What is Vertigo?

What is vertigo?

Vertigo is described as feeling a sensation of movement, generally spinning, even when no movement is occurring. It is also considered a distorted sensation of movement during a normal head movement.¹ Treatment for vertigo depends on multiple factors.

Is vertigo the same as dizziness or motion sickness?

Vertigo and dizziness are linked to conditions or disorders that affect the vestibular system, which is responsible for maintaining our balance and position. Vertigo is usually considered a type of dizziness but recent research suggests that may not be the case.

Dizziness is used to describe a number of sensations without feeling a false or distorted movement.² However, clinical evidence suggests the difference between vertigo and dizziness is not of much use in diagnosing or treating the patient’s medical condition.^1,2

Motion sickness is a condition triggered by real (riding in an airplane or ship) or virtual (virtual reality headsets) motion to which the person has not adapted.³ It is similar to vertigo in that both conditions are triggered by the stimulation of the vestibular system and are associated with symptoms such as nausea and vomiting.⁴ However, motion sickness usually develops in people with a functioning vestibular system.^3,4 Patients with underlying diseases affecting the vestibular system do not generally develop motion sickness.³

What causes vertigo?

Vertigo can be classified as peripheral or central vertigo based on the cause.⁵ The cause can originate from a disorder in the ear or the central nervous system.

Peripheral Vertigo

Peripheral vertigo is linked to disorders affecting the inner ear and the vestibular nerve. It is more common than central vertigo, affecting over seventy five percent of vertigo patients.⁶ Peripheral vertigo is generally benign, while central vertigo is considered to be more serious, needing immediate medical attention.²

Disorders associated with peripheral vertigo include benign paroxysmal positional vertigo (BPPV), vestibular neuritis and Ménière’s disease.  Over ninety percent of cases of vertigo is caused by BPPV, vestibular neuritis and Ménière’s disease.⁶

Benign paroxysmal positional vertigo occurs due to calcium crystal deposits known as canaliths dislodging in the ear canal.⁵ Patients with BPPV can experience brief episodes of vertigo, triggered by sudden changes in head position.^2,5 The onset of these episodes are sudden and they last for no more than a minute.⁵

Vestibular neuritis is a medical condition caused by an ear infection that results in the inflammation of the vestibular nerve.² It develops following an upper respiratory viral infection in over twenty percent of cases.⁵ However, in some cases, the disease may be caused by a bacterial infection. Patients with vestibular neuritis generally experience episodes of vertigo that are sudden and spontaneous.^2,5 These episodes can last between a few seconds and several days.

Ménière’s disease is a disorder affecting the inner ear caused by elevated endolymphatic pressure.² Patients with the disorder can experience vertigo that is spontaneous and can develop hearing loss and tinnitus.⁵

Central Vertigo

Central vertigo is linked to disorders originating in the brain and spinal cord. These disorders include vestibular migraines, cerebrovascular disease, and acoustic neuroma.

Vestibular migraine is a medical condition affecting individuals with a history of migraines.² These individuals experience episodes of vertigo that are generally spontaneous.

Patients with cerebrovascular diseases experience vertigo due to a blockage or insufficient blood supply to the brain and inner ear. Around half of patients report having vertigo as their symptom.² Vertigo can be considered a warning sign of a stroke. ⁵

Acoustic neuroma, also known as vestibular schwannoma, is a benign tumor formed in the Schwann cell sheath in the vestibular nerve.⁶ Patients experience severe vertigo that can last continuously for several hours and occurs often throughout the day. These vertigo episodes can have a negative impact on the patient’s quality of life, which can potentially make it difficult to walk or work without assistance.⁶

According to studies, patients treated with radiosurgery have experienced better improvement in their quality of life than those receiving other treatments.⁶ However, more research is needed to assess vertigo caused by this condition.

Trauma, psychiatric or cardiovascular causes

Vertigo can occur due to anxiety, stress, and medications as well as cardiovascular problems such as low blood pressure.^1,2

Vertigo is a common symptom arising from head or neck trauma, blast injuries, or ear barotrauma (increased ear pressure).  In most cases, the symptoms generally last for minutes, days, or even weeks. However, in some cases, the symptoms can be long-term.⁵

How is vertigo diagnosed?

When a patient presents with symptoms linked to vertigo, the physician performs a diagnosis by taking their medical history and conducting a physical examination.

The doctor performs the diagnosis using procedures that involve examining the timing and triggers of the symptoms, to help determine the cause of vertigo.^1,2 Vertigo symptoms assessed include hearing loss, nystagmus (abnormal eye movements), loss of balance, gait instability, nausea, and vomiting.²

The physical examination comprises both cardiac and neurological assessments, targeted to the patient’s condition. The cardiac assessment involves measuring the orthostatic blood pressure, which is done while the patient is standing and in a supine position.²

Eye movements are assessed to help differentiating stroke (a central cause of vertigo) from peripheral vertigo.²

The Dix-Hallpike maneuver is performed to help diagnose benign paroxysmal positional vertigo.² This procedure comprises a set of maneuvers during which the patient’s head is moved. A positive result is achieved when any of the movements triggers vertigo with or without evoking abnormal eye movements.²

What is the treatment for vertigo?

There are several therapies available to treat or manage vertigo. The choice of treatment for vertigo is based on the patient’s medical condition or disorder.

Treatment of benign paroxysmal positional vertigo

Benign paroxysmal positional vertigo is usually treated with the Epley manoeuver. This procedure can be performed at home or at the clinic. The Epley maneuver involves canalith repositioning during which the dislodged canaliths are moved back to their original positions in the ear canal.²

The half somersault maneuver is another treatment used for BPPV, designed to be performed at home. According to a 2012 study, published in Audiology and Neurotology Extra, researchers found that patients preferred the half somersault maneuver over the Epley maneuver because it made them feel less dizzy.⁷ However, the same study reports that the Epley maneuver is considered to be the more effective treatment done in a clinical setting or by a physical therapist.

Brandt-Daroff exercises can also be used to help treat BPPV. This treatment can be performed at home. According to a 2018 study, published in the Pakistan Journal of Medical Sciences, Brandt-Daroff exercises were found to be as effective as the Epley maneuver in treating BPPV.⁸

It is recommended that patients consult their doctor, regarding choosing a treatment for vertigo.

Treatment for vestibular neuritis

Vestibular neuritis is usually treated with medications and vestibular rehabilitation exercises. These medications include antiemetics, benzodiazepines, and antihistamines and help suppress the symptoms associated with the disorder.²

Treatment for Ménière’s disease

The symptoms of Ménière’s disease are initially managed by limiting salt and alcohol consumption as well as lowering caffeine. If vertigo cannot be managed by this initial treatment, then patients are prescribed medications such as thiazide diuretics or glucocorticoids.²

Treatment of central vertigo disorders

Vestibular migraines are generally treated by identifying and preventing factors that trigger the migraines. Patients with this condition are recommended to relieve stress as well as get sufficient sleep and exercise.²

Patients with cerebrovascular diseases are generally treated with antiplatelet reduction and by decreasing the risk factors associated with stroke.²

You should speak to your doctor if you experience any symptoms associated with vertigo.

Written by Ranjani Sabarinathan, MSc                                                                                      

References

1. Newman-Toker DE, Edlow JA. TiTrATE: A Novel, Evidence-Based Approach to Diagnosing Acute Dizziness and Vertigo. Neurol Clin. 2015;33(3):577-viii. doi:10.1016/j.ncl.2015.04.011

• Muncie HL, Sirmans SM, James E. Dizziness: Approach to Evaluation and Management. Am Fam Physician. 2017 Feb 1;95(3):154-162. PMID: 28145669.

• Leung AK, Hon KL. Motion sickness: an overview. Drugs Context. 2019;8:2019-9-4. Published 2019 Dec 13. doi:10.7573/dic.2019-9-4

• Zajonc TP, Roland PS. Vertigo and motion sickness. Part II: Pharmacologic treatment. Ear Nose Throat J. 2006 Jan;85(1):25-35. PMID: 16509240.

• Thompson TL, Amedee R. Vertigo: a review of common peripheral and central vestibular disorders. Ochsner J. 2009;9(1):20-26.

• Dayal M, Perez-Andujar A, Chuang C, Parsa AT, Barani IJ. Management of vestibular schwannoma: focus on vertigo. CNS Oncol. 2013;2(1):99-104. doi:10.2217/cns.12.30

• Foster CA, Ponnapan A, Zaccaro K, Strong D. A comparison of two home exercises for benign positional vertigo: Half somersault versus Epley Maneuver. Audiol Neurotol Extra 2012;2:16-23.

• Cetin YS, Ozmen OA, Demir UL, Kasapoglu F, Basut O, Coskun H. Comparison of the effectiveness of Brandt-Daroff Vestibular training and Epley Canalith repositioning maneuver in benign Paroxysmal positional vertigo long term result: A randomized prospective clinical trial. Pak J Med Sci. 2018;34(3):558-563. doi:10.12669/pjms.343.14786
• Image by Felix Hu from Pixabay