Tuesday, December 2, 2014

Aging and Vertigo: How to Deal? How to Treat?

What is Vertigo?

Vertigo is the feeling of spinning or falling through space when there is no motion. Sensations associated with vertigo include a sense of spinning, tumbling, falling forward or backward, or the ground rolling beneath one's feet. It may be difficult to focus visually; many people find it uncomfortable to keep their eyes open during vertigo spells. Sweating, nausea, and vomiting are also common. Depending on the cause, vertigo can last from a few minutes to days.

Vertigo is not a disease, but a symptom of a broad range of disorders, diseases, and conditions, including:
* Diseases or disorders of the inner ear (such as motion sickness; the formation of “sludge” in the inner ear, which causes the inner ear to send a confusing motion signal to the brain; or tumors in the inner ear).
* Injuries or other damage to the inner ear (for example, from drugs such as aspirin and some diuretics, chemotherapeutics, and antibiotics).
* Diseases or disorders of the brain (such as tumors, migraine, transient ischemic attack or stroke, or a psychiatric disease or disorder).
* Disorders affecting the acoustic nerve, which connects the inner ear to the brain.
* Ménière’s disease or Ménière’s syndrome.
* Viral and bacterial infections.
* Allergies.
* Multiple sclerosis.
* Damage to the nerves in the neck that help the brain monitor the relative position of the neck and trunk (this form of vertigo, called cervical vertigo, often occurs after an injury such as a whiplash injury but may be associated with arthritis in the neck or degenerative cervical spine disease).
* Low blood pressure.

Under normal circumstances, the brain relies on three sensory systems to maintain spatial orientation: the vestibular system (inner ear), visual system (eyes), and somatosensory system (conveys information from the skin, joint, and muscle receptors). These three systems overlap, allowing the brain to assemble an accurate sense of spatial orientation. However, a compromised system or conflicting signals can cause vertigo.

The vestibular system is most often involved with vertigo. The sensory organs for the vestibular system are located in the bony labyrinths of the inner ear. They include three semicircular canals and an otolithic apparatus on each side. The otolithic apparatus consists of tiny particles of calcium carbonate suspended in a gelatinous matrix in two structures called the utricle and saccule. These particles shift in response to movement in a straight line, stimulating cilia (hair-like fibers) that are embedded in the gel. Movement at an angle is detected by the semicircular canals. These components work together to provide a sense of spatial orientation.

Vertigo Classification

Broadly classified, vertigo is usually either physiologic or pathologic. Physiologic vertigo is normal and occurs when there is a conflict between the signals sent to the brain by the vestibular system and by the other balance-sensing systems of the body. It can also occur when the head is subjected to unfamiliar movements, such as the rolling motion associated with seasickness, spinning for an extended period, or when the head is held in an unusual position (e.g., head and neck are tilted back for an extended period). Physiologic vertigo is usually easily corrected, either by moving the head and neck into a more normal position or focusing on an external reference point to give the vestibular system an opportunity to stabilize. This is why a person with motion sickness is advised to look into the distance and focus on some faraway point, such as the horizon.

Pathologic vertigo occurs because of lesions or disorders in any of the three sensory systems (usually the vestibular system). Pathologic vertigo is further broken down into the following:
* Labyrinthine dysfunction—Labyrinthine dysfunction can occur as a result of any disease or condition that affects the ability of the vestibular organs (the labyrinths) to communicate with the brain.
* Vertigo of the vestibular nerve—Diseases of the eighth (vestibular) cranial nerve cause vertigo of the vestibular nerve.
* Central vertigo—Lesions on the brainstem or cerebellum (parts of the nervous system in which information from the vestibular system is integrated with information from the eyes and musculoskeletal position sensors, or proprioceptors) can cause central vertigo.
* Psychogenic vertigo—Psychogenic vertigo usually occurs with panic attacks or agoraphobia (fear of open spaces).

No matter what the cause, vertigo is common, affecting millions of people annually. Episodes of vertigo increase with age, accounting for more than 61% of all cases of dizziness by age 65 years. The overall incidence of dizziness, vertigo, and imbalance is 5 to 10% of the overall population and 40% in patients older than 40 years.

Types of Vertigo

Benign Paroxysmal Positional Vertigo

Benign paroxysmal positional vertigo (BPPV) occurs after a sudden movement of the head. It is one of the most common types of vertigo. Women are affected twice as often as men are, and the average age of onset is the mid-50s.

BPPV is usually harmless and often no cause is detected (i.e., idiopathic). In some cases, however, BPPV is caused by age-related degeneration or head trauma. Patients with BPPV have short-lived episodes of temporary dizziness, lightheadedness, imbalance, and nausea. Symptoms of BPPV, which usually develop suddenly after a change in head position, may be severe enough to cause vomiting. Typical motions that cause episodes of BPPV include getting out of bed, rolling over, bending down, and looking up while standing. One of the characteristic symptoms of BPPV is rapid movement of the eye in one direction followed by a slow drift back to its original position. This involuntary movement of the eyes is a type of nystagmus. Doctors can sometimes tell what kind of vertigo is present by the nature of the nystagmus.

BPPV occurs when debris from the otoliths settles into the posterior semicircular canal. This renders the canal oversensitive to the pull of gravity, producing a constant sense of motion or falling.

Ménière’s Syndrome and Ménière’s Disease

The terms Ménière’s disease and Ménière’s syndrome are sometimes used interchangeably. However, even though both involve the inner ear apparatus, they are not the same disorder. Ménière’s disease develops due to idiopathic (or unknown) causes, while Ménière’s syndrome is secondary to other diseases such as inner ear inflammation caused by syphilis, thyroid disease, or head trauma. Of the two, the most common is idiopathic Ménière’s disease.

Ménière’s of either variety is recognized by a classic triad of symptoms: vertigo; low-frequency, fluctuating hearing loss; and tinnitus (ringing in the ears). Also, the condition is characterized by a condition known as endolymphatic hydrops, or increased hydraulic pressure in the inner ear's endolymphatic system. Although researchers have long suspected that endolymphatic hydrops was the underlying cause of the symptoms of Ménière’s disease, newer studies have called into question an even deeper cause. The endolymphatic hydrops in Ménière’s disease may be caused by neurotoxicity and progressive damage to the cochlear nerve in the ear; the increased pressure is a result rather than a cause. Some early research has suggested that nerve cell toxicity is mediated by nitric oxide, which is an important mediator in the inflammatory process. This suggests that agents that block nitric oxide may someday be important in the treatment of Ménière’s.

In the meantime, while researchers are still pursuing these findings, other treatments may come to the forefront. For instance, because people with Ménière’s disease have been shown to have characteristic abnormalities in their inner ear and an elevated level of free radicals, free radical scavengers may be of benefit in treating Ménière’s.

People who have Ménière’s may experience attacks of vertigo that last 1 to 8 hours. These attacks (and the accompanying tinnitus) can be severe. There may also be an aura (such as a sensation of seeing lights or smelling odors). These symptoms may last an indefinite period. In the worst cases, hearing loss is permanent.

Other Types

Other types of vertigo include:
* Vestibular neuronitis involves an attack of vertigo that occurs without accompanying disruption of hearing. Its symptoms may persist for up to several weeks before clearing, but usually abate within a matter of days. It is sometimes referred to as vestibular neuropathy.
* Labyrinthitis is an acute inflammation of the labyrinths, often caused by viral infections, although it can also be caused by reactions to medications or toxins. People with labyrinthitis experience an acute onset of severe vertigo that lasts several days to a week. It is typically accompanied by hearing loss and tinnitus.
* Phobic postural vertigo is the second most common diagnosis in people with dizziness or vertigo, although there is some debate about whether this is a single disorder or represents a group of different conditions with possible different causes. Phobic postural vertigo, which is characterized by nonrotational vertigo with postural and gait instability, mainly occurs in people with an obsessive-compulsive personality.
* Migraine-associated vertigo is a disorder that can accompany a migraine headache. In medical practices focused on treating migraine, 27 to 42% of patients report episodic vertigo. A large number (about 36%) of these patients also experienced vertigo during headache-free periods.
* Posttraumatic vertigo immediately follows head trauma. In most cases, it causes damage to the inner ear mechanisms in the absence of other central nervous system signs. The interval between injury and onset of symptoms can be days or even weeks. The mechanism for the delay of symptoms is uncertain but includes hemorrhage into the labyrinth, with later development of labyrinthitis in the fluids of the inner ear.
* Central nervous system dysfunction causes of vertigo are varied and include brainstem vascular disease, arteriovenous malformation, tumor of the brainstem and cerebellum, multiple sclerosis, and vertebrobasilar migraine.

Conventional Treatment of Vertigo

Although BPPV and some other common causes of vertigo are relatively harmless and disappear over time, there are other forms whose appearance might signify the beginning of a more serious condition. Because of this, it is always recommended that any case of vertigo to be evaluated by an experienced physician.

The conventional treatment of vertigo depends on its underlying cause. In the case of BPPV, the most common therapy is repositioning exercises that redistribute the calcium carbonate back throughout the inner ear. There are various forms of repositioning exercises, including the Epley maneuver. In the Epley maneuver, the person lies down and the head is moved from side to side, with each position being held about 30 seconds. This has been shown to redistribute the calcium deposits in the inner ear, thus reestablishing normal function. Nonsurgical, nonpharmaceutical exercises such as the Epley maneuver have an excellent record of reversing vertigo caused by BPPV.

Epley maneuver and two more alternative treatments will be reviewed in more details below.

Treatment of Ménière’s is aimed at controlling the vertigo, usually through salt restriction or diuretics to relieve the elevated pressure in the endolymphatic sac. Similarly, glucocorticoids may be prescribed. For severe cases, surgery is sometimes recommended to decompress the endolymphatic sac. Unfortunately, no effective therapy for tinnitus or hearing loss has been identified.

Other pharmaceuticals used to suppress vestibular abnormalities include anticholinergics, benzodiazepines, and antihistamines. Some patients with nausea use antiemetics.

Epley Maneuver at Home

If your vertigo comes from your left ear and side:
* Sit on the edge of your bed. Turn your head 45 degrees to the left. Place a pillow under you so when you lie down, it rests between your shoulders rather than under your head.
* Quickly lie down, face up, with your head on the bed (still at the 45-degree angle). The pillow should be under your shoulders. Wait 30 seconds (for any vertigo to stop).
* Turn your head halfway (90 degrees) to the right without raising it. Wait 30 seconds.
* Turn your head and body on its side to the right, so you are looking at the floor. Wait 30 seconds.
* Slowly sit up, but remain on the bed a few minutes.

If the vertigo comes from your right ear, reverse these instructions. Sit on your bed, turn your head 45 degrees to the right, and so on.

Do these movements three times before going to bed each night, until you have gone 24 hours without dizziness.

If you need more clear and details video instructions, you may search YouTube for the related educational clips on proper self-performance of Epley Maneuver.

Semont Maneuver

This exercise is similar to the Epley maneuver, though not as popular in the U.S. For dizziness from the left ear and side:
* Sit on the edge of your bed. Turn your head 45 degrees to the right.
* Quickly lie down on your left side. Stay there for 30 seconds.
* Quickly move to lie down on the opposite end of your bed. Do not change the direction of your head.
* Keep it at a 45-degree angle and lie for 30 seconds. Look at the floor.
* Return slowly to sitting and wait a few minutes.
* Reverse these moves for the right ear.

Again, do these moves three times a day until you go 24 hours without vertigo.

Half Somersault or Foster Maneuver

Some people find this maneuver easier to do:
* Kneel down and look up at the ceiling for a few seconds.
* Touch the floor with your head, tucking your chin so your head goes toward your knees. Wait for any vertigo to stop (about 30 seconds).
* Turn your head in the direction of your affected ear (i.e. if you feel dizzy on your left side, turn to face your left elbow). Wait 30 seconds.
* Quickly raise your head so it is level with your back while you are on all fours. Keep your head at that 45-degree angle. Wait 30 seconds.
* Quickly raise your head so it is fully upright, but keep your head turned to the shoulder of the side you're working on.  Then slowly stand up.

You may have to repeat this a few times for relief. After the first round, rest 15 minutes before trying a second time.

General Exercises for Vertigo

There are several additional general exercises for vertigo that can help decrease vertigo and dizziness. There are following suggested exercises to treat vertigo and improve balance, but be sure to consult with your physician before starting any exercise program:

Eye Exercises:
* Look up, then down. First, slowly, and then, quickly.
* Look from side to side. First, slowly, and then, quickly.
* Focus on your finger at arm’s length. Move your finger from side to side, keeping your eyes focused on the finger.

Head Exercises:
* Bend your head forward and then backward with eyes open. First, slowly, and then, quickly.
* Turn your head from side to side. First, slowly, and then, quickly.
* As your dizziness improves, these head exercises can be done with your eyes closed.

* In sitting, shrug your shoulders.
* Turn your shoulders from side to side.
* Bend forward and pick up objects from the ground. Then, sit up.

* From sitting, stand up. Sit down again. Do this with eyes open.
* Repeat with your eyes closed.
* In standing, pass a small rubber ball from one hand to the other under one knee.

* Walk across the room with your eyes open. Repeat this with your eyes closed.
* Walk up and down a slope with your eyes open. Repeat this with your eyes closed.
* Walk up and down stairs with your eyes open. Repeat this with your eyes closed.

Note that these exercises do not substitute the maneuvers, described earlier, but should complement them for the most efficient recovery process.

Vertigo Medications

Commonly prescribed medications for vertigo include the following:
* meclizine hydrochloride (Antivert)
* diphenhydramine (Benadryl)
* scopolamine transdermal patch (Transderm-Scop)
* promethazine hydrochloride (Phenergan)
* diazepam (Valium)

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

Nutritional Approaches to Vertigo

As a symptom, vertigo is always a reason to see a physician. At the same time, however, for conditions in which vertigo persists (e.g., Ménière’s disease), a number of nutrients might be considered to counteract the effects, including:
* Antioxidants—Antioxidants mitigate the damaging effects of free radicals on tissues, cell membranes, and DNA. Vitamin C, vitamin E, lipoic acid, and glutathione are among the most important antioxidants. * Vitamin C has been shown to have a beneficial effect on patients with Ménière’s disease when given in combination with glutathione. Glutathione, which is a powerful antioxidant, has been demonstrated to be effective in treating vertigo induced by Ménière’s disease. Because glutathione is poorly absorbed by the body, it is recommended taking precursors to glutathione, including N-acetylcysteine and lipoic acid. It is worth noting, however, that the role of L-glutamate has been studied in vertigo with somewhat conflicting results. There is some evidence that the neurotoxicity associated with some forms of vertigo is mediated by glutamate. Glutamate-blocking drugs have also been proposed as treatment for vertigo.
* Vitamin B6—Studies have reported positive effects using vitamin B6 on drug-induced vertigo and nausea, suggesting that vitamin B6 appears to offer protection against this form of vertigo.
* Ginkgo biloba—Researchers in Poland have found that vertigo induced by vestibular receptor impairment can be reduced by Ginkgo biloba extract. According to their study, almost all of the 45 patients who received 120 mg twice daily of Ginkgo biloba extract for 30 days showed a significantly increased ability to compensate for vestibular lesions and subsequently experienced fewer episodes of vertigo. These results confirmed the earlier work performed by researchers who found that patients who received Ginkgo biloba extract at 80 mg twice daily had their vertigo and dizziness reduced by as much as 65%.
* Coenzyme Q10 (CoQ10)—During a multicenter clinical trial of 2664 patients with congestive heart failure, 73% reported a decrease in the incidence of vertigo after only 3 months of treatment with 50 to 150 mg of CoQ10 daily.
* Ginger—Volunteers who took ginger and were then subjected to induced motion sickness (which includes vertigo as a symptom) experienced delayed onset of motion sickness and reported a shorter recovery time. These results have been confirmed by other studies that showed that ginger reduced motion sickness and its associated vertigo.
* Avoid substances that can affect circulation, including caffeine, tobacco, or alcohol.
* Drink plenty of fluids.

Sources and Additional Information:


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