Vertigo

What is Vertigo?

Vertigo, a common reason people go to the doctor or the emergency room, is a sign of a problem with the vestibular system – the body’s balance system. It’s often described as a feeling of spinning or moving, usually in circles. It’s important to distinguish vertigo from other types of dizziness, like feeling lightheaded, which is usually linked to feeling like you’re about to faint. Vertigo can affect anyone, regardless of age. In young people, it’s usually caused by issues with the middle ear. However, in older people, doctors need to take special care when assessing vertigo because it can increase the risk of falls.

What Causes Vertigo?

Vertigo, or the feeling of dizziness or a spinning sensation, is usually caused by an issue in the vestibular system, which is part of the inner ear and brain that helps control balance and eye movements. This issue can arise from different areas of the vestibular system (peripheral or central).

Common causes of vertigo from the peripheral, or outer part of the vestibular system, include conditions like benign paroxysmal positional vertigo (BPPV) and Ménière disease. BPPV occurs when tiny calcium particles clump up in the inner ear, causing short, intense episodes of vertigo that come and go. However, Ménière disease is more complex, with symptoms like ringing in the ears, hearing loss, and a feeling of fullness in the ear, along with vertigo. This usually happens due to increased fluid levels in the parts of your inner ear.

Other reasons for peripheral vertigo might be inflammation in the inner ear, often due to a viral infection, such as acute labyrinthitis or vestibular neuritis. Ramsay Hunt syndrome is another viral cause; it involves reactivation of the chickenpox virus (Varicella-zoster) in the inner ear, causing vertigo and often facial paralysis. Less common reasons are cholesteatoma (abnormal skin growth in the middle ear), otosclerosis (an unusual bone growth in the ear), and a perilymphatic fistula (an abnormal opening in one of the inner ear fluids), usually due to injury.

Central causes, or issues in the brain, that lead to vertigo should also be taken into account. These could include serious conditions like stroke, especially those relating to the cerebellum (a part of the brain involved in balance) or vertebrobasilar system (a key blood supply to the brain). Other severe causes might be tumors in the brain, including a type of brainstem glioma, medulloblastoma, and vestibular schwannoma, which can cause symptoms of vertigo along with hearing loss. Vestibular migraines also cause vertigo; they come with one-sided intense headaches and other symptoms like nausea, vomiting, light and sound sensitivity. Multiple sclerosis, a disease that affects the brain and spinal cord, can also cause vertigo.

Vertigo can also occur due to medications like anticonvulsants and psychological disorders such as mood, anxiety disorders, and somatization (when mental factors lead to physical symptoms).

Risk Factors and Frequency for Vertigo

Vertigo, a sensation of feeling off balance, is more common in women than men, with women experiencing it two to three times more often. It can occur in association with other medical conditions like depression and heart disease. The likelihood of having vertigo tends to increase as people get older, and the specific rates may vary depending on the exact cause of the vertigo.

• About 5% of the general population experiences vertigo each year and the annual new cases rate is 1.4%.
• Between 15% and over 20% of adults experience dizziness, including vertigo, each year.
• For a specific type of vertigo known as benign paroxysmal positional vertigo, the annual rate is about 1.6%, while for vestibular migraine, it’s less than 1%.
• Vertigo has a significant impact on daily life, as nearly 80% of those surveyed reported it disrupts their daily activities, including work, and often requires additional medical care.
• The rate of Menière’s disease, which can cause vertigo, is reported to be 0.51%, which is a remarkable increase compared to earlier reports.

Signs and Symptoms of Vertigo

When diagnosing the cause of a patient’s dizziness, it’s imperative to first establish whether the patient is actually experiencing vertigo. A common way to identify this is to ask the patient if it feels like the room is spinning around them. If the patient confirms vertigo, a thorough medical history is then used to differentiate between central and peripheral causes.

One of the main ways to identify the underlying cause of vertigo is through a detailed analysis of how the symptoms occurred over time. For example, if the patient experiences brief, recurring episodes of vertigo, it might be due to benign paroxysmal positional vertigo. However, if the episode lasts for several minutes to hours, it could be due to a vestibular migraine or something more serious like a transient ischemic attack. Extended episodes could be caused by peripheral and central issues such as vestibular neuritis or a stroke.

It’s also crucial to pay attention to associated symptoms as this can help specialists distinguish between a central and a peripheral cause. While nausea and vomiting often accompany acute vertigo, they aren’t clues to a specific cause. If a patient reports neurologic issues such as double vision, speech difficulties, difficulties swallowing, and numbness or weakness, these are alarming signs of potential central causes, such as a stroke affecting the back of the brain or multiple sclerosis, and should be further examined. Furthermore, other symptoms to look for include headaches, sensitivity to light, and visual disturbances which often come with vestibular migraines. Vertigo can also be linked to Ménière disease; symptoms include deafness and a ringing or buzzing noise in your ear. Other causes for concern may include recent viral infections that lead to inflammation of the inner ear and conditions related to the vestibular nerve.

• Recurring vertigo lasting a few minutes or less – possible benign paroxysmal positional vertigo
• Single episode lasting minutes to hours – potentially due to a vestibular migraine or serious underlying diagnosis such as a transient ischemic attack
• Extended episodes – possible peripheral or central causes such as vestibular neuritis or stroke
• Nausea and vomiting – common with acute episodes of vertigo but not specific to any particular cause
• Focal neurologic deficits (double vision, difficulties with speech or swallowing, numbness, or weakness) – concerning for central causes like vertebrobasilar stroke or multiple sclerosis
• Symptoms of headache, sensitivity to light, and visual disturbances – often accompany vestibular migraines
• Deafness and tinnitus – associated with Ménière disease
• Viral infection history – could lead to labyrinthitis and vestibular neuritis
• Medication history and potential substance or alcohol use – certain medications and substances can affect vestibular function

The list of vertigo symptoms and signs is not exhaustive, and the presence or absence of each may not conclusively confirm or rule out a particular diagnosis. A thorough physical examination is still necessary to determine the cause of vertigo. Various techniques are used, including assessing for nystagmus, the head impulse test, skew test, and the HINTS (Head Impulse-Nystagmus-Test for Skew) test for vertigo.

It is also worthwhile to conduct the Dix-Hallpike maneuver if benign paroxysmal positional vertigo (BPPV) is suspected, and to test patients’ gait and balance. Often, patients with unilateral peripheral disorders might lean or fall toward the side of the lesion, while those with cerebellar lesions might need assistance walking, and their direction of falling with Romberg testing is variable.

Other necessary tests include an otoscopic exam to rule out any obvious infection such as acute otitis media, and bedside tests of hearing (Weber and Rinne tests) can be useful in differentiating other causes of vertigo. However, if a cause cannot be identified despite a unilateral hearing loss strongly pointing to a peripheral etiology, further diagnostic imaging with MRI could be necessary.

It’s important to note that many doctors mistakenly skip the basics of history and physical examination, leading to unnecessary imaging and medications. Furthermore, there is currently insufficient high-quality evidence to suggest that the absence of hearing loss, as assessed by pure tone audiometry, can predict benign paroxysmal positional vertigo (BPPV) in patients with vertigo.

Testing for Vertigo

The acronym STANDING represents a four-step approach for evaluating nystagmus, a medical term for rapid, involuntary movements of the eyes. This strategy involves looking at spontaneous and positional nystagmus, evaluating the direction of nystagmus, conducting the head impulse test, and evaluating a person’s balance (staNdinG).

Tests done in a lab usually don’t provide helpful information for identifying the cause of vertigo, a sensation of feeling off balance. However, if a doctor suspects something within the brain could be causing this feeling, an imaging test may be used.

Vertigo can be brought on by either a central lesion, like a stroke, or a peripheral lesion, like vestibular neuritis. Vestibular neuritis is an inflammation of the inner ear which causes vertigo. In both these conditions, the vertigo can last for several days. This can make it difficult for medical professionals to distinguish between the two.

If a patient is at risk for a stroke, has specific neurological symptoms, experiences a new headache, or if their physical examination does not align with a peripheral lesion, they may need to have a neuroimaging scan. The preferred method is using a MRI and MRA, as they can provide more detailed and accurate images of central lesions than a CT scan could.

However, if a MRI cannot be done or the doctor decides it’s not appropriate for the patient, a CT scan could be used instead. In this case, thin slices are particularly useful for looking at the brain stem and cerebellum.

Treatment Options for Vertigo

The treatment for vertigo, a sensation of feeling off balance, often involves addressing its underlying cause; this means that improving the cause of the imbalance can reduce vertigo symptoms.

In acute, or short-term episodes, medications can help control the symptoms of vertigo. Commonly used drugs include antihistamines (which help with allergies and irritation), benzodiazepines (a type of tranquilizer), and antiemetics (which help prevent vomiting). Meclizine is a frequently used antihistamine and is safe to use during pregnancy. However, as these medications can cause sleepiness, they should be used with care in older patients.

Other treatments are available for patients with a constant balance disorder on one or both sides. Physical therapy with vestibular rehabilitation is one such method. This form of exercise helps the brain use vision and a sense of physical position to maintain balance, lessening symptoms of vertigo, dizziness caused by movement, and improving daily activities.

Some patients, particularly those with vestibular neuritis (an inflammation of the inner ear causing vertigo), benefit from both medications and physical therapy. For these patients, corticosteroids, which reduce inflammation, and vestibular rehabilitation are recommended. Meanwhile, patients with Ménière’s disease, an inner ear disorder causing vertigo, can be sensitive to high salt diets, caffeine, and alcohol. Avoiding these triggers, in addition to medicine and vestibular rehabilitation, can provide effective relief. Diuretics, which help the body remove salt and water to reduce blood pressure, can also be used in these cases.

Non-medicinal treatments can help those with benign paroxysmal positional vertigo, a condition in which specific head movements trigger vertigo. One such treatment is the Epley maneuver, a sequence of head movements that can help filter out calcium particles in the ear. This exercise can be done at home, decreasing symptoms of vertigo within 24 hours for up to 90% of patients. If this maneuver does not help, surgical options are available, although there is a risk of hearing loss.

What else can Vertigo be?

Vertigo, a sensation of feeling off balance, can be a bit tricky to diagnose because it could come from either a central or peripheral issue in the vestibular system, the inner ear and brain structures that control balance and eye movements. So, it’s important that doctors can tell the difference between vertigo and other balance or fainting problems, like disequilibrium and pre-syncope, which can include symptoms like imbalance and lightheadedness. A wide range of causes, including metabolic, blood vessel, inflammation, drug-induced, and hormonal reasons, can trigger these symptoms.

Here are some medical conditions which could cause these symptoms:

• Acute anemia (a lack of red blood cells)
• Anxiety disorders
• Benign positional vertigo (vertigo triggered by specific changes in the position of your head)
• Brain tumors
• Chronic anemia (long-term lack of red blood cells)
• Giant cell arteritis (an inflammation of the lining of your arteries)
• Herpes simplex encephalitis (a rare life-threatening condition thought to be caused by the herpes virus)
• Labyrinthitis (an inner ear disorder)
• Mastoiditis (an infection of the mastoid bone behind the ear)
• Ménière’s disease (a disorder of the inner ear)
• Meningitis (an inflammation of the membranes surrounding your brain and spinal cord)
• Migraine headaches
• Multiple sclerosis (a disease in which the immune system eats away at the protective covering of nerves)
• Stroke (damage to the brain from interruption of its blood supply)
• Vertebrobasilar atherothrombotic disease (a condition in which a blood clot blocks blood flow in the back of the brain)
• Vestibular neuronitis (an inflammation of the inner ear usually caused by a viral infection)
• Wernicke’s encephalopathy (a serious brain disorder most commonly caused by a thiamine or vitamin B1 deficiency)

What to expect with Vertigo

Benign paroxysmal positional vertigo, a condition that causes brief episodes of mild to intense dizziness, has a 50% chance of recurring within five years. It is also common for patients to experience lingering dizziness due to anxiety even a year after being diagnosed with vestibular neuritis, a condition that causes inflammation of the inner ear.

Researchers like Perrez-Garrigues and colleagues have found that vertigo episodes are most frequent in the early years of the condition and decrease as the years go by. This decrease occurs regardless of whether patients are treated or not, and most patients eventually reach a phase where they no longer have episodes of vertigo.

Similar to vertigo, the loss of hearing also tends to be highest at the onset of the condition and then stabilizes over time. Typically, once a patient has lost hearing, it does not return.

The severe dizziness associated with labyrinthitis, an inflammation of the inner ear that might cause dizziness and loss of balance, usually improves within a few days. However, patients may have milder symptoms for several weeks. Generally speaking, as long as the patient doesn’t experience serious neurological side effects, the outlook is good. Yet, if patients do have neurological complications, they may need further treatments. For instance, a ventriculoperitoneal shunt, which is a medical device that relieves pressure on the brain caused by fluid accumulation, may be needed for patients experiencing excess fluid in the brain as a result of bacterial meningitis.

Possible Complications When Diagnosed with Vertigo

To correctly identify the cause of dizziness, it’s essential to distinguish between vertigo (a sensation of feeling off balance) and other sources of feeling unsteady or dizzy. Not only that, but it’s also critical to differentiate whether the vertigo is coming from the central nervous system (like the brain) or the peripheral nervous system (like the inner ear). Correctly diagnosing these conditions is especially crucial when they pose serious threats to a person’s health, like tumors, infections, or cerebrovascular accidents (commonly known as strokes).

Common Causes of Dizziness:

• Vertigo
• Central nervous system disorders
• Peripheral nervous system disorders
• Tumors
• Infections
• Cerebrovascular accidents (strokes)

Preventing Vertigo

Labyrinthitis, an inflammation of the inner ear, is often a secondary infection caused by other types of infections such as otitis media (a middle ear infection) or meningitis (an infection of the protective membranes around the brain and spinal cord). By quickly diagnosing and effectively treating these other infections, the chance of developing labyrinthitis can be reduced or its long-term complications can be minimized. Staying current with vaccinations also plays a key role in reducing the risk of labyrinthitis, as it can help prevent diseases like measles, mumps, or rubella which can cause this condition.

Patients experiencing vertigo (a sensation of feeling off balance) should try to move around as much as they can as soon as they feel up to it. This can help with vestibular compensation, which is a process that helps the body regain balance and improve overall prognosis. It’s also worth noting that patients who take certain medications such as benzodiazepines or antihistamines to treat their vertigo may experience slower balance recovery.

Ménière’s disease is another condition that affects the inner ear causing symptoms like vertigo. It is suspected when the patient experiences hearing loss in one ear, episodes of vertigo lasting from several minutes to several hours, and tinnitus (ringing in the ears). Patients experiencing these symptoms should consider seeking medical attention as soon as possible.

In cases of BPPV (Benign paroxysmal positional vertigo, a condition where changes in head position cause sudden vertigo), it’s most important to explain to patients that the condition is not life-threatening. The tendency of this condition to resolve with a favourable outcome can help patients understand that it’s not severe. But, patients should also be informed that BPPV has a high recurrence rate, and might need further treatment even after successful initial management with repositioning maneuvers.