Vertigo

Have you ever felt like the room is spinning, even when you're perfectly still? This unsettling sensation, often described as dizziness, is frequently labelled as vertigo. It's more than just a fleeting moment of unsteadiness; vertigo is a specific type of dizziness characterised by a false sense of motion. This can feel as though you are spinning or tilting, or that your surroundings are moving around you. 

While often a symptom of an underlying condition rather than a disease itself, vertigo can significantly impact daily life, affecting balance, coordination, and overall well-being.

At its core, vertigo is an illusion of movement. The term itself comes from the Latin word "vertere," meaning "to turn" or "to spin." It arises from a disturbance in the balance system of the body, primarily involving the inner ear, the brainstem, and the brain. These intricate systems work together to provide us with a sense of spatial orientation and equilibrium. When there's a mismatch or disruption in the signals being sent from these areas, the brain can misinterpret this information, leading to the false sensation of movement.

It's important to distinguish vertigo from other forms of dizziness. Lightheadedness, for instance, is a feeling of faintness or being about to pass out. Disequilibrium refers to a loss of balance. Vertigo, however, has a distinct rotational or spinning component. People experiencing vertigo might describe feeling like they are on a merry-go-round or that the objects around them are whirling. This sensation can be accompanied by other symptoms such as nausea, vomiting, sweating, and difficulty walking.

The intensity and duration of a vertigo episode can vary greatly, from brief moments lasting seconds to prolonged periods lasting hours or even days. The triggers for vertigo can also differ depending on the underlying cause. Some individuals might experience vertigo triggered by specific head movements, while others might have more spontaneous and unpredictable episodes. 

Vertigo is a relatively common health complaint, affecting people of all ages, although it is more prevalent in older adults. Accurately determining the exact prevalence can be challenging as many individuals may not seek medical attention for occasional or mild episodes. 

Worldwide Prevalence:

Globally, the lifetime prevalence of vertigo is estimated to be around 20-30%. This means that approximately one in five to one in three people will experience at least one episode of vertigo during their lifetime. 

Prevalence in India:

Specific data on the prevalence of vertigo in India is somewhat limited compared to Western countries. However, available studies suggest that the prevalence is likely to be within a similar range to global figures, potentially even higher in certain age groups. 

Vertigo is broadly classified into two main categories based on the origin of the problem: peripheral vertigo and central vertigo.

Peripheral Vertigo: This is the most common type of vertigo and originates from problems in the inner ear or the vestibular nerve, which connects the inner ear to the brainstem. The inner ear contains the vestibular system, responsible for sensing head movements and maintaining balance. Common causes of peripheral vertigo include:

• Benign Paroxysmal Positional Vertigo (BPPV): This is the most frequent cause of vertigo. It occurs when small calcium carbonate crystals (otoconia) in one part of the inner ear dislodge and move into another part, usually the semicircular canals. Specific head movements, such as tilting the head up or down, turning over in bed, or sitting up, can trigger brief episodes of intense vertigo.
• Ménière's Disease: This inner ear disorder is characterised by episodes of vertigo, hearing loss, tinnitus (ringing in the ears), and a feeling of fullness in the ear. The exact cause is unknown but is thought to involve an abnormal buildup of fluid in the inner ear.
• Vestibular Neuritis (Labyrinthitis): This condition involves inflammation of the vestibular nerve (vestibular neuritis) or both the vestibular nerve and the inner ear labyrinth (labyrinthitis), usually caused by a viral infection. It typically results in sudden onset of severe, persistent vertigo, often accompanied by nausea and vomiting. Hearing loss may occur in labyrinthitis but is usually absent in vestibular neuritis.

Central Vertigo: This type of vertigo arises from problems in the central nervous system, specifically the brainstem or the cerebellum, which are involved in processing balance information. Central vertigo is often more serious than peripheral vertigo and can be caused by:

• Stroke or Transient Ischemic Attack (TIA): Disruption of blood flow to the brainstem or cerebellum can lead to sudden and severe vertigo, often accompanied by other neurological symptoms such as double vision, slurred speech, weakness, or numbness.
• Multiple Sclerosis (MS): This autoimmune disease affects the central nervous system and can sometimes cause vertigo as one of its symptoms due to damage to the balance pathways in the brain.
• Brain Tumours: Although less common, tumours in the brainstem or cerebellum can compress or damage balance-related structures, leading to vertigo.
• Migraine: Some types of migraine, known as vestibular migraine or migrainous vertigo, can cause episodes of vertigo, even without a severe headache. These episodes may be accompanied by other migraine symptoms such as sensitivity to light and sound.
• Head Injury: Trauma to the head can damage the inner ear or the central nervous system, resulting in vertigo.

Peripheral Vertigo Causes (Inner Ear/Vestibular Nerve):

• Benign Paroxysmal Positional Vertigo (BPPV): The most common culprit, triggered by the displacement of otoconia within the semicircular canals of the inner ear. These crystals normally reside in the utricle and saccule, which sense linear acceleration and gravity. When they move into the semicircular canals, which detect rotational movements, they send false signals to the brain during certain head positions.
• Ménière's Disease: This chronic inner ear disorder involves an abnormal accumulation of endolymph, the fluid in the inner ear. This buildup can disrupt the function of the balance and hearing organs, leading to episodes of vertigo, tinnitus, hearing loss, and aural fullness. The exact cause of Ménière's disease is unknown, but factors such as viral infections, autoimmune reactions, and genetic predisposition may play a role.
• Vestibular Neuritis and Labyrinthitis: Inflammation of the vestibular nerve (neuritis) or both the nerve and the labyrinth (labyrinthitis) is often triggered by viral infections, such as herpes simplex virus. This inflammation disrupts the transmission of balance signals from the inner ear to the brain.
• Acoustic Neuroma: This is a non-cancerous tumour that grows on the vestibulocochlear nerve, which connects the inner ear to the brain. As the tumour grows, it can compress the nerve, leading to gradual hearing loss, tinnitus, and sometimes vertigo.
• Perilymph Fistula: This rare condition involves a tear or defect in one of the membranes separating the middle ear from the inner ear. This can cause perilymph fluid to leak into the middle ear, leading to vertigo and hearing problems, often triggered by changes in air pressure or strenuous activity.

Central Vertigo Causes (Brainstem/Cerebellum):

• Stroke and TIA: Disruption of blood supply to the brainstem or cerebellum, often due to a blood clot or haemorrhage, can damage the balance centres and pathways, resulting in sudden and severe vertigo. TIAs, or "mini-strokes," involve a temporary disruption of blood flow and can also cause transient vertigo.
• Multiple Sclerosis (MS): The demyelination (damage to the protective covering of nerve fibres) that occurs in MS can affect the brainstem and cerebellum, leading to a variety of neurological symptoms, including vertigo.
• Brain Tumours: Tumours in the posterior fossa (the back part of the brain containing the brainstem and cerebellum) can directly compress or invade balance-related structures, causing vertigo.
• Vestibular Migraine: This type of migraine is characterised by episodes of vertigo that can occur with or without a headache. The exact mechanisms are not fully understood but are thought to involve changes in brain activity that affect both pain and balance processing.
• Head Injury: Traumatic brain injury, even mild concussion, can damage the inner ear or the central nervous system, leading to post-traumatic vertigo.
• Certain Medications: Some medications, such as certain antibiotics, diuretics, and anticonvulsants, can have side effects that include dizziness and vertigo.
• Basilar Migraine: A rare type of migraine that affects the base of the brain and can cause vertigo, double vision, and other neurological symptoms.

• Loss of Balance: Difficulty maintaining stability, feeling unsteady on your feet, and an increased risk of falls.
• Nausea and Vomiting: The spinning sensation can often trigger feelings of sickness and may lead to vomiting.
• Lightheadedness: A feeling of faintness or being about to pass out, although this is distinct from the spinning sensation of vertigo itself.
• Sweating: Episodes of vertigo can sometimes be accompanied by excessive sweating.
• Abnormal Eye Movements (Nystagmus): Involuntary, rapid eye movements, which can be horizontal, vertical, or rotary. Nystagmus is often a key sign that helps doctors diagnose the type and cause of vertigo.
• Headache: Especially in cases of vestibular migraine or central vertigo caused by conditions like stroke or brain tumours.
• Tinnitus: Ringing, buzzing, or other sounds in the ears, particularly common in Ménière's disease and sometimes in other inner ear disorders.
• Hearing Loss: Can occur in Ménière's disease, labyrinthitis, and acoustic neuroma.
• Feeling of Fullness in the Ear (Aural Fullness): A common symptom of Ménière's disease.
• Difficulty Concentrating: The unsettling sensation of vertigo can make it hard to focus and think clearly.
• Double Vision (Diplopia): More common in central vertigo, indicating a potential problem in the brainstem.
• Weakness: Can occur in central vertigo, particularly in cases of stroke or MS.
• Difficulty Speaking (Dysarthria): Another potential symptom of central vertigo.

Diagnosing the cause of vertigo involves a comprehensive approach that includes a detailed medical history, a thorough physical examination, and often specific diagnostic tests.

Medical History: Your doctor will ask detailed questions about your symptoms, including:

• How the vertigo feels (spinning, tilting, swaying).
• When the vertigo started and how long episodes typically last.
• What triggers your vertigo (specific movements, changes in position).
• Any associated symptoms such as nausea, vomiting, headache, hearing loss, or tinnitus.
• Your past medical history, including any previous ear infections, head injuries, or neurological conditions.
• Any medications you are currently taking.

Physical Examination: This will include a general neurological examination to assess balance, coordination, and reflexes. Specific tests for vertigo include:

• Dix-Hallpike Manoeuvre: This test is commonly used to diagnose BPPV. It involves quickly moving the patient from a sitting position to a lying position with the head turned to one side. The doctor will observe the patient's eyes for nystagmus, which can indicate the affected ear and the type of BPPV.
• Head Impulse Test (HIT): The doctor will ask the patient to focus on their nose while the doctor gently but quickly turns the patient's head to one side. In a healthy individual, the eyes remain fixed on the nose. If the vestibular nerve is not functioning properly on one side, the eyes will briefly move away from the nose and then quickly flick back.
• Romberg's Test: The patient stands with their feet together and arms at their sides, first with their eyes open and then with their eyes closed.1 Increased unsteadiness with eyes closed suggests a problem with proprioception (sense of body position), which can contribute to balance issues.
• Gait Assessment: Observing how the patient walks can reveal balance problems.

Diagnostic Tests: Depending on the findings of the history and physical examination, your doctor may recommend further tests:

• Electronystagmography (ENG) and Videonystagmography (VNG): These tests record eye movements to assess the function of the vestibular system. ENG uses electrodes placed around the eyes, while VNG uses video cameras to track eye movements. These tests can help identify nystagmus and other abnormal eye movements that occur with vestibular disorders.
• Rotary Chair Testing: The patient sits in a rotating chair, and their eye movements are recorded as the chair moves at different speeds and directions. This test can help assess the function of the inner ear and brain pathways involved in balance.
• Vestibular Evoked Myogenic Potentials (VEMPs): This test measures the function of specific balance organs in the inner ear (the saccule and utricle) and their nerve pathways to the brainstem by recording muscle responses to sound or vibration.
• Audiometry (Hearing Test): This test evaluates hearing function and can help identify hearing loss associated with certain causes of vertigo, such as Ménière's disease or acoustic neuroma.
• Magnetic Resonance Imaging (MRI) and Computed Tomography (CT) Scans: These imaging techniques can be used to visualise the brain and rule out central causes of vertigo such as stroke, brain tumours, or multiple sclerosis. MRI is generally preferred for evaluating soft tissues of the brain and inner ear.
• Blood Tests: In some cases, blood tests may be ordered to check for underlying medical conditions that could contribute to dizziness or vertigo.

The treatment for vertigo depends largely on the underlying cause. In many cases, vertigo resolves on its own, especially peripheral vertigo caused by conditions like vestibular neuritis, as the brain can often compensate for the inner ear imbalance over time. However, various treatments can help alleviate symptoms and speed up recovery.

Treatment for Peripheral Vertigo:

• Epley Manoeuvre (for BPPV): This is a series of specific head movements performed by a healthcare professional to reposition the otoconia (calcium crystals) back into the utricle, where they no longer cause problems. The Semont manoeuvre and Foster manoeuvre are other similar repositioning techniques. Patients can often be taught to perform these manoeuvres at home for recurring BPPV.
• Medications:
  • Antihistamines (e.g., meclizine, dimenhydrinate): Can help reduce nausea and vomiting associated with vertigo and may have some effect on the vestibular system.
  • Anticholinergics (e.g., scopolamine): Can also help with nausea and vomiting but may have side effects such as drowsiness and dry mouth.
  • Benzodiazepines (e.g., diazepam, lorazepam): Can suppress vestibular activity and reduce anxiety related to vertigo, but they can be sedating and have the potential for dependence, so they are usually used short-term.
  • Corticosteroids (e.g., prednisone): May be prescribed for vestibular neuritis to reduce inflammation of the vestibular nerve.
• Vestibular Rehabilitation Therapy (VRT): This is a form of physiotherapy that uses specific exercises to help the brain compensate for inner ear problems. VRT exercises may include gaze stabilisation exercises, balance training, and habituation exercises to reduce sensitivity to motion. A physiotherapist specialising in vestibular disorders can design a tailored VRT program.
• Surgery: In rare cases of peripheral vertigo that don't respond to other treatments, surgery may be considered. For example, a labyrinthectomy (removal of the inner ear balance organs) might be an option for severe, unilateral Ménière's disease with significant hearing loss in the affected ear. Another surgical option for Ménière's disease is endolymphatic sac decompression, which aims to reduce pressure in the inner ear.

Treatment for Central Vertigo:

Treatment for central vertigo focuses on addressing the underlying neurological condition. This may involve:

• Medications: Depending on the cause, medications might include anti-inflammatory drugs for MS flares, anti-migraine medications for vestibular migraine, or medications to manage stroke risk factors.
• Rehabilitation: Similar to peripheral vertigo, vestibular rehabilitation therapy can help improve balance and reduce dizziness associated with central vertigo. Occupational therapy and speech therapy may also be beneficial depending on other neurological symptoms.
• Surgery: In cases of brain tumours or structural abnormalities causing central vertigo, surgery may be necessary to remove or reduce the size of the lesion.
• Treatment for Stroke or TIA: Prompt medical attention and treatment are crucial for stroke and TIA to minimise brain damage and address the cause of vertigo. This may involve medications to dissolve blood clots or prevent further clots, as well as rehabilitation therapies.

Treatment for Specific Conditions:

• Ménière's Disease: Management often involves a combination of strategies, including a low-sodium diet, diuretics to reduce fluid retention, medications (Brands available: Vertin), and sometimes more invasive treatments like steroid injections into the middle ear or surgery in severe cases.
• Vestibular Migraine: Treatment focuses on preventing migraine attacks with medications (e.g., beta-blockers, tricyclic antidepressants, anticonvulsants) and treating acute episodes with pain relievers and antiemetics. Vestibular rehabilitation can also be helpful.

The choice of treatment will be tailored to the individual based on the specific diagnosis, the severity of symptoms, and their overall health. It's essential to work closely with your doctor to develop an appropriate management plan.

Some alternative therapies that people with vertigo have explored include:

• Herbal Remedies: Ginger, ginkgo biloba, and feverfew are some herbs that have been suggested for managing dizziness and related symptoms. However, their efficacy for vertigo specifically is not well-established, and they can interact with other medications.
• Acupuncture: This traditional Chinese medicine technique involves inserting thin needles into specific points on the body. Some people with vertigo report symptom relief with acupuncture, but more rigorous scientific studies are needed to confirm its effectiveness.
• Chiropractic Care: Some chiropractors claim that spinal manipulation can help with balance problems and vertigo, particularly if there is a suspected issue with the upper cervical spine. However, the evidence supporting this approach for most types of vertigo is limited.
• Homeopathy: This alternative medical system uses highly diluted substances to stimulate the body's healing response. There is currently no reliable scientific evidence to support the use of homeopathy for vertigo.
• Yoga and Tai Chi: These mind-body practices focus on improving balance, flexibility, and coordination, which may indirectly help some individuals cope with the balance issues associated with vertigo. Specific poses and movements may need to be modified to avoid triggering symptoms.
• Biofeedback: This technique teaches individuals to control involuntary bodily functions, such as heart rate and muscle tension. It may help some people manage the anxiety and stress that can accompany vertigo.

• Age: Vertigo is more common in older adults due to age-related changes in the inner ear and an increased risk of conditions like BPPV, Ménière's disease, and stroke.
• Previous History of Vertigo: Individuals who have experienced vertigo before are at a higher risk of recurrence.
• Head Injury: Trauma to the head can damage the inner ear or the brain, increasing the likelihood of developing post-traumatic vertigo.
• Certain Medical Conditions: Conditions such as diabetes, high blood pressure, and cardiovascular disease can increase the risk of stroke and other conditions that can lead to central vertigo. Autoimmune disorders like multiple sclerosis also increase the risk.
• Ear Infections: Both middle ear and inner ear infections can sometimes trigger or contribute to vertigo.
• Family History: There may be a genetic predisposition to certain conditions that cause vertigo, such as Ménière's disease.
• Certain Medications: As mentioned earlier, some medications have dizziness or vertigo as a potential side effect.
• Alcohol Consumption: Excessive alcohol intake can disrupt balance and may trigger episodes of vertigo in susceptible individuals.
• Stress and Anxiety: While not a direct cause, stress and anxiety can sometimes exacerbate vertigo symptoms.

• Falls and Injuries: The loss of balance associated with vertigo significantly increases the risk of falls, which can lead to injuries such as fractures, sprains, and head trauma, especially in older adults.
• Reduced Quality of Life: Frequent or unpredictable episodes of vertigo can interfere with daily activities, work, social engagements, and overall well-being. The fear of experiencing another episode can lead to anxiety and avoidance behaviours.
• Psychological Impact: Living with a chronic condition like recurrent vertigo can lead to feelings of frustration, anxiety, and depression. The unpredictability of attacks can be particularly distressing.
• Difficulty with Daily Tasks: Simple tasks like walking, climbing stairs, reading, or even turning the head can become challenging during a vertigo episode.
• Motion Sickness: Individuals with a history of vertigo may be more susceptible to motion sickness.
• Dehydration: Severe nausea and vomiting associated with prolonged vertigo can lead to dehydration and electrolyte imbalances.
• Loss of Productivity: Frequent or severe vertigo can result in missed workdays and reduced productivity.

Living with recurrent vertigo can be challenging, but adopting certain strategies can help manage symptoms and improve your quality of life:

• Move Slowly and Carefully: Avoid sudden movements, especially of the head, as these can often trigger vertigo. Get up slowly from lying down or sitting positions.
• Use Assistive Devices if Needed: If you experience frequent balance problems, consider using a cane or walking stick for added stability.
• Modify Your Home Environment: Make your home safer by removing tripping hazards, using non-slip mats in the bathroom and kitchen, and ensuring good lighting.
• Sit Down Immediately: If you feel an episode of vertigo coming on, sit or lie down immediately to prevent falls.
• Focus on a Fixed Point: During a vertigo attack, focusing your eyes on a stationary object in front of you may help reduce the sensation of spinning.
• Avoid Driving or Operating Heavy Machinery: Do not drive or operate dangerous equipment if you are experiencing vertigo or feel unsteady.
• Stay Hydrated: Dehydration can sometimes worsen dizziness. Drink plenty of fluids throughout the day.
• Limit Alcohol and Caffeine: As mentioned before, these substances can sometimes exacerbate symptoms.
• Get Adequate Rest: Fatigue can make vertigo worse. Ensure you get enough sleep.
• Manage Stress and Anxiety: Practice relaxation techniques to help cope with the stress and anxiety associated with vertigo.

Misconception: Vertigo is just a general term for dizziness.

Reality: Vertigo is a specific type of dizziness characterised by a false sensation of movement, usually spinning or whirling. Other types of dizziness include lightheadedness and disequilibrium.

Misconception: Vertigo is a disease itself.

Reality: Vertigo is usually a symptom of an underlying condition affecting the balance system, such as BPPV, Ménière's disease, or vestibular neuritis.

Misconception: Vertigo is always severe and debilitating.

Reality: The severity and frequency of vertigo episodes can vary greatly. Some individuals experience mild, infrequent episodes, while others have more severe and debilitating attacks.

It's important to consult a doctor if you experience new, persistent, or severe episodes of vertigo, especially if accompanied by any of the following symptoms, as these may indicate a more serious underlying condition:

• Sudden onset of severe vertigo.
• Vertigo accompanied by double vision, slurred speech, weakness, or numbness. These could be signs of a stroke or TIA.
• Severe headache along with vertigo.
• Hearing loss or tinnitus that develops suddenly or worsens.
• Fever.
• Difficulty walking or maintaining balance.
• Loss of consciousness.
• Chest pain or shortness of breath.

Even if your vertigo symptoms are mild or intermittent, it's still a good idea to see a doctor to determine the underlying cause and receive appropriate advice and treatment. 

• What do you think is causing my vertigo?
• What type of vertigo do I have (peripheral or central)?
• What tests will I need to undergo?
• What are the treatment options for my condition?
• Are there any medications you recommend, and what are their potential side effects?
• Would vestibular rehabilitation therapy be helpful for me?
• Are there any specific exercises I can do at home?
• What are the possible complications of my condition?
• Are there any lifestyle changes I should make?
• What are the warning signs that I should seek immediate medical attention?
• How can I prevent future episodes of vertigo?
• How long can I expect my symptoms to last?
• When can I expect to see improvement with treatment?

• Be Patient and Understanding: Vertigo symptoms can be unpredictable and debilitating. Offer empathy and avoid dismissing their experiences.
• Help Create a Safe Environment: Ensure their home is free of tripping hazards. Offer assistance with tasks that require balance, such as walking or climbing stairs.
• Offer Practical Assistance: Help with errands, transportation to appointments, or household chores, especially during episodes of severe vertigo.
• Be Mindful of Triggers: If they know their triggers (e.g., specific movements, loud noises), help them avoid these situations when possible.
• Be Prepared for Sudden Episodes: Know what to do if they experience a vertigo attack while you are with them. Help them sit or lie down in a safe place.

Vertigo, the unsettling sensation of spinning, can significantly impact daily life. While often a symptom of underlying issues within the intricate balance system of the inner ear or brain, understanding its various types, diverse causes, and characteristic symptoms is the first step towards effective management. Accurate diagnosis, often involving a thorough medical history, physical examination, and specific diagnostic tests, is crucial for identifying the root cause. 

Fortunately, a range of treatments, from simple repositioning manoeuvres to medications and vestibular rehabilitation therapy, can help alleviate symptoms and improve quality of life. By being aware of risk factors, taking preventive measures where possible, and adopting practical tips for living with vertigo, individuals can learn to navigate the dizzying world and minimise its impact.