Vertigo - All you need to know

Vertigo Definition

Vertigo is a symptom of an underlying condition rather than a condition on itself, it is commonly described as a sensation that you or the world around you is spinning or moving. This symptom can go unnoticeable or become so severe that one is unable to do everyday tasks.

To better understand this symptom, a basic understanding of how balance is maintained into the body is required. The sense of balance depends on a combined input from various parts of our sensory system that include:

Eyes, which help determine where the body is in space and how it’s moving;
Sensory nerves that send signals to our brain about body movements and positions;
Inner ear which houses the receptors that help detect gravity and back and forth motion.

Dizziness and vertigo are one of the most common symptoms that bring patients to medical consultation. The incidence of vertigo and dizziness is 5-10% but can go as high as 40% in subjects over 40 years old. The incidence of falling as a direct consequence of vertigo is about 25% for patients older than 65 years.

The role of primary care physicians and neurologists is to assess the causes of vertigo and other symptoms related to this.

Epidemiology

Vertigo affects both men and women, although women are around two to three times more often than males to suffer from it. It's been linked to a number of comorbid illnesses, including depression and cardiovascular disease. The prevalence rises with age and varies according to the underlying diagnosis. According to a general population study, the 1-year prevalence of vertigo is around 5%, with an annual incidence of 1.4 percent.

Dizziness, including vertigo, affects around 15% to 20% of individuals each year. The one-year prevalence of benign paroxysmal positional vertigo is about 1.6 percent, and it is less than 1% for vestibular migraine. The impact of vertigo should not be underestimated, since approximately 80% of study respondents indicated a disruption in everyday activities, including work, as well as the need for further medical treatment.

Vertigo causes- inner ear problems?

Vertigo types

Most often vertigo is caused by inner-ear problems, such as:

BPPV (Benign Paroxysmal Positional Vertigo) occurs when canaliths (calcium particles) that are normally found in the ear dislodge and collect in the inner ear. Since the inner ear helps keep your balance by sending signals to the brain related to head and body movements this can cause a variety of symptoms, including vertigo. BPPV has no known cause yet but age might play a role;

Meniere disease is an inner-ear disorder caused by a buildup of fluid, which causes changes in pressure in the ear. Vertigo due to Ménière disease can be accompanied by tinnitus (ringing in the ears) and hearing loss;
Labyrinthitis. This disorder is a result of an infection of the inner ear labyrinth that may occur when flu, cold or middle ear infection spreads to the inner ear. People with labyrinthitis may also experience hearing loss, tinnitus, headaches, vision changes, and ear pain besides dizziness with vertigo.
Vestibular neuritis is caused by an infection that results in the inflammation of the vestibular nerve. It is somewhat similar to labyrinthitis except it does not affect the hearing. It is often accompanied by blurred vision, severe nausea, and a feeling of losing balance;
Bilateral vestibular hypofunction (BVH) results in difficulty maintaining balance, especially when walking in a dark place or on uneven surfaces, and in a decrease of the person’s ability to see clearly when moving their head. This increases their risk of falling, therefore can degrade their physical condition. Patients who suffer from BHV or BHL (bilateral vestibular loss) complain of a sense of being off-balance rather than having an actual postural instability and this symptom can lessen or even disappear once the person sits or lays down. The feeling of dizziness is also heightened with head movements and persists in as many as 60% of the patients.

Other causes:

Cholesteatoma is a benign skin growth that develops in the middle ear as a result of repeated infections. As it grows in size it can damage the middle ear’s bone structures which can eventually lead to hearing loss and dizziness.
Vestibular migraine or migrainous vertigo is diagnosed when the vestibular system is repeatedly affected in someone who has a history of migraines. About 40% of people who suffer from migraines also show vestibular symptoms. Key symptoms of vestibular migraine include neck pain, discomfort turning or bending down, feeling pressure in the head or in the ear, tinnitus, and partial or complete loss of vision alongside dizziness and a migraine (but they can also appear on their own).

Sometimes vertigo can be associated with:

Head, brain, or neck injuries;
Certain medications that can damage the ear (check the side-effects of medications);
Ear surgery;
Perilymphatic fistula, caused by a leak of inner ear fluid into the middle ear due to a tear in either one of the membranes between the middle and the inner ear;
Osteosclerosis, when a problem with the growth of a middle ear bone is prior to hearing loss;
Stroke or transient ischemic attack (more commonly known as a mini-stroke)
Cerebellar or brainstem problems;
Syphilis;
Ataxia;
Migraines.

Central vertigo

Central vertigo is less common than peripheral vertigo and is caused by problems in parts of the brain such as the cerebellum (located at the base of the brain) or the brainstem. Some causes for central vertigo include:

Migraines are described as a severe headache that is generally felt as a throbbing pain either at the front or on one side of the head. It is more common in young people;
Multiple sclerosis is a condition that affects the central nervous system (both brain and spinal cord);
A brain tumor in the cerebellum;
A stroke or transient ischemic attack (TIA) happens when blood supply to the brain is disrupted;
Acoustic neuroma is a rare benign tumor that develops on the acoustic nerve;

Similar symptoms can be present in the presence of brain tumors.

Vertigo Hereditary?

Vertigo is a symptom itself that is not hereditary, but the various conditions and syndromes that cause it might be. Some of these appear to involve certain genetic factors that may run in the family. In addition, a person with recurrent vertigo might have a hereditary genetic component. The doctor will ask about your family history. Some examples of conditions or syndromes that involve genetic factors are:

Migrainous vertigo;
Bilateral vestibular hypofunction;
Familial Ménière's disease;
Familial episodic ataxia.

Pathophysiology

The symptom of vertigo is caused by asymmetry in the vestibular system. Damage or malfunction in the peripheral system, such as the vestibular labyrinth or vestibular nerve, or a central disruption in the brainstem or cerebellum, can cause asymmetry. Though there may be a chronic vestibular disruption, vertigo is never permanent since the central nervous system adjusts over days to weeks.

Vertigo can be caused by tumors. The most prevalent lesion in the cerebellopontine angle is schwannoma. The most frequent extra-axial tumor in adults is meningioma. It is the second most frequent cerebellopontine angle lesion. Glomus jugulare and glomus jugulotympanicum are chemoreceptor system cancers that are the most common primary tumors of the jugular foramen.

Patients with known primary neoplasia or numerous brain lesions should be evaluated for metastases. The source of the infection should be considered. The most prevalent cause is viral labyrinthitis. Otomastoiditis is a tympanic and mastoid cavity infection. Bacterial agents are usually at blame, with Streptococcus pneumoniae and Haemophilus influenza being the most prevalent.

Vertigo Symptoms

Once a time course has been established, it is critical to screen for concomitant symptoms, which can assist differentiate between a central and a peripheral etiology. Nausea and vomiting are common during acute bouts of vertigo and are not caused by a specific etiology. Providers must inquire about any focal neurologic abnormalities such as diplopia, dysarthria, dysphagia, and numbness or weakness to rule out central causes that may be progressive or life-threatening, such as a vertebrobasilar stroke or multiple sclerosis.

The absence of any localized neurological deficiency does not rule out the possibility of a significant central process, but its existence is quite worrying and warrants additional investigation. Moving along the spectrum of central causes and accompanying symptoms, physicians should question headache, photophobia, and visual auras, as they are frequently linked with vestibular migraines. There are a slew of additional symptoms connected with vertigo caused by a peripheral lesion.

Patients with Ménière illness may have deafness and tinnitus. They may have recently had a viral infection, which can result in acute labyrinthitis and vestibular neuritis. Finally, it is critical to go through a patient's prescription list as well as their social history for any substance or alcohol usage. Anticonvulsants, salicylates, and antibiotics are examples of medications that can affect vestibular function.

People with vertigo usually describe it as a feeling of:

Spinning;
Losing balance;
Being pulled to one direction/tilting.

Other symptoms that can accompany vertigo:

Nausea and even vomiting;
Nystagmus (abnormal uncontrollable eye movements);
Headache;
Sweating
Tinnitus (ringing in the ears).

Vertigo Diagnosis

The evaluation of a patient who complains about vertigo begins with an evaluation of the history of the symptoms, followed by a complete neuro-otologic physical examination. The physician will most likely ask about the onset and duration of the symptoms, and also about triggers that may or may not accompany this sensation.

Once vertigo has been established, a comprehensive history assists the provider in distinguishing between a central and peripheral cause. One of the most effective methods for determining the underlying etiology is to elicit a time course of symptoms. Recurrent vertigo lasting a few minutes or less, for example, is frequently linked with benign paroxysmal positional vertigo.

A vestibular migraine or a more serious underlying condition, such as a transient ischemic stroke, might induce a single episode lasting minutes to hours. Prolonged episodes can occur as a result of both peripheral and central causes, such as vestibular neuritis or stroke.

You should also expect to be asked to describe your symptoms with other words than “dizzy” as it is commonly used nonspecifically to describe vertigo, syncope, presyncope, falling, unsteadiness, etc. The history taking and exam is essential because it studies in detail the characteristics of vertigo:

Sudden vertigo that lasts for minutes could be caused by migraines or brain or vascular disease especially if accompanied by cerebrovascular risk factors;
Vertigo that lasts for only a few seconds and is triggered by head or body changes in positions are most likely caused by benign paroxysmal positional vertigo (BPPV);
Vertigo that lasts for hours could be due to Ménière disease;
Vertigo that can go on for days and is accompanied by nausea is most commonly due to vestibular neuritis.

The Physical Exam

In patients who show signs of vertigo, the general physical exam should put emphasis on the assessment of vital signs and cardiovascular and neurologic systems. The ears will be examined seeking infection or inflammation of either the external or the middle ear.

Sometimes it can be needed several hearing and or balance tests:

Head movement testing in case the doctor suspects that it’s benign paroxysmal positional vertigo, in which case a test called the Dix-Hallpike maneuver is performed to verify the diagnosis;
Posturography is a test, which relieves parts of your balance system you rely on the most and which are giving problems. You are required to stand bare-foot on a platform and asked to keep your balance under certain circumstances;
Eye movement testing is when the doctor observes the path of your eyes when you track a moving object. You may also be given an eye motion test while water is placed in your ear canal;
Rotary chair testing requires you to sit in a computer-controlled chair that moves slowly in a full circle.

Once a time course has been established, it is necessary to screen for accompanying symptoms, which can assist in identifying a central part of a peripheral etiology. Nausea and vomiting are common symptoms of acute vertigo and are not caused by a specific etiology. Because it is critical to rule out central reasons that may be progressive or life-threatening, such as a vertebrobasilar stroke or multiple sclerosis, physicians must inquire about any focal neurologic abnormalities such as diplopia, dysarthria, dysphagia, and numbness or paralysis.

The absence of any localized neurological deficiency does not rule out the possibility of a significant central process, but its existence is quite worrying and should be studied further. Moving along the spectrum of central causes and accompanying symptoms, physicians should question headache, photophobia, and visual auras, as they frequently accompany vestibular migraines.

There are also plenty of additional symptoms connected with vertigo caused by a peripheral lesion. Patients with Ménière illness may have deafness and tinnitus. They may have recently had a viral infection, which can result in acute labyrinthitis and vestibular neuritis. Finally, it is critical to go through a patient's prescription list as well as their social history for any substance or alcohol usage. Anticonvulsants, salicylates, and antibiotics are examples of medications that can disrupt vestibular function.

Gait and balance tests can also help with localization. Patients with unilateral peripheral problems frequently lean or fall to the lesion's side, but patients with cerebellar lesions are frequently unable to walk without help, and the direction of falling with Romberg tests is vary.

A significant number of primary care and specialty physicians overlook the basics of history and physical examination, resulting in unneeded imaging and drugs.

The otoscopic exam should be conducted to rule out any visible infection, such as acute otitis media, and bedside hearing tests can help differentiate other causes of vertigo. To assess conductive and sensorineural hearing loss, Weber and Rinne tests are done at the patient's bedside. Audiometry, on the other hand, is more sensitive than bedside testing in diagnosing hearing loss.

A unilateral hearing loss clearly suggests a peripheral origin, however further diagnostic imaging using MRI is required if a reason cannot be established. There is inadequate high-quality data to predict BPPV in individuals with vertigo based on the lack of hearing loss as measured by pure tone audiometry.

How to prepare for an appointment?

A family doctor might be able to diagnose and treat the cause of dizziness or may refer to an ENT specialist or to a neurologist. Before the appointment keeps in mind:

Ask about any pre-appointment restrictions. When you make the appointment make sure to ask if anything needs to be done in advance, such as restricting your diet or withholding from certain medications.
Describe your dizziness in specific terms. An accurate description of your symptoms is crucial to a diagnosis. Is the room spinning or are you spinning in the room? Do you feel like you might faint?
Make a list of any other health conditions or symptoms you have including anything that may not be directly related to dizziness.
Mention key personal information, including any major stresses or life changes that occurred recently and may have interfered with your mental health.
Make a list of all medications (including over-the-counter medications and supplements or vitamins) that you are currently taking;
Make a list of questions you might want to ask your doctor.

Vertigo treatment

The treatment of vertigo is determined by the etiology, and addressing the underlying etiology frequently improves the symptoms of vertigo.

Medications may be beneficial in suppressing vestibular sensations during acute episodes that might last from a few hours to several days. Antihistamines, benzodiazepines, and antiemetics are the most often utilized drugs for symptom alleviation.

Medicine is sometimes required to treat nausea associated with vertigo or the infection or inflammation that caused vertigo, in which case antibiotics may be prescribed. Antidiuretics may reduce the pressure caused by the fluid buildup caused by Ménière’s disease. Preventive medicine for migraines may help prevent migraine attacks. Anti-anxiety medications such as diazepam (valium) and alprazolam (Xanax) may help with anxiety-induced vertigo;

Meclizine, the most commonly used antihistamine, is safe to take throughout pregnancy. Because of their sedative effects, antihistamines, benzodiazepines, and antiemetics should be used with caution in older patients.

Physical therapy with vestibular rehabilitation is another non-pharmacologic therapeutic option for people with persistent unilateral or bilateral vestibular impairment. Vestibular rehabilitation exercises teach the brain to maintain balance by using alternate visual and proprioceptive cues. Several randomized controlled studies have demonstrated advantages in vestibular rehabilitation, such as a reduction in vertiginous symptoms, a reduction in movement-induced dizziness, and an improvement in activities of daily living.

A mix of pharmacologic and nonpharmacologic treatment is advised for certain individuals, notably those with vestibular neuritis. Corticosteroids, in addition to vestibular therapy, are advised in the acute setting for vestibular neuritis. Lifestyle changes, in addition to medication and vestibular therapy, have been demonstrated to be useful in people with Ménière illness.

Patients suffering from Ménière illness may be especially vulnerable to high salt diets, coffee, and alcohol. Keeping away from identified triggers might help to reduce symptoms. When diet changes alone are insufficient to manage symptoms, diuretics may be recommended. Acute bouts can be managed symptomatically with vestibular suppressants such as meclizine.

Non-pharmacologic treatments help patients with benign paroxysmal positional vertigo. The Epley technique and canalith repositioning are the basic treatments for BPPV.

Epley Technique

The Epley technique has the advantage of being simple enough for the patient to do at home. To conduct a modified Epley technique, advise the patient to lie upright on a bed with their head rotated 45 degrees to the left and a pillow behind them. The pillow should be positioned such that while they are supine, the pillow is immediately under their shoulders.

Once the patient is in place, they should rapidly return to the pillow and recline their head into the bed. They must remain in this posture for 30 seconds. They should then tilt their heads 90 degrees to the opposite side and remain in this posture for another 30 seconds without raising their heads. After 30 seconds, they should move their body and head 90 degrees to the right and wait 30 seconds more. Finally, they should position themselves on the correct side of the bed.

This procedure should be done at least three times a day until the patient has no more episodes of positional vertigo for 24 hours. The Epley technique, which works in 50 to 90 percent of patients.

Unfortunately, BPPV is persistent in a subset of people, and surgical therapy may be an option, especially if symptoms are incapacitating. Occlusion of the posterior canal with bone plugs or transection of the posterior ampullary nerve are surgical possibilities. Hearing loss is a possibility with either surgical treatment.

Vestibular Rehabilitation

Vestibular rehabilitation is a type of physical therapy that aims to improve the vestibular system by building its strength. This sort of therapy is usually recommended to those who have recurrent episodes of vertigo and is based on training other senses to compensate for vertigo.

Injections with antibiotics into the inner ear disable the balance function of the injected ear. The other ear will take over the function;

Removal of the inner ear sense organ (labyrinthectomy)

Rarely used and involves disabling the vestibular labyrinth in the affected ear. Just like in the case of injections, the unaffected ear will take over the balance function. This is only recommended and used for those who did not respond to any medications or treatments and also have serious hearing loss;

Vertigo treatment at home

DO's and DON'Ts

DO:

Try to relax as anxiety can worsen vertigo
Sleep with your head slightly raised on a few pillows;
Sit down the second you feel dizzy;
Move your head slowly when performing any daily activities;
Lie still in a quiet, dark room when you get any spinning sensations;
A walking stick may be useful if you’re at risk of falling;
Get out of bed slowly and sit for a while before getting up;
Do simple exercises that correct the symptoms.
Avoid using caffeine, alcohol, salt, tobacco as these can worsen the symptoms;
Stay hydrated;
Fall-proof your home by removing any tripping hazards and replacing usual mats with non-slip mats on your bath and shower floors;
Keep your house well-lit, as dim lights and dark places can worsen your symptoms;
Avoid driving a car or operating any machineries if you experience frequent and sudden episodes of dizziness;

DON'T:

Stretch your neck, for instance when trying to reach something high above your head;
Bend over to pick things up (squatting to lower yourself is a better alternative).

Some types of vertigo caused by migraines have certain triggers and causes, although they are not very well understood. They are likely related to an unusual electrical charge in the neurons that sets off the brain’s pain receptors. Common triggers include:

Stress, anxiety;
Consumption of caffeine, alcohol, and even dairy products;
Lack of sleep or too much sleep;
Environmental factors like bright lights;
Hormonal changes (during menstruation, menopause, and pregnancy).

Medicine is sometimes required to treat nausea associated with vertigo or the infection or inflammation that caused vertigo, in which case antibiotics may be prescribed. Antidiuretics may reduce the pressure caused by the fluid buildup caused by Ménière's disease. Preventive medicine for migraines may help prevent migraine attacks. Anti-anxiety medications such as diazepam (valium) and alprazolam (Xanax) may help with anxiety-induced vertigo;

If you notice what happens prior to a vertigo episode, write it down and discuss it with your doctor or GP. Sometimes avoiding these triggers or developing a regular sleep schedule can prevent them from happening. Some preventive measures include:

Eating a healthy diet and drinking enough water;
Getting a regular amount of sleep every night and following a sleep schedule that is right for you;
Trying to manage stress;
Exercising regularly;
Avoiding any foods or drinks that might trigger another vertigo episode (caffeine, alcohol, dairy).

Vertigo in Pregnancy

Nausea and dizziness are very common during pregnancy and this is due to hormonal changes as they affect the characteristics of the fluid in your body. A study conducted in 2010 suggests that hormonal changes could also alter the inner ear but with time the pregnant woman gets used to these changes so the symptoms improve.

Also, women who are more susceptible to migraines are more likely to have them during their pregnancy (since hormone changes could potentially trigger migraines) and vertigo might be a secondary symptom. A 2019 study also showed that fainting is common among pregnant women. Fainting during the first trimester can increase the risk of a variety of complications such as preterm birth and even some congenital abnormalities. Also, and for pregnant women, it can increase the risk of cardiac problems or pulmonary embolism.

Feeling lightheaded early in pregnancy is very common as hormones lead to a dilation of blood vessels. This may improve or worsen as the pregnancy progresses. More specifically, an increase in the pregnancy hormone (human chorionic gonadotropin) may cause dizziness and nausea but they usually get better by the end of the first trimester.

However, toward the end of the second trimester, the body struggles to make and use insulin which can eventually cause gestational diabetes (that makes some women feel dizzy). If the symptoms do not go away on their own, asking your doctor about possible treatment plans is necessary.

Read more here: Everything you need to know about Pregnancy"

If vertigo is a secondary symptom of pregnancy, a doctor might suggest making changes in your diet to manage low blood sugar, insulin or other medications that might be used to treat gestational diabetes, antibiotics are prescribed if the cause for dizziness is a bacterial infection.

Preventive measures for Vertigo in Pregnancy

Pregnant women may reduce the risk of dizziness by:

Standing up slowly and sitting on the edge of the bed for a couple of minutes prior to standing up;
Exercising gently;
Eating small meals during the day that are rich in protein and nutrients;
Drinking enough water;
Regulating stress and anxiety through support from loved ones, breathing exercises, meditation, yoga, and psychotherapy;
Laying on the left side of the body keeps the uterus from putting pressure on the liver and improves blood flow to the baby.

When to seek help

Consider making an appointment with your GP if you suspect you have vertigo and the symptoms do not go away on their own or keep coming back. If you experience any of the following symptoms, emergency medical care is needed:

Severe shortness of breath;
Seizures;
Fever;
Chest pain;
Sudden, severe headache;
Numbness or paralysis of arms or legs;
Ongoing vomiting;
Double vision;
Slurred speech or confusion;
Stumbling or difficulty walking;
Facial numbness or weakness;
Any signs of premature labor, such as contractions or fluid coming from the vagina in pregnant women.

Differential Diagnosis

Vertigo has a wide differential diagnosis since it can be caused by a central or peripheral vestibular system injury. As a result, it's critical to distinguish vertigo from signs of disequilibrium and pre-syncope, such as imbalance and lightheadedness. These symptoms can be caused by a variety of metabolic, vascular, inflammatory, iatrogenic, and endocrine factors.

Anemia
Anxiety disorders
Benign positional vertigo
Brain neoplasms
Giant cell arteritis
Herpes simplex encephalitis
Labyrinthitis
Mastoiditis
Ménière disease
Meningitis
Migraine headache
Multiple sclerosis
Stroke
Vertebrobasilar atherothrombotic disease
Vestibular neuronitis

Prognosis

The recurrence rate of benign paroxysmal positional vertigo is 50% after 5 years. One year after vestibular neuritis, over a third of patients continue to experience dizziness related to anxiety.

Complications

The key to making a diagnosis is distinguishing vertigo from other causes of dizziness or imbalance, as well as distinguishing central from peripheral vertigo causes. In the case of life-threatening diseases, a correct diagnosis is critical. These include neoplasms, infections, and cerebrovascular accidents.

Conclusion

Vertigo is rather a symptom of an underlying condition than a condition on itself and sometimes needs medical assessment to find its root cause. If you think you have vertigo and it interferes with your everyday life, you find yourself avoiding certain places or physical activity, talk to your doctor. He might refer you to an ENT or neurologist for further assessment of your symptoms if he suspects your vertigo requires specialist advice. Although some studies say that certain types are hereditary, more research needs to be made, but make sure you have your medical and familial history and all your current medications at hand if the doctor should ask.