Vertigo – the world is spinning and balance fails

In many momentary situations vertigo is perfectly explainable. Often it is even expectable and therefore not scary at all. Prolonged, recurring or sudden and unexpectedly started vertigo is however an uncomfortable feeling for which you wish to find the reason sooner than later.

Balance is cooperation between the eyes, inner ear and the nervous system

Good balance requires seamless cooperation between the inner ear’s semicircular canals, the eyes and the peripheral nerves, which indicate proprioception in the joints. This is all coordinated in the central nervous system. A sudden illness in any balance regulating organ can lead to a feeling of vertigo and difficulty in balance. A thorough symptom description and a clinical examination will usually lead to the cause behind the vertigo and therefore examinations with technological instruments are not needed. Positively in most cases the vertigo episodes will subside on their own. In the most difficult phase, medication or physiotherapeutic treatment may help.

Roughly defined, a symptom of vertigo in which one feels like the surroundings are spinning around fast refers to a disturbance in the vestibular system. Difficulty in balance, feeling wobbly and unstable implies, that there is a disturbance in the balance regulation system. With aging and as possible illnesses, which require medication increase the causes of vertigo also increase and it can be difficult to find one clear cause for the vertigo.

The most important thing is to evaluate what does the person mean when they say, that they are experiencing vertigo. Are the surroundings spinning, are they spinning in a certain direction? In what situations does the person experience vertigo and how long does it last or is it ongoing? Does the ground feel wobbly? Has there been falling down incidents? Has the person had inflammatory diseases or head injuries recently? Is the vertigo experienced at a specific time of the day? The person’s age, previous illnesses and medication in use have a significance when evaluating vertigo symptoms.

The most common reason for vertigo is in the inner ear

Vertigo is a very common symptom in basic health care. Studies have showed, that the reasons for vertigo vary considerably in the adult population. Therefore, the data is not always comparable by age or nomenclature. Around 5 to 11 patients out of a 100 who come to the general practitioner’s office experience vertigo.

Benign paroxysmal positional vertigo (BPPV), a sudden sensation, that you are spinning, vestibular neuronitis (VN), an infection of the vestibular nerve in the inner ear and Meniere’s disease (MD) are the most common causes of vertigo in the adult population. All of these causes of vertigo have to do with a disturbance in the inner ear or in its nerve messages. International studies have shown, that about 10-45 % of vertigo patients suffer from one of the problems mentioned above. Aging increases the possible causes of vertigo due to the development of other illnesses, that affect the state of health.

Benign paroxysmal positional vertigo is a common reason for vertigo

Benign paroxysmal positional vertigo (BPPV) is estimated to occur on 64/1000 patients yearly, so it is not a very rare symptom. Vertigo symptoms are diagnosed with every age group, but it is most common on people above the age of 40. BPPV is more common with women than men (W:M = 2:1). The symptom doesn’t last very long, usually above 10 to 20 seconds. Vertigo episodes often occur when turning over in bed, going to or getting up from bed or tilting head down- or backwards. The symptoms often include a feeling of nausea, but rarely actually throwing up. The feeling of vertigo is uncomfortable in the sense, that the person will consciously try to avoid positions and situations where vertigo is experienced.

Sometimes the BPPV is obvious. There might have been a previous brain injury, an infection in the vestibular system or a circulatory collapse. However, with about 60% of the patients there isn’t any specific reason for these symptoms. The current understanding of BPPV is, that it is caused by collections of calcium crystals known as otoliths clustering in one semicircular canal of either inner ear. As a result, the messages sent from the semicircular canals about the head’s positions are falsified in the central nervous system and this results in short-term vertigo. BPPV usually gets better on its own in a few weeks, sometimes months, but its recovery can be speeded up with posture treatment. With some BPPV patients the symptoms recur.

Diagnosing BPPV doesn’t require doing examinations with technological instruments, since a thorough symptom description and a systematic clinical examination are enough to lead to the right diagnosis. BPPV’s clinical examination uses the Dix-Hallpike test, which evaluates eye movements and especially if nystagmus (involuntary eye movement) shows up when tilting and bending the head. Nystagmus is the strongest when tilting the head to the side of the damaged semicircular canal, which also makes the patient’s vertigo get stronger.

The treatment used for BPPV is posture correction

The treatment of BPPV could be described as desensitization. Its goal is to get the otolith out of the semicircular canals. This is done by systematic posture correction with the help and guidance of a physiotherapist with expertise in BBPV. Learning to follow the posture correcting treatments will irritate the central nervous system’s compensatory nervous system to adapt to adjusting balance and settling vertigo.

Beginning the BPPV posture correcting treatment is often very uncomfortable for the patient as the positions where the vertigo is the strongest will need to be found. There aren’t any medication treatments for BPPV and the recommendation is, that medication treatments should not even be tried, especially in the long-term. This is, because the vertigo medication, which affects the nervous system may even slow down the process of the nervous system adapting to the inner ear problems.

Vestibular neuronitis, infection of the vestibular nerve in the inner ear

Vestibular neuronitis’ (VN) leading symptom is dizziness, which usually begins suddenly as a strong feeling of the surroundings spinning around fast. On the preceding days leading to the short vertigo episode there may be some balancing difficulties. It is often found out (with 60% of the patients), that the patient has had some kind of an infection in the preceding few weeks before the vertigo episode. Often the infection has been in the upper respiratory tract area, the throat or the sinus, rarely in the ears. Often the first intense episode of vertigo is experienced in the morning after waking up. There may be more episodes in the following few days, but most likely the intensity will go down with each episode.

VN can occur at any age and most typically it occurs on an otherwise healthy young or a middle-aged person. The reason for VN is understood to be either antibody-mediated or a damage to the toxic vestibular nerve and its central nervous system connection. Hearing does not get worse during the episode, but as the surroundings spin, balance will fail. Nausea is common during the episode and throwing up is not rare either. Nystagmus from horizontal or rotary movements and weak balance are detected in a clinical examination.

The symptoms often ease within a few weeks and almost without exceptions, full recovery happens within three months. Prognosis is therefore good. If recovery does not however happen, other causes for the vertigo episodes should be considered. Treatment according to the symptoms is only recommended on the first few days of the episodes.

Meniere's disease – ears are ringing, and hearing gets worse

Prosper Meniere´ named this vertigo disease after himself already in 1861. The symptoms of this disease aren’t limited to episodes of vertigo. Additionally, to the vertigo, hearing gets worse and ears ring. A feeling of pressure in the ear is a normal symptom during an episode of vertigo. The episodes of vertigo are distinctly longer than with BPPV or VN. As the episodes recur, an ear specialist will be able to detect the hearing loss.

The reasons for MD are still unknown. The increase of pressure of the liquid circulating in the semicircular canals of the inner ears makes the episode start. Immunological, viral, circulatory as well as hereditary causes have been considered possible for causing MD. The prevalence of MD is estimated to be 1 out of a 1000 people and usually the first episodes begin between the ages of 20 and 50. Under 10% of people with MD are found to have hereditary MD. With about 80% of the patients the vertigo is always parallel, especially during the first few years, but as the sickness progresses the symptoms can change so, that the vertigo is bidirectional.

A MD episode lasts distinctly longer than in BPPV or VN and often lasts even hours. Vertigo is therefore incapacitating as the patient must go to bed rest. The possibility of falling down during the episode is big and additionally to ear symptoms there might be headaches.

Meniere´s disease is a progressive disease

MD advances over the years differently, but as the disease goes on a gradual progression can be noticed. In the first years of the sickness, the episodes consist of vertigo and hearing loss. However, in between the episodes hearing goes back to normal. In the next phase vertigo is at its worst and hearing can worsen also in between the episodes. The time between the episodes vary considerably. As the sickness progresses, the hearing loss becomes permanent and starts to advance, but the vertigo episodes will rarely occur. Usually clinical examinations, which are done in between the episodes, won’t find anything abnormal, especially if the patient is in the first phase of the sickness. During an episode, the examination can detect nystagmus and the slight hearing loss. Over the years sensorineural hearing loss can be detected. Before getting a MD diagnosis or receiving treatment, examinations by an ear specialist are always required.

American academy of otolaryngology organization has defined the diagnostic criteria for MD followingly:

  • At least two sudden vertigo episodes, that last at least for 20 minutes
  • Audiometrically documented sensorineural hearing loss
  • Ringing in the ears, meaning tinnitus or feeling of pressure in the ear

Tension headaches and vertigo

The muscle tension in the neck shoulder region muscles is a very common reason for vague episodes of vertigo with working age people. The vertigo is rather swaying than rotative in this case. The feeling of vertigo can include nausea and a squeezing or a throbbing headache. The symptoms often increase throughout the day. In these cases, a clinical examination detects tension and sometimes tenderness in the neck shoulder region muscles. The shoulder line may also be dragged up or inclined forward. Bending the head to the sides may be difficult, but nystagmus won’t be present like in BPPV.

To treat problems in the neck shoulder region muscles, the factors maintaining the muscle tension need to be first identified and then interfered with. Imaging examinations are needed especially if there has been an injury to the head or neck region prior to the symptom. Physiotherapeutic advice and treatment will be useful, such as determining and possibly removing the factors, often work factors, that maintain tension. Temporary medication either locally or orally taken will often help in the first stages of the symptoms, but a long-term use of medication is not recommended.

Vertigo as a symptom of a neurological disorder

A lot of neurological disorders can include balance issues and dizziness. Nausea and throwing up are not the primary symptoms. Disorders of the brainstem, cerebellum, spinal cord or peripheral nervous system (polyneuropathic) include balancing issues as part of the symptoms. With Parkinson’s disease as well as with similar diseases, the ability to balance gets weaker, which causes unsteadiness when changing directions and sometimes the patient even falls down. The Parkinson’s disease or its medication can be causing the sudden drop in blood pressure when standing up after lying down. This is the case of orthostatic hypotension.

Vertebrobasilar circulatory disorders always begin suddenly and can either pass quickly or leave secondary symptoms. The carotid arteries control the circulation of blood in the inner ear, brainstem and cerebellum. A carotid artery disease will almost always cause vertigo. Usually with vertigo originating from the carotid arteries there are other symptoms and findings, that indicate, that the vertigo is connected to the brain. The symptoms can be simultaneous sight problems, speech impairment or collapsing incidents. The short-term episode is called vertebrobasilar insufficiency and the episodes can recur on their own. Double vision during the vertigo episodes often refers to a more serious problem in the cerebral circulation and an increased risk of a stroke.

From the neurological disorders, a basilar migraine is one that includes episodes of headaches, vertigo, double vision, unsteady movements, balancing issues and speech impairment as symptoms. Basilar migraine episodes are common with young women and the episodes often ease with age. Also, with epileptic seizures the prodrome can be a sudden feeling of dizziness and vertigo.

Rarely ever is the cause of vertigo episodes genetic. In the previous years, the process of recognizing the genetic diseases, which cause vertigo episodes, called episodic ataxia conditions has been learned. Almost without an exception, a genetic disorder results in a defect in the structures of ion channels in neurons. Usually the transportation of either calcium or calcium ions in the cell membrane disturbs.

Heart arrhythmia or medication can cause vertigo

When determining the causes of long-term or recurring vertigo it is always important to examine the patient’s general state of health. Heart arrhythmia, anemia or sudden blood pressure fluctuations can cause vertigo. In these cases, appropriate examinations are required to determine the treatment.

Vertigo is not an unlikely side effect of medication either. Experiencing vertigo while starting medication or after taking certain medication strongly refers to the link between the vertigo and the medication. Vertigo may also be a consequence of taking multiple medications at a time.

Vertigo is a common symptom of panic disorder

Strong emotional outbursts can cause feelings of dizziness. People with panic disorders are used to experiencing vertigo as part of the anxiety symptoms. Whether the symptoms include vertigo or not depends totally on the situation. Vertigo can occur at high places, in the line at the grocery store, in a crowd etc. Appropriate medication will often help, but other therapeutic treatment possibilities should also be considered.

Vertigo – rarely indicates a serious illness

Vertigo is a perfectly normal symptom. In most cases the cause is harmless and it’s able to be determined through a systematical and thorough symptom diagnosis and a clinical examination. Surprisingly, as normal and common as vertigo is, the information about it and its treatment is incoherent and often the treatment efforts don’t have a solid research base to rely on. In most cases the vertigo is occasional and very rarely an indication of a serious illness. Neurological or ear specialist’s examinations are needed especially when there are other symptoms in addition to the vertigo or there are findings, that suggest doing further examinations. Hearing loss, difficulty with speech, seeing in double or trouble with eyesight are examples of these symptoms.

However, it is important to remember, that the harmless positional vertigo can cause dangerous situations for example on the road or at work. The possibility to treat vertigo with medication is very limited and especially with benign positional vertigo medication usually does not help. With vestibular neuronitis medication according to symptoms is recommended only in short-term.

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