Vertigo

By Dr. Loretta Lanphier, ND, CN, HHP, CH

Our sense of balance and our hearing are intricately involved in a master plan of sensory input that works along with our brains to tell us what our orientation is in relation to the force of gravity. That’s a fancy way of saying that the whole system is designed to help us sense “up” from “down.” When the messages get scrambled, we get confusing and sometimes false readings. When things go awry in this particular function of the body we call it vertigo.

What is Vertigo?

Vertigo is the sensation that you or the environment around you is moving, when in fact there is no movement actually occurring. It is not to be confused with general, nonspecific terms like “dizziness” or “lightheadedness.” These may be experienced during an episode of vertigo, but they are distinct from it. True vertigo must be associated with the illusion of movement. Dizziness and other similar symptoms may have many causes, but there are relatively few causes for vertigo.

Vertigo can make you feel like your head is spinning on the inside or like your whole body is twirling around, similar to the sensation one gets on a merry-go-round. It makes you feel very unsteady, and during an episode it may be difficult to walk without falling. Often these disorienting symptoms will worsen depending on the position of your body or head. Vertigo symptoms may last for less than a minute, or for more than an hour. Most cases of vertigo are the result of dysfunction in the workings of the inner ear or caused by a problem in the brain.

What Causes Vertigo?

  • The most common type of vertigo is called Benign Paroxysmal Positional Vertigo (BPPV), and is caused by problems within the inner ear. We will go into more detail about BPPV later in this article.
  • Some vertigo is caused by inflammation within the inner ear. One particular structure that is found in the inner ear is called the labyrinth, and inflammation of it is known as labyrinthitis. This condition produces vertigo that usually comes on suddenly. It is also often accompanied by hearing loss.
  • Trauma to the head or neck can also produce vertigo. This type often goes away on its own as the trauma heals.
  • Acoustic neuroma is a tumor of the inner ear that can also lead to vertigo. Clues that you may have a tumor in this area include hearing loss and ringing in the ear, usually on one side only.
  • Vascular problems, such as reduced blood flow to the brain can also cause vertigo. A cerebral hemorrhage will often produce vertigo, in addition to other symptoms such as headaches, difficulty walking, and an odd visual symptom that will not allow the patient to look towards the side of the brain where the hemorrhage occurred. No matter how hard he or she may try, the eyes will reflexively look away from the affected side.
  • Meniere disease is characterized by vertigo, hearing loss, and ringing in the ears. The vertigo may come on suddenly and be quite severe, but it is usually intermittent. The other symptoms may fluctuate, and patients may have periods when they have no symptoms at all.  
  • Migraine headaches may also exhibit vertigo. The vertigo often appears before the headache, and may be a regular feature of the “aura” phase for some migraine sufferers, whereby certain symptoms will appear that precede the actual headaches.  

What Are the Symptoms of Vertigo?

As stated above, the defining characteristic of true vertigo, and the one that separates it from dizziness or feeling faint, is the sensation of motion. This may feel like you are moving, or that your surroundings are moving, or both. Along with this sense of movement, other common symptoms may include:

  • Abnormal eye movements
  • Nausea
  • Vomiting
  • Perspiration
  • Hearing loss on one or both sides
  • Difficulty seeing clearly
  • Difficulty walking
  • Worsening symptoms when changing positions or moving
  • Constant or intermittent vertigo
  • Decreased level of consciousness
  • Weakness
  • Difficulty talking

Symptoms such as these can be the result of inner ear and related balance problems, so while they can be very disconcerting and even frightening, they may be relatively harmless. However, if any of the following are experienced as well, an immediate trip to the emergency room would probably be a good idea:

  • Significant speech impairment
  • Total hearing loss
  • Severe weakness in an arm or leg
  • Chest pain
  • Rapid or unusually slow heart rate
  • Unsteady gait that leads to falling or difficulty walking
  • Double vision
  • Total loss of vision
  • Severe headache, or one that is new or different
  • Loss of consciousness

Any of these signs could indicate a serious medical condition that should be immediately evaluated. Possibilities might include Parkinson’s disease, stroke, multiple sclerosis, brain tumor, or heart disease.

BPPV

Let’s take a more in depth look at this most common form of vertigo. Perhaps it will help us better understand all types of vertigo.

In a nutshell, the defining characteristics of BPPV are brief (usually less than a minute) episodes of vertigo accompanied by intense dizziness that are typically associated with a change in the position of your head. Patients report that it can affect them when they first sit up in the morning, or when they lie down from an upright position. Many also experience episodes when they move their head to look up, such as when reaching for something on a high shelf.

Most cases of BPPV are intermittent, both in frequency and in intensity. Sometimes episodes will not occur for quite a long time, only to disappoint patients by returning unexpectedly. Abnormal eye movements called nystagmus are also typically found with BPPV. These rhythmic patterns are characterized by alternating cycles of smooth movement in one direction, followed by a rapid return in the opposite direction. The nystagmus typically occurs for a few seconds after the offending head movement, and the vertigo continues for about 30 seconds to a minute. BPPV is usually only found in one ear, but in rare cases it can occur in both ears (bilateral BPPV).

What Causes BPPV?

The structures that are responsible for our sense of balance are found within the inner ear. One of the main parts of this system is called the vestibular labyrinth. Inside this structure are two semicircular canals that are filled with fluid and equipped with very fine sensors that help to gauge and monitor the movements of the head. These canals are attached to another tiny feature called the utricle that contains tiny grains of calcium carbonate called otoconia. The otoconia are linked to sensors that read relativity regarding gravity and back-and-forth motions. If the otoconia become detached from their sensors and become free floating in the fluid of the canals, false readings can occur that can “feel” like movement when there is no movement. This condition is called BPPV. When individuals with BPPV move their head in a certain position, the otoconia can irritate nerve endings and give the false readings. In other positions, no nerve endings are contacted, thus no vertigo symptoms.

The most common risk factor for BPPV is aging. Beyond that, BPPV can occur from trauma to the head, as a complication from certain types of ear surgery, or rarely from a virus that infects the inner ear.

How is BPPV Diagnosed?

If you are experiencing signs of vertigo, it is important to determine what is causing it. Since the majority of vertigo symptoms are the result of BPPV, it is fortunate that there is a very simple and definitive test that can determine if you have BPPV. It is called the Dix-Hallpike test, and it involves moving a patient into certain positions and then analyzing the resulting symptoms if any occur. Basically, the person is seated on an examination table, and his head is turned either to the right or left. He is then moved quickly into a lying down position, with his head hanging off the end of the table. The patient must keep eyes open at all times, and the practitioner can then watch for signs of nystagmus.   It is almost a certain diagnosis if nystagmus is observed, and if the patient experiences vertigo after 5 or 10 seconds, and if the vertigo disappears in less than a minute. Once the vertigo has passed, he is returned to a sitting position and the procedure is done in reverse, turning the head the opposite way. Sometimes returning to a sitting position will also elicit vertigo and nystagmus in the opposite rotary direction. It is rare that anyone has BPPV in both ears. The ear that is downward during the procedure is the affected side. Once the Dix-Hallpike test has indicated positive for BPPV, it is fairly safe to assume that other causes of vertigo can be dismissed.

What About Treatment for BPPV?

BPPV, and vertigo in general, can be a very troublesome condition, although it is rarely dangerous, except indirectly due to the danger of falling during an episode. But it can be extremely upsetting to your daily routine. In that sense, it could be called life controlling in some cases. But, there is a bit of good news associated with BPPV:  There is an excellent non-invasive, drug-free treatment available for BPPV that is successful over 90% of the time. It is known as the Canalith Repositioning Procedure (CRP). Also known as the Epley Maneuver, it involves putting patients through a series of movements that are designed to move the otoconia from the semicircular canal back into the utricle where they won’t cause problems anymore. CRP only takes about five minutes, but the patient is not allowed to lie down flat or bend over for 48 hours. They must sleep propped up in pillows or in a reclining chair, and that is the hardest part of the whole procedure.  In two weeks, the Dix-Hallpike test is repeated, and about 80% of patients are symptom free. If it is necessary, CRP can be repeated, and the success rate then approaches 95%.

Vertigo can be very uncomfortable and disruptive to a person’s life, but it is indeed fortunate that most vertigo can be cured without surgery or drugs. When dealing with such a delicate system as the inner ear, the discovery of a procedure such as CRP is truly a blessing.

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