Vertigo

Vertigo is a distinct form of dizziness characterized by an inaccurate perception of motion or rotation. Individuals experiencing vertigo often feel as though they or their surroundings are moving when no actual movement is occurring. This sensation can be disorienting and can vary in intensity from mild to severe.

Is There any Difference Between Vertigo and General Dizziness?

Vertigo specifically refers to a spinning or rotational sensation, often likened to the feeling of being on a merry-go-round. This can be either subjective (feeling like the person is moving) or objective (feeling like the surroundings are moving). Headache and Migraine Problem

Dizziness is a broader term that encompasses various sensations, including lightheadedness, unsteadiness, or a feeling of impending fainting. Dizziness can be caused by a range of factors, including dehydration, low blood sugar, or anxiety.

What is The Prevalence and Impact of Vertigo?

Vertigo is a common symptom, affecting approximately 20-30% of the general population at some point in their lives. It is particularly prevalent among older adults (1).

Benign Paroxysmal Positional Vertigo (BPPV) is the most common form of peripheral vertigo, accounting for about 20% of all dizziness cases in outpatient clinics (2).

What is The Impact on Daily Life

Vertigo can significantly impact an individual’s quality of life. Severe episodes can lead to difficulties in performing daily activities, increased risk of falls, and reduced ability to work or engage in social activities.

Chronic vertigo can lead to psychological consequences such as anxiety and depression due to the persistent fear of vertigo attacks.

What are the first signs of vertigo?

Identifying the first signs of vertigo is crucial for timely diagnosis and management. The onset of vertigo can vary depending on its underlying cause, but common initial symptoms include:

1. Spinning Sensation: The hallmark sign of vertigo is a sudden onset of a spinning or rotational sensation. This can be described as feeling like you or your surroundings are moving or rotating, even when you are stationary. This sensation can be very disorienting and may last from a few seconds to several minutes.
2. Loss of Balance: Individuals experiencing vertigo often report a sense of imbalance or unsteadiness. This can make it difficult to stand or walk and may increase the risk of falls. The feeling of being pulled to one side is also common.
3. Nausea and Vomiting: Nausea and vomiting are common accompanying symptoms of vertigo. The severity of these symptoms can vary, with some people experiencing mild queasiness and others having severe vomiting episodes.
4. Abnormal Eye Movements (Nystagmus): Nystagmus, or rapid, involuntary eye movements, often accompanies vertigo. This can be observed by others or felt by the person experiencing vertigo as their eyes move uncontrollably. Nystagmus can provide clues about the underlying cause of vertigo and is often used in clinical diagnosis.
5. Sweating: Excessive sweating or clamminess can occur with vertigo, particularly during acute episodes. This is often associated with the body’s response to nausea and the disorientation caused by the spinning sensation.
6. Hearing Changes: In some cases, vertigo can be accompanied by changes in hearing, such as a sudden loss of hearing, tinnitus (ringing in the ears), or a feeling of fullness in the ear. These symptoms are particularly common in conditions like Meniere’s disease.
7. Headache: Although not always present, a headache can accompany vertigo, particularly in cases of vestibular migraine or other central causes of vertigo.
8. Feeling of Motion Sickness: Similar to the feeling experienced when on a boat or a roller coaster, vertigo can cause motion sickness. This includes sensations of dizziness, nausea, and an urge to lie down.

At What Age Does Vertigo Start?

Vertigo can affect individuals at any age, but certain types are more common at specific stages of life:

Children and Adolescents

Benign Paroxysmal Vertigo of Childhood (BPVC): A type of vertigo that occurs in young children, typically between the ages of 2 and 12. BPVC is often outgrown as the child gets older.

Vestibular Migraines: Can begin in adolescence, especially in those with a family history of migraines.

Adults

Benign Paroxysmal Positional Vertigo (BPPV): More common in adults, particularly in those over the age of 50. BPPV is the most common cause of vertigo and is often triggered by changes in head position.

Meniere’s Disease: Typically diagnosed in adults between the ages of 20 and 60. It is less common in children and the elderly.

Vestibular Neuritis: Can occur in adults of any age but is most commonly seen in middle-aged individuals.

Elderly

Age-Related Vestibular Degeneration: Vertigo in the elderly can be due to degeneration of the vestibular system with aging. This can lead to increased episodes of dizziness and imbalance.

Chronic Conditions: Elderly individuals are more likely to have chronic conditions such as cardiovascular disease or diabetes, which can contribute to vertigo.

Why Do People Get Vertigo?

Vertigo is caused by issues affecting the inner ear or the brain. Here are the primary causes of vertigo:

Peripheral Causes (Inner Ear)

Benign Paroxysmal Positional Vertigo (BPPV): The most prevalent cause of vertigo, arises when micro calcium crystals (otoconia) within the inner ear dislodge and migrate into the semicircular canals. This disturbance hinders the typical flow of fluid and transmits erroneous signals to the brain regarding the position and motion of the head (2).

Meniere’s Disease: Caused by an abnormal buildup of fluid in the inner ear, leading to episodes of vertigo, tinnitus (ringing in the ears), hearing loss, and a feeling of fullness in the ear. The exact cause is unknown, but it may be related to a combination of genetic and environmental factors (3).

Vestibular Neuritis: An inflammation of the vestibular nerve, often due to a viral infection. Symptoms include sudden, severe vertigo, nausea, vomiting, and imbalance, typically without hearing loss.

Labyrinthitis: Similar to vestibular neuritis, but also includes hearing loss due to inflammation of both the vestibular nerve and the cochlea, often caused by viral or bacterial infections.

Central Causes (Brain)

Migraine-Associated Vertigo: Migraines can cause vertigo either during or between headache episodes. Vestibular migraines are characterized by vertigo, dizziness, and balance disturbances, sometimes without a headache (4).

Stroke and Transient Ischemic Attacks (TIAs): Reduced blood flow to the brain, particularly the cerebellum or brainstem, can cause vertigo. Symptoms may include sudden dizziness, imbalance, and other neurological signs like weakness or double vision.

Multiple Sclerosis (MS): Vertigo can occur in MS due to demyelination affecting the brainstem or cerebellum. Other symptoms include visual disturbances, muscle weakness, and coordination problems.

Causes of Vertigo in Women

The causes of vertigo in women can be influenced by both general and gender-specific factors:

Hormonal Influences

Menstrual Cycle: Fluctuations in estrogen and progesterone during the menstrual cycle can affect the vestibular system, leading to an increased likelihood of vertigo episodes around menstruation (5).

Pregnancy: Hormonal changes during pregnancy, as well as changes in blood volume and pressure, can contribute to dizziness and vertigo. Morning sickness and dehydration can also exacerbate these symptoms.

Menopause: Hormonal changes during menopause can affect balance and increase the frequency of vertigo episodes. Estrogen plays a role in maintaining inner ear function, and its decrease during menopause can lead to vestibular disturbances.

Psychological Factors

Stress and Anxiety: Women are more prone to stress and anxiety, which can exacerbate vertigo symptoms. Chronic stress can affect the vestibular system and lead to episodes of dizziness and imbalance.

Is Vertigo Genetic?

While most cases of vertigo are not directly inherited, there can be a genetic predisposition to conditions that cause vertigo. For example:

Familial Migraine: Migraines, including vestibular migraines, can run in families, suggesting a genetic component.

Meniere’s Disease: Familial pattern in Meniere’s disease, indicates that genetic factors might play a role in its development.

Genetic predisposition may also influence the likelihood of developing conditions like BPPV or vestibular neuritis, although these conditions are typically influenced by environmental factors and other triggers.

Can Lack of Sleep Cause Vertigo?

Yes, lack of sleep can contribute to the development of vertigo. Here’s how:

1. Impact on the Vestibular System: Adequate sleep is essential for maintaining proper functioning of the vestibular system, which is responsible for balance and spatial orientation. Sleep deprivation can disrupt this system, leading to symptoms of dizziness and vertigo.
2. Increased Stress and Anxiety: Lack of sleep can increase stress levels and exacerbate anxiety, both of which are known to contribute to dizziness and vertigo. Stress and anxiety can cause muscle tension and alter blood flow, potentially affecting balance.
3. Migraine Triggers: Poor sleep is a common trigger for migraines, including vestibular migraines, which can present with vertigo. Ensuring sufficient and quality sleep is important for managing migraine-related vertigo.
4. General Fatigue and Cognitive Impairment: Sleep deprivation can lead to general fatigue and cognitive impairment, which can make individuals more prone to experiencing vertigo. Fatigue can also reduce the body’s ability to compensate for any vestibular dysfunction.

Can Depression Cause Vertigo?

Yes, depression can be associated with vertigo. The relationship between depression and vertigo is complex and can be bidirectional:

Psychogenic Vertigo: Psychological factors, including depression and anxiety, can contribute to the sensation of vertigo. Individuals with depression may experience dizziness and imbalance as part of their symptomatology.

Impact of Chronic Vertigo on Mental Health: Chronic vertigo can significantly impact an individual’s quality of life, leading to the development of depression. The persistent discomfort and disability caused by vertigo can result in feelings of hopelessness and sadness.

Physiological Links: Depression can lead to physiological changes in the brain that affect balance and vestibular function. Neurotransmitter imbalances, particularly involving serotonin and norepinephrine, play a role in both depression and the regulation of vestibular pathways (6).

What are The Best Treatments for Vertigo

The treatment for vertigo depends on its underlying cause. Here are some of the most effective treatments for various types of vertigo:

Benign Paroxysmal Positional Vertigo (BPPV)

Canalith Repositioning Maneuvers: The Epley maneuver is the most common and effective treatment for BPPV. This series of head movements helps move dislodged calcium crystals (otoconia) from the semicircular canals back to the vestibule where they can be absorbed (2).

Brandt-Daroff Exercises: These exercises involve repeated movements to help desensitize the vestibular system and reposition the otoconia. They can be performed at home and are useful for preventing recurrences.

Meniere’s Disease

Medications: Diuretics can help reduce fluid buildup in the inner ear, while antiemetics and antihistamines (e.g., meclizine) can help manage vertigo and nausea during acute attacks.

Dietary Changes: A low-sodium diet and avoiding caffeine, alcohol, and nicotine can help reduce the frequency and severity of episodes.

Intratympanic Injections: In severe cases, injections of corticosteroids or gentamicin into the middle ear can help control symptoms (7).

Vestibular Neuritis

Medications: Corticosteroids, such as prednisone, can reduce inflammation of the vestibular nerve. Antiemetics and antihistamines can help control nausea and dizziness.

Vestibular Rehabilitation Therapy (VRT): Physical therapy exercises designed to improve balance and reduce dizziness by retraining the brain to compensate for the loss of vestibular function (8).

Vestibular Migraine

Migraine Prophylaxis: Medications such as beta-blockers (e.g., propranolol), calcium channel blockers (e.g., verapamil), and antiepileptic drugs (e.g., topiramate) can help prevent migraines and associated vertigo.

Lifestyle Modifications: Identifying and avoiding migraine triggers, such as certain foods, stress, and lack of sleep, can help reduce the frequency of vertigo episodes (9).

Chronic Subjective Dizziness (CSD)

Cognitive Behavioral Therapy (CBT): CBT can help manage anxiety and depression associated with chronic dizziness. It focuses on changing negative thought patterns and behaviors that contribute to the symptoms.

Vestibular Rehabilitation Therapy (VRT): As with vestibular neuritis, VRT can help retrain the brain to manage chronic dizziness and improve balance.

What is medicine for vertigo?

The choice of medication for vertigo depends on the underlying cause and the severity of the symptoms. Here are some common medications used to treat vertigo:

Antihistamines

Meclizine (Antivert, Bonine): Often used to treat vertigo associated with vestibular disorders such as BPPV and vestibular neuritis. It helps reduce dizziness and nausea.

Dimenhydrinate (Dramamine): Commonly used for motion sickness but can also be effective in managing vertigo symptoms.

Benzodiazepines

Diazepam (Valium) and Clonazepam (Klonopin): Used to relieve vertigo symptoms, especially when anxiety is a contributing factor. These medications can help calm the nervous system and reduce dizziness, but they are typically used for short-term relief due to the risk of dependence and side effects.

Antiemetics

Promethazine (Phenergan) and Metoclopramide (Reglan): Used to control nausea and vomiting associated with vertigo. These medications can be particularly helpful during acute vertigo episodes.

Corticosteroids

Prednisone: Effective in reducing inflammation in cases of vestibular neuritis or labyrinthitis, helping to alleviate vertigo symptoms.

Diuretics

Hydrochlorothiazide (Microzide) and Acetazolamide (Diamox): Used in the treatment of Meniere’s disease to reduce fluid buildup in the inner ear and prevent vertigo episodes.

Antibiotics or Antivirals

Used when vertigo is caused by an infection, such as bacterial labyrinthitis. The choice of antibiotic or antiviral medication will depend on the specific infection identified.

Calcium Channel Blockers and Beta-Blockers

Verapamil and Propranolol: Used as prophylactic treatments for vestibular migraines to prevent the frequency of vertigo episodes.

How to Prevent Vertigo

Preventing vertigo involves managing underlying conditions, avoiding known triggers, and maintaining overall health. Here are some strategies:

Manage Underlying Conditions

Meniere’s Disease: Follow a low-sodium diet to reduce fluid retention in the inner ear. Avoid caffeine, alcohol, and tobacco, which can exacerbate symptoms.

Migraines: Identify and avoid migraine triggers, such as certain foods, stress, and lack of sleep. Use prophylactic medications if prescribed by your healthcare provider.

BPPV: Be cautious with head movements and avoid sudden changes in position.

Healthy Lifestyle Choices

Hydration: Stay well-hydrated to prevent dizziness and vertigo.

Balanced Diet: Eat a balanced diet to maintain overall health and avoid low blood sugar, which can cause dizziness.

Regular Exercise: Engage in regular physical activity to improve balance and overall health.

Avoid Triggers

Stress Management: Practice stress-reducing techniques such as yoga, meditation, or deep breathing exercises.

Sleep Hygiene: Ensure you get adequate and quality sleep to prevent fatigue-related vertigo.

Environmental Factors: Avoid environments with poor lighting or those that can induce motion sickness.

Regular Medical Check-Ups

Regular check-ups can help manage chronic conditions and prevent vertigo episodes. Follow your healthcare provider’s recommendations for treatment and lifestyle adjustments.

Which are The Best Exercises to Reduce Vertigo?

Certain exercises can help reduce vertigo by improving balance and retraining the brain to compensate for vestibular issues. Here are some effective exercises:

Canalith Repositioning Maneuvers for BPPV

Epley Maneuver: Designed to move the dislodged calcium crystals in the inner ear to a location where they won’t cause vertigo. Here’s how to perform it:

1. Sit on a bed and turn your head 45 degrees to the affected side.
2. Lie back quickly with your head still turned and shoulders on the pillow. Stay in this position for 30 seconds.
3. Turn your head 90 degrees to the other side without raising it and hold for another 30 seconds.
4. Turn your body and head another 90 degrees to the side you’re facing, and hold for 30 seconds.
5. Sit up slowly.

Brandt-Daroff Exercises

These exercises help desensitize the vestibular system:

1. Sit upright on the edge of your bed.
2. Lie down quickly on one side, keeping your head at a 45-degree angle. Stay in this position for 30 seconds.
3. Sit up again and stay upright for 30 seconds.
4. Repeat on the other side. Perform these exercises 5 times on each side, 2-3 times a day.

Vestibular Rehabilitation Therapy (VRT)

Cawthorne-Cooksey Exercises: Designed to improve balance and coordination. These exercises include:

1. Eye Movements: Move your eyes up and down, then side to side, without moving your head. Do this 20 times each.
2. Head Movements: Move your head up and down, then side to side, keeping your eyes focused on a fixed point. Do this 20 times each.
3. Shoulder Shrugs: Shrug your shoulders up and down 20 times.
4. Sitting to Standing: Practice standing up and sitting down without using your hands, 20 times.
5. Walking: Walk in a straight line with your eyes open, then with your eyes closed.

Balance Exercises

Standing on One Foot: Practice standing on one foot for 30 seconds, then switch to the other foot. Perform this exercise with your eyes open, and once confident, try with your eyes closed.

Tandem Walking: Walk in a straight line, placing one foot directly in front of the other, heel to toe. Practice this for 20 steps.

References

1. Neuhauser, H.K., Radtke, A., Von Brevern, M., Feldmann, M., Lezius, F., Ziese, T. and Lempert, T., 2006. Migrainous vertigo: prevalence and impact on quality of life. Neurology, 67(6), pp.1028-1033. https://www.neurology.org/doi/abs/10.1212/01.wnl.0000237539.09942.06
2. Von Brevern, M., Radtke, A., Lezius, F., Feldmann, M., Ziese, T., Lempert, T. and Neuhauser, H., 2007. Epidemiology of benign paroxysmal positional vertigo: a population based study. Journal of Neurology, Neurosurgery & Psychiatry, 78(7), pp.710-715. https://jnnp.bmj.com/content/78/7/710.short
3. Paparella, M.M., 1991. Pathogenesis and pathophysiology of Meniere’s disease. Acta Oto-Laryngologica, 111(sup485), pp.26-35. https://www.tandfonline.com/doi/abs/10.3109/00016489109128041
4. Furman, J.M. and Marcus, D.A., 2012. Migraine and motion sensitivity. CONTINUUM: Lifelong Learning in Neurology, 18(5), pp.1102-1117. https://journals.lww.com/continuum/fulltext/2012/10000/Positional_Dizziness.11.aspx
5. Balaban, C.D., 2016. Neurotransmitters in the vestibular system. Handbook of clinical neurology, 137, pp.41-55. https://www.sciencedirect.com/science/article/pii/B9780444634375000030
6. Balaban, C.D. and Thayer, J.F., 2001. Neurological bases for balance–anxiety links. Journal of anxiety disorders, 15(1-2), pp.53-79. https://www.sciencedirect.com/science/article/pii/S0887618500000426
7. Pullens, B. and van Benthem, P.P., 2011. Intratympanic gentamicin for Meniere’s disease or syndrome. Cochrane Database of Systematic Reviews, (3) https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD008234.pub2/abstract
8. Strupp, M. and Brandt, T., 2009, November. Vestibular neuritis. In Seminars in neurology (Vol. 29, No. 05, pp. 509-519). © Thieme Medical Publishers. https://www.thieme-connect.com/products/ejournals/html/10.1055/s-0029-1241040
9. Lempert, T., Olesen, J., Furman, J., Waterston, J., Seemungal, B., Carey, J., Bisdorff, A., Versino, M., Evers, S. and Newman-Toker, D., 2012. Vestibular migraine: diagnostic criteria. Journal of Vestibular Research, 22(4), pp.167-172. https://content.iospress.com/articles/journal-of-vestibular-research/ves00453

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Dr. M Shahadat Hossain

Physiotherapy Specialist at ASPC Manipulation Therapy Centre

BSPT (DU), MSc PT(DU), PhD-fellow (JU), Dip. in-Manipulation Therapy (Certified ETOMG-Belgium), McKenzie (A&B), Mulligan and dry Needling (India) Faculty Member of Bangladesh Health profession Institute (CRP), Savar.
Assistant professor, Dhaka College of Physiotherapy
Chief Consultant(Ex): Popular Medical college Hospital, Dhanmondi- 2.
Chairman and Chief Consultant: ASPC Manipulation Therapy Centre, Nurjahan Road, Mohammadpur.
Founder and conceptual inventor: Structural Diagnosis and Management (SDM) concept.
Secretary: Centre for the Rehabilitation of Autism and Person with Disabilities (CARD).
Secretary-General: Bangladesh Physiotherapy Association (BPA).
Phone +88 01712-867364
Email aspc.dhaka@gmail.com
Website https://aspc.com.bd

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