Vertigo Overview

Vertigo Overview Vertigo is the feeling that you or your environment is moving or spinning. It differs from dizziness in that vertigo describes an illusion of movement. When you feel as if you yourself are moving, it's called subjective vertigo, and the perception that your surroundings are moving is called objective vertigo. Unlike nonspecific lightheadedness or dizziness, vertigo has relatively few causes.

Vertigo Causes Vertigo can be caused by problems in the brain or the inner ear. •

Benign paroxysmal positional vertigo (BPPV) is the most common form of vertigo and is characterized by the sensation of motion initiated by sudden head movements or moving the head in a certain direction. This type of vertigo is rarely serious and can be treated.

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Vertigo may also be caused by inflammation within the inner ear (labyrinthitis), which is characterized by the sudden onset of vertigo and may be associated with hearing loss. The most common cause of labyrinthitis is a viral or bacterial infection.

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Meniere's disease is composed of a triad of symptoms: episodes of vertigo, ringing in the ears, and hearing loss. People have the abrupt onset of severe vertigo, fluctuating hearing loss, as well as periods in which they are symptom-free.

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Acoustic neuroma is a type of tumor that can cause vertigo. Symptoms include vertigo with one-sided ringing in the ear and hearing loss.

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Vertigo can be caused by decreased blood flow to the base of the brain. Bleeding into the back of the brain (cerebellar hemorrhage) is characterized by vertigo, headache, difficulty walking, and inability to look toward the side of the bleed. The result is that the person's eyes gaze away from the side with the problem. Walking is also extremely impaired.

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Vertigo is often the presenting symptom in multiple sclerosis. The onset is usually abrupt, and examination of the eyes may reveal the inability of the eyes to move past the midline toward the nose.

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Head trauma and neck injury may also result in vertigo, which usually goes away on its own.

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Migraine, a severe form of headache, may also cause vertigo. The vertigo is usually followed by a headache. There is often a prior history of similar episodes but no lasting problems.

Vertigo Symptoms Vertigo implies that there is a sensation of motion either of the person or the environment. This should not be confused with symptoms of lightheadedness or fainting. •

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If true vertigo exists, there is a sensation of disorientation or motion. In addition, the patient may also have any or all of these symptoms: o

Nausea or vomiting

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Sweating

o Abnormal eye movements The duration of symptoms can be from minutes to hours, and symptoms can be constant or episodic. The onset may be due to a movement or change in position. It is important to tell the doctor about any recent head trauma or whiplash injury as well as any new medications the patient is taking.

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The patient may have hearing loss and a ringing sensation in the ears.

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The patient might have visual disturbances, weakness, difficulty speaking, decreased level of consciousness, and difficulty walking.

Exams and Tests The evaluation of vertigo consists primarily of a medical history and physical exam. The history is comprised of four basic areas. 1. The doctor may want to know if the patient feels any sensation of motion, which may indicate that true vertigo exists. Report any nausea, vomiting, sweating, and abnormal eye movements. 2. The doctor may ask how long the patient has symptoms and whether they are constant or come and go. Do the symptoms occur when moving or changing positions? Is the patient currently taking any new medications? Has there been any recent head trauma or whiplash injury? 3. Are there any other hearing symptoms? Specifically, report any ringing in the ears or hearing loss. 4. Does the patient have weakness, visual disturbances, altered level of consciousness, difficulty walking, abnormal eye movements, or difficulty speaking? The doctor may perform tests such as a CT scan if a brain injury is suspected to be the cause of vertigo. Blood tests to check blood sugar levels and the use of an electrocardiogram (ECG) to look at heart rhythm may also be helpful.

Medical Treatment The choice of treatment will depend on the diagnosis. •

Vertigo can be treated with medicine taken by mouth, through medicine placed on the skin (a patch), or drugs given through an IV.

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Specific types of vertigo may require additional treatment and referral: o

Bacterial infection of the middle ear requires antibiotics.

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For Meniere's disease, in addition to symptomatic treatment, people might be placed on a low salt diet and may require medication used to increase urine output.

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A hole in the inner ear causing recurrent infection may require referral to an ear, nose, and throat (ENT) specialist for surgery.

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In addition to the drugs used for benign paroxysmal positional vertigo, several physical maneuvers can be used to treat the condition. o

Vestibular rehabilitation exercises consist of having the patient sit on the edge of a table and lie down to one side until the vertigo resolves followed by sitting up and lying down on the other side, again until the vertigo ceases. This is repeated until the vertigo no longer occurs.

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Particle repositioning maneuver is a treatment based on the idea that the condition is caused by displacement of small stones in the balance center (vestibular system) of the inner ear. The head is repositioned to move the stones to their normal position. This maneuver is repeated until the abnormal eye movements are no longer visible.

Medications Commonly prescribed medications for vertigo include the following: •

meclizine hydrochloride (Antivert)

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diphenhydramine (Benadryl)

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scopolamine transdermal patch (Transderm-Scop)

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promethazine hydrochloride (Phenergan)

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diazepam (Valium)

These medications should be taken only as directed and under the supervision of a doctor.

Next Steps Follow-up Anyone with a new diagnosis of vertigo should follow-up with his or her doctor or be referred directly to a neurologist or ENT specialist.

Prevention •

People whose balance is affected by vertigo should take precautions to prevent injuries from falls.

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Those with risk factors for stroke should control their high blood pressure and high cholesterol and stop smoking.

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Patient's with Meniere's disease should limit salt in their diet.

Outlook The prognosis depends on the source of the vertigo. •

Vertigo caused by problems in the inner ear, while usually self-limited, in some cases can become completely incapacitating. The use of drugs and rehabilitation exercise is mainstay of treatment. Most commonly this will make the symptoms completely go away or make the condition tolerable.

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The prognosis of vertigo from a brain lesion depends on the amount of damage done to the central nervous system. Vertigo caused by a brain lesion may need emergency evaluation by a neurologist and neurosurgeon.

Other Vertigo Symptoms

Advertising Disclaimer Peripheral vestibular disorders also may cause the following symptoms: • • • • • • • • • • • •

Blurred vision Fatigue and reduced stamina Headache Heart palpitations (rapid fluttering of the heart) Imbalance Inability to concentrate Increased risk for motion sickness Muscle ache (especially of the neck and back) Nausea and vomiting Reduced cognitive function (i.e., thinking and memory) Sensitivity to bright lights and noise Sweating

Vertigo caused by a central vestibular disorder usually develops gradually. In addition to vertigo, central vestibular disorders (e.g., stroke [brain attack], migraine) may cause the following symptoms: Double vision (diplopia) Vertigo Causes

Advertising Disclaimer Vertigo, or dizziness, usually results from a disorder in the peripheral vestibular system (i.e., structures of the inner ear). Dizziness also may occur as a result of a disorder in the central vestibular system (i.e., vestibular nerve, brainstem, and cerebellum). In some cases, the cause of vertigo is unknown. Peripheral vestibular disorders include the following: • • • • •

Benign paroxysmal positional vertigo (BPPV; most common peripheral disorder; may be accompanied by hearing loss, reduced cognitive function, and facial muscle weakness) Cogan's syndrome (inflammation of connective tissue in the cornea; results in vertigo, ringing in the ears [tinnitus], and loss of hearing) Ménière disease (fluctuating pressure of inner ear fluid [endolymph]; results in severe vertigo, ringing in the ears [tinnitus], and progressive hearing loss) Ototoxicity (i.e., ear poisoning) Vestibular neuritis (inflammation of vestibular nerve cells; may be caused by viral infection)

Benign paroxysmal positional vertigo (BPPV) usually affects one of the sensing tubes in the inner ear called the posterior semicircular canal. BPPV occurs when debris made up of calcium carbonate and protein (called otoliths or ear crystals) builds up in and moves around in the posterior semicircular canal. BPPV also can affect the anterior canal or the horizontal canal. When the head is moved in certain ways (e.g., turning in bed, looking up, bending over), the calcium crystals move around and trigger inner ear sensors, causing a brief sensation of spinning. Inner ear degeneration (usually occurs in elderly patients), head trauma, and inner ear infection (e.g., otitis media, labyrinthitis) can cause BPPV.

Advertising Disclaimer Some medications and environmental chemicals (e.g., lead, mercury, tin) can cause ototoxicity (i.e., ear poisoning), which may result in damage to the inner ear or the 8th cranial nerve (acoustic nerve) and cause vertigo. The damage can be permanent or temporary. Long-term use or high doses of certain antibiotics (e.g., aminoglycosides [streptomycin, gentamicin]) and antineoplastics (e.g., cisplatin, carboplatin) can cause permanent ototoxicity. Medications that may cause temporary ototoxicity include the following: • •

Anticonvulsants (e.g., phenytoin, carbamazepine) Antidepressants (e.g., clomipramine, amoxapine)

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Antihypertensives (e.g., labetalol, enalapril) Loop diuretics (e.g., bumetanide, furosemide) Pain relievers (e.g., aspirin) Prescription and over-the-counter cold medicines Quinine (e.g., chloroquine, quinidine)

Alcohol, even in small amounts, can cause temporary vertigo in some people. • • • • • • •

Headache (may be severe) Impaired consciousness Inability to speak due to muscle impairment (dysarthria) Lack of coordination Nausea and vomiting Weakness

Complications Severe vertigo can be disabling and may result in complications such as irritability, loss of selfesteem, depression, and injuries from falls. Falls are the leading cause of serious injury in people over the age of 65. Vertigo Diagnosis Advertising Disclaimer It is important to diagnose the cause of vertigo, or dizziness, as quickly as possible to rule out serious conditions such as cardiovascular disease, stroke, hemorrhage, or tumor. Diagnosis includes clinical history, physical and neurological examination, blood tests, and imaging tests (e.g., CT scan, MRI scan). Important considerations include the following: • • • •

What triggers the vertigo? What other symptoms occur? How long does the dizziness last? What improves or worsens symptoms?

Physical examination includes measuring blood pressure and heart rate. Neurological examination includes testing facial and vestibular nerves and muscles, strength, coordination, balance, and walking (gait). The positional vertigo test is used to help distinguish peripheral from central vestibular disorders. In this test, the patient sits on a table with the head turned to the side. The physician then supports the head and lowers it gently below the table while the patient lies back. The

patient reports symptoms of vertigo while the physician looks for circular movement of the eyes (called nystagmus).

Advertising Disclaimer A delay between the onset of nystagmus and the sensation of vertigo usually indicates a peripheral vestibular disorder. Lack of a delay may indicate a central vestibular disorder. The test is repeated with the head turned in the opposite direction. Electronystagmography (ENG) is a neurological test used to evaluate the vestibular system. It involves testing hearing in both ears (audiometry tests), testing eye movements, and evaluating responses to changes in posture and position. Blood tests include a complete blood count (CBC) and kidney and thyroid panels to rule out systemic diseases (e.g., kidney disease, hypothyroidism). If the patient is taking medication, drug levels are obtained. Imaging tests may be used to detect brain abnormalities (e.g., stroke, tumor). Computed tomography (CT scan) produces x-ray images of the brain and magnetic resonance imaging (MRI scan) uses a magnetic field to produce detailed images of brain tissue and arteries in the neck and brain Vertigo Treatment Advertising Disclaimer Treatment for vertigo, or dizziness, depends on identifying and eliminating the underlying cause. If a particular medication is responsible for the condition, lowering the dosage or discontinuing the drug may eliminate vertigo. Vestibular Rehabilitation Therapy Vestibular rehabilitation therapy (VRT) is a type of physical therapy used to treat vertigo. The goal of treatment is to minimize dizziness, improve balance, and prevent falls by restoring normal function of the vestibular system. In VRT, the patient performs exercises designed to allow the brain to adapt to and compensate for whatever is causing the vertigo. The success of this treatment depends on several factors including the following: • • • • •

Age of the patient Cognitive function (e.g., memory, ability to follow directions in order) Coordination and motor skills Overall health of the patient (including the central nervous system) Physical strength

Advertising Disclaimer Vestibular rehabilitation therapy is designed by a physical therapist under the direction of a physician. In most cases, patients visit the therapist on a limited basis and perform customdesigned exercises at home, several times a day. As the patient progresses, difficulty of the exercises increases until the highest level of balance is attained during head movement, eye movement (i.e., tracking with the eyes), and walking. According to the American Academy of Neurology, the most effective treatment for benign paroxysmal positional vertigo (BPPV) caused by ear crystals in the posterior semicircular canal, is a technique called the canalith repositioning procedure, or the Epley maneuver. In this procedure, a physician or physical therapist assists the patient in performing a series of head and body movements, which move the calcium crystals out from the posterior semicircular canal and into another inner ear canal, where it is absorbed by the body. Another technique (called the Semont maneuver) also may be effective, but additional studies are needed Vertigo Medication Advertising Disclaimer Ear infections (e.g., otitis media, labyrinthitis) caused by bacteria may be treated using antibiotics (e.g., amoxicillin, ceftriaxone). Myringotomy is a surgical procedure that may be used to treat chronic ear infections. In this procedure, which is performed under anesthesia, an incision is made in the eardrum and a small tube is placed in the opening to prevent fluid and bacteria from building up inside the ear. BPPV that does not respond to canalith repositioning may be treated with meclizine (Antivert®), an oral antiemetic that can be taken up to 3 times a day, or only as needed. Meclizine may cause drowsiness, dry mouth, and blurred vision. If meclizine is ineffective, benzodiazepines such as clonazepam (Klonopin®) or antihistamines such as promethazine (Phenergan®) may be prescribed. Side effects of clonazepam include drowsiness, lack of coordination (ataxia), and confusion. Promethazine may cause drowsiness, fatigue, insomnia, and tremors. Ménière disease may be treated by reducing sodium (salt) intake and with diuretic medications. A short, tapered course of corticosteroids (e.g., prednisone) may be prescribed early in the disease to reduce inflammation and stabilize hearing. Antibiotics (e.g., gentamicin) may be administered into the middle ear (called intratympanic perfusion) to treat severe vertigo caused by Ménière disease. Vertigo caused by migraine can often be treated with medication.

Cerebrovascular disease (stroke), tumors, and multiple sclerosis may require treatment with medication, radiation, or surgery. Questions to Ask Your Doctor about Vertigo • • • • • • •

What do you suspect is causing my vertigo? Why do you suspect this cause? What kinds of activities may trigger or worsen my vertigo symptoms? Is there anything I should do or avoid doing to help reduce the severity and frequency of symptoms? What types of examinations, evaluations, and/or diagnostic tests will be performed to determine if an underlying condition is causing my dizziness? How do I prepare for these exams and tests? Do you recommend that I see a specialist or visit a hospital or medical center that specializes in vertigo for my condition? Why or why not? What is the usual prognosis for people with this type of vertigo? In addition to dizziness, what other symptoms and complications related to this type of vertigo may develop? What should I do if I experience new symptoms or serious complications? Telephone number to call: Advertising Disclaimer

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Can the underlying cause for my vertigo usually be successfully treated? If so, do you expect treatment to resolve my dizziness and other vertigo symptoms? What is the recommended treatment for my vertigo? Why do you recommend this treatment? If this treatment is unsuccessful, what other treatment options might you recommend? Will I undergo vestibular rehabilitation therapy to treat my vertigo? If so, how often will I have therapy and how long will therapy last? What is the canalith repositioning procedure, also called the Epley maneuver? Might this technique be used to treat my vertigo? Will medication(s) be used to treat my vertigo? If so, which medications? What are the most common side effects of the medication(s)? What types of severe side effects may occur? What should I do if I experience severe side effects? Telephone number to call: Might surgery be required to treat my condition? Why or why not? If I do require surgery, what type of surgery may be performed and how do I prepare for the procedure? What can I expect following surgery to treat vertigo? What should I do if I experience complications after surgery? Telephone number to call: Do you recommend that I participate in a vertigo clinical trial or explore newer treatment options? Can you recommend a local or online support group for patients with vertigo?