms and answering questions such as:

• What do the sensations feel like?
• When do they come on?
• How long do they last? Do they come and go or are they there all the time?
• Are there any situations that trigger the sensations, such as moving your head?

They will also want to know:

• Is there anything that you do that makes the symptoms better or worse?
• Are the sensations accompanied by nausea or vomiting?
• Do you experience any other symptoms such as ringing in the ears or hearing loss when you have an episode of dizziness or vertigo?
• Do you have other MS symptoms at the same time? It can be useful to keep a symptom diary to help recognise any patterns.
• Have you had any recent changes to your medication that coincide with these symptoms?

The pattern of your symptoms can help distinguish between problems with the inner ear and the possible involvement of MS.

The next step will be a physical examination to look at how you move and whether your symptoms can be brought on by any particular movements. The health professional will also look for:

• any abnormal eye movements such as nystagmus
• how your eyes move when your head moves
• any problems with your coordination, balance or walking
• any issues with sensation or strength.

You should have checks to exclude non-MS related causes. This includes:

• low blood pressure
• dehydration
• migraine
• infections
• common inner ear disorders – such as labyrinthitis and vestibular neuritis (NHS.UK) and benign paroxysmal positional vertigo (BPPV) (ACPIVR).

If BPPV is suspected, specific movements can be performed to help with diagnosis. The most common tests are the Dix-Hallpike manoeuvre (Royal Berkshire NHS Foundation Trust) (PDF 582.36KB) and Supine Roll Test (Vestibular First). They look to see whether tiny loose crystals in your inner ear are causing your dizziness or vertigo. 

The health professional carrying out the assessment may request an MRI scan if non-MS related causes have been ruled out or other tests suggest MS-related dizziness or vertigo. An MRI scan can establish if there is evidence of new or active MS lesions in the brainstem, cerebellum or the balance pathways.

Sometimes dizziness and vertigo can resolve without treatment. If you do need treatment, the treatment you are offered will depend on what is causing your dizziness or vertigo.

The main aims of treatment will be to relieve symptoms and improve your balance. 

Antibiotics might be prescribed if symptoms are caused by a bacterial infection. For viral infections, over-the-counter pain-relieving medication can help with any pain or fever. You may also be prescribed a medication that can be used to help reduce dizziness and vertigo such as:

• antihistamines (NHS.UK)
• motion sickness (NHS.UK) tablets
• anti-nausea medicines
• vestibular sedatives or suppressants.

These medicines are usually only prescribed over the short term (typically for 3-5 days but for no longer than 1 week) to make symptoms more manageable. If used over the longer term they can slow down recovery. The long-term goal in treating dizziness and vertigo is to use strategies that help the brain adapt and recover, rather than sedating it.

If an MRI scan shows active inflammation and you are experiencing dizziness or vertigo that is having a significant impact on your life because of an MS relapse, your neurologist may suggest treatment with steroids. They may also look at whether you’re eligible to take a disease modifying therapy (DMT), or if you are already on a DMT whether you want to stay on your current treatment or explore other options, to reduce the risk of future relapses.

You may also be given specialist exercises that can help improve your balance. The right exercises for you will depend on the cause of your symptoms. It is important to have an assessment with a health professional so they can prescribe appropriate exercises and teach you how to do them effectively. 

Your GP or MS team can refer you to the appropriate service in your area to be taught these exercises. This might be to a physiotherapist or neurophysiotherapist, a specialist vestibular rehabilitation clinic or your local ear, nose and throat (ENT) clinic.

If you are found to have BPPV your healthcare professional will be able to treat it by helping you move into certain positions. They may be able to do this with you straight away or, if you need more assistance to move around, they can refer you to a specialist centre where they have equipment that can help. BPPV and MS-related dizziness and vertigo can happen at the same time.

If the cause is not thought to be BPPV, you may be offered vestibular rehabilitation (ACPIVR). Your health professional will show you exercises that can gradually make your brain less sensitive to certain movements and retrain your balance system, such as Cawthorne-Cooksey exercises (ENTUK.ORG). They might include:

• head and eye exercises to help stabilise your gaze
• general balance exercises
• general mobility exercises
• strategies to reduce the risk of falls.

You will be asked to do the exercises so they bring on mild symptoms for a very short time each day. It is likely that your rehabilitation will also include building in movements and activities that bring on your symptoms as part of your day-to-day life. An example of this might be practising putting washing in your washing machine. You might start this exercise sitting down and then work up to doing the movement whilst standing. 

The exercises should bring on your symptoms, but these should settle quickly after you’ve completed them. If the symptoms don’t settle quickly it is important to let your health professional know so they can modify the exercises to an appropriate level for you. Your tolerance to movements and activities should build up as your brain gradually adapts. It’s important that you do the exercises regularly to get the most benefit. It can take time for the exercises to work, so persistence is important. You will only be expected to do the exercises for a few minutes a couple of times a day initially. 

Most people have good and bad days. It is quite normal to find your symptoms worsen if you’re tired, stressed or have a cold. But, after a few weeks of regular daily practice you should notice that the exercises start to make you feel less dizzy.

Over time, the exercises will be made more challenging, for example by increasing the speed or practising them in different positions or environments.

Getting an assessment is the vital first step before looking at self-help options. The natural reaction is probably to try and avoid the movements that trigger your symptoms, but it is important to try and keep moving as much as safely possible. Reducing your activity or not moving your head can lead to joint and muscle stiffness that can end up making things worse in the longer term. 

It is useful to recognise any factors that trigger your dizziness and vertigo. This is not so that you avoid them entirely, but to make you more mindful of when you might need to take extra care. Recognising your triggers can help you feel more in control and better prepared for future episodes of dizziness or vertigo.

• Balance
• Physiotherapy
• Rehabilitation
• Falls
• Dizziness in multiple sclerosis (ACPIVR)
• Vestibular rehabilitation (ACPIVR)
• Labyrinthitis and vestibular neuritis (NHS.UK)
• Benign paroxysmal positional vertigo (BPPV) (Ménière’s & Vestibular UK)
• Ménière’s disease (NHS.UK)
• Medicines and dizziness (ACPIVR)
• Dizziness and balance: how to start your recovery (ACPIVR)
• Dix-Hallpike and Epley manoeuvres for benign paroxysmal positional vertigo (BPPV) (Royal Berkshire NHS Trust) (PDF 582.36KB)
• BPPV exercises at home (NHS Tayside) (PDF 578KB)
• Cawthorne-Cooksey exercises (ENT.UK)

This information has been developed by the MS Trust Health Information team. Our team produces accurate evidence-based information to help you navigate your every day – working alongside health professionals. We would like to thank Prof Jenny Freeman, Professor of Physiotherapy and Rehabilitation, School of Health Professions, University of Plymouth and Dr Rachel Dennett, Lecturer in Physiotherapy, School of Health Professions, University of Plymouth for checking the clinical accuracy of this information.