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