Vertigo & Dizziness: An Overview

Introduction to Dizziness

Dizziness is a prevalent complaint encountered in clinical practice and can generally be categorized into one of four types: vertigo, disequilibrium, presyncope, or lightheadedness. The most common causes of vertigo include benign paroxysmal positional vertigo (BPPV), Meniere’s disease, vestibular neuritis, labyrinthitis, and vestibular migraines.

Presyncope or faintness can be linked to inadequate hydration and various medications (such as antihypertensives or heart rate-lowering agents), necessitating a review of the medication regimen. Disequilibrium refers to a sense of imbalance or unsteadiness that is not typically accompanied by the spinning sensation of vertigo. Disequilibrium may be associated with conditions such as Parkinson’s disease, diabetic neuropathy, cerebellar ataxia, and sensory deficits in the lower extremities due to peripheral neuropathy. Lightheadedness can often be caused by psychiatric conditions, which can create a sensation of faintness or a feeling as though one might pass out. This includes conditions such as depression, anxiety, and hyperventilation syndrome.

Physical examination techniques such as evaluating for nystagmus, performing the Dix-Hallpike maneuver, and checking orthostatic blood pressure (from sitting to standing) can help narrow the differential diagnosis of dizziness. Measuring blood pressure changes when a patient moves from sitting to standing can help diagnose orthostatic hypotension. A significant drop in blood pressure upon standing can cause presyncope or lightheadedness. This condition can result from dehydration, certain medications, or autonomic dysfunction. Identifying orthostatic hypotension is crucial as it points to a cardiovascular cause of dizziness rather than a vestibular or neurological one.

Vertigo is a type of dizziness characterized by a false sensation of movement, such as spinning, swaying, or tilting. It can significantly impact a person’s quality of life by affecting balance, coordination, and the ability to perform daily activities. Vertigo arises from disruptions in the vestibular system, which includes parts of the inner ear and brain that process sensory information related to motion, equilibrium, and spatial orientation.

Types of Vertigo: Peripheral vs. Central

1. Peripheral Vertigo:
   
   Origin: This type of vertigo originates from problems in the inner ear, which is crucial for maintaining balance.
   
   Common Causes:
   
   Benign Paroxysmal Positional Vertigo (BPPV):
   Caused by dislodged calcium carbonate crystals (otoconia) in the inner ear.
   
   Meniere’s Disease:
   A disorder involving abnormal fluid accumulation in the inner ear, leading to episodes of vertigo (usually episodic), tinnitus (ringing in the ears), and fluctuating hearing loss.
   
   Labyrinthitis:
   Inflammation of the labyrinth (part of the inner ear), usually due to viral or bacterial infections, causing vertigo (usually constant), hearing loss, and sometimes tinnitus. Both balance and hearing functions are affected.
   
   Vestibular Neuritis:
   Inflammation of the vestibular nerve, typically viral in origin, resulting in severe vertigo without hearing loss. This condition affects balance but does not impact hearing or cause tinnitus.
   
   
2. Central Vertigo:
   
   Origin: Central vertigo is due to problems in the brain, particularly in the brainstem or cerebellum.
   
   Common Causes:
   
   Vestibular Migraines:
   A subtype of migraine that presents with vertigo as a predominant symptom, which can occur even in the absence of a headache. This condition is associated with abnormal brain activity that disrupts the vestibular system, leading to episodes of dizziness and balance disturbances.
   
   Multiple Sclerosis (MS):
   A chronic autoimmune neurological condition that leads to the demyelination of nerve fibers in the central nervous system, including the brainstem. This loss of myelin disrupts the normal transmission of nerve signals, potentially causing symptoms such as vertigo, dizziness, and balance problems, along with other neurological deficits.
   
   Stroke or Transient Ischemic Attack (TIA):
   A stroke or TIA involves the interruption of blood flow to parts of the brain responsible for balance and coordination, such as the cerebellum or brainstem. This disruption can cause sudden and severe vertigo, along with other symptoms like weakness, numbness, speech difficulties, visual disturbances, and veering to one side. Prompt diagnosis and treatment are critical to reduce the risk of permanent damage or recurrence.
   
   Tumors:
   Abnormal growths in the brainstem or cerebellum can exert pressure on structures involved in processing balance and spatial orientation signals. These tumors can lead to vertigo, dizziness, headaches, and coordination issues. Symptoms may progress gradually, and other neurological signs, such as visual changes, hearing loss, or facial numbness, may also occur depending on the tumor’s location and size.
   

Understanding the distinction between peripheral and central vertigo is crucial for accurate diagnosis and effective treatment planning. Peripheral vertigo typically has a better prognosis and can often be managed with specific maneuvers and medications, whereas central vertigo might require more comprehensive neurological evaluation and intervention.

Benign Paroxysmal Positional Vertigo (BPPV)

BPPV is one of the most common causes of vertigo. It occurs when tiny calcium carbonate crystals, known as otoconia, become dislodged from their usual location in the utricle and migrate into one of the semicircular canals of the inner ear. These canals contain fluid and fine hair-like sensors that monitor the rotation of the head. When these crystals interfere with the fluid movement, they send incorrect signals to the brain, causing dizziness and the sensation of spinning. BPPV can affect different semicircular canals (posterior, horizontal, or anterior), with the posterior canal being the most commonly involved.

Symptoms:

• Brief episodes (usually resolves within 30 seconds up to two minutes) of dizziness triggered by changes in head position.
• Nausea and imbalance.
• A sense that you or your surroundings are spinning or moving.
• Loss of balance or unsteadiness.
• Vomiting in severe cases.

Diagnosis and Treatment:

• Dix-Hallpike Maneuver:
  A test to diagnose BPPV by observing jerking eye movements (nystagmus) when the head is moved in specific ways.
• Epley Maneuver:
  A series of head movements to move the otoconia out of the ear canal, relieving symptoms.
• Medications:
  Meclizine can provide temporary relief.
• Vestibular Rehabilitation:
  Exercises to improve balance and reduce symptoms.
• Surgery:
  Rarely needed, but may involve canal plugging to prevent otoconia movement.

Vestibular Migraines

Vestibular migraines are a subtype of migraine that predominantly involves vertigo, which may occur with or without the typical migraine headache. These migraines can be challenging to diagnose due to the variability in symptoms. Recent research suggests that vestibular migraines result from abnormal neural activity that affects the vestibular pathways in the brain, which are responsible for processing balance and spatial orientation. The vertigo associated with vestibular migraines can last from minutes to hours and, in some cases, even days (typically episodic). This condition is frequently seen in individuals with a history of migraines and can be triggered by factors such as stress, lack of sleep, certain foods, and hormonal changes. Treatment typically involves a combination of lifestyle modifications, medication, and vestibular rehabilitation therapy to manage symptoms and prevent attacks.

Symptoms:

• Vertigo lasting from minutes to hours, occasionally extending to days.
• Sensitivity to motion, light, and sound.
• Nausea and imbalance.
• Head motion-induced dizziness.
• Unsteadiness and loss of balance.
• Subjective hearing symptoms such as ringing, fullness, or pressure in one or both ears, although significant hearing loss should prompt consideration of other conditions like Meniere’s disease.

Vestibular Migraine Diagnostic Criteria

1. At least five episodes fulfilling criteria 3 and 4 below.
2. Current or past history of migraine with or without aura.
3. Vestibular symptoms of moderate or severe intensity, lasting between 5 minutes and 72 hours. Vestibular symptoms include:
   • Vertigo (spinning sensation)
   • Other illusions of self-motion or object motion
   • Positional vertigo
   • Head motion intolerance
4. At least 50% of episodes are associated with at least one of the following migrainous features:
   • Headache with at least two of the following four characteristics:
     a) Unilateral location
     b) Pulsating quality
     c) Moderate or severe intensity
     d) Aggravation by routine physical activity
   • Photophobia (light sensitivity) and phonophobia (sound sensitivity)
   • Visual aura

Diagnostic tests may include (there are no definitive diagnostic tests for vestibular migraine):

• Neurological examination to check for any neurological deficits.
• Brain MRI to rule out other brain conditions like stroke, tumors, etc.
• Audiological tests to check for hearing loss which may indicate other vestibular disorders.

Treatment:

Managing vestibular migraines typically involves a combination of medications, lifestyle changes, and vestibular rehabilitation therapy (VRT).

• Medications:
  Preventive: Tricyclic antidepressants, beta-blockers, calcium channel blockers, antiepileptic drugs (such as topiramate), and calcitonin gene-related peptide (CGRP) antagonists, Botox.
• Lifestyle Modifications:
  Maintaining a regular sleep and meal schedule.
  Avoiding known dietary triggers (such as aged cheeses, processed meats, and alcohol).
  Regular exercise and stress management techniques.
  Blue light–blocking glasses.
• Vestibular Rehabilitation Therapy (VRT):
  Exercises to improve balance and reduce sensitivity to motion.
  Gradual and challenging postural stability and gaze stability exercises.
  Habituation exercises to attenuate dizziness response to provocative movements.
• Symptom relief:
  Triptans, nonsteroidal anti-inflammatory drugs (NSAIDs), antiemetics, antihistamines, and rarely benzodiazepines.
• Supplementation:
  Vitamin B2 (Riboflavin), Magnesium, and Feverfew can help reduce the frequency and severity of vestibular migraines, though can take several months to work.

Meniere’s Disease

Meniere’s disease is a chronic condition of the inner ear characterized by episodes of vertigo, fluctuating hearing loss, tinnitus (ringing in the ears), and a sensation of fullness or pressure in the ear. It is believed to result from an abnormal volume or composition of fluid in the inner ear. This fluid imbalance can disrupt the signals sent from the inner ear to the brain, leading to vertigo and other symptoms. Meniere’s disease typically affects one ear and can lead to permanent hearing loss if not managed properly. The exact cause of this fluid imbalance is not known, but it may be related to genetics, allergies, autoimmune conditions, or viral infections.

Symptoms:

• Sudden and severe vertigo lasting for hours.
• Fluctuating hearing loss.
• Tinnitus (ringing in the ear).
• Aural fullness (feeling of fullness in the ear), popping sensation in the ear.
• Nausea and vomiting during vertigo episodes.

Diagnosis and Treatment:

• Hearing Tests:
  Audiometry is performed to assess hearing function and identify the characteristic low-frequency hearing loss associated with Meniere’s disease.
• MRI Brain/IAC:
  Magnetic Resonance Imaging is used to rule out other potential causes of symptoms, such as tumors or multiple sclerosis, that can mimic Meniere’s disease.
• Mediations:
  – Diuretics: These help reduce fluid retention and prevent the buildup of endolymphatic fluid in the inner ear, which is thought to cause Meniere’s disease symptoms.
  – Anti-vertigo Drugs: Medications like meclizine or diazepam can help alleviate vertigo symptoms during acute episodes.
• Lifestyle:
  – Low-Sodium Diet: Reducing sodium intake can help decrease fluid retention in the body and reduce the frequency and severity of Meniere’s disease episodes.
  – Avoiding Caffeine and Alcohol: These substances can exacerbate symptoms by affecting fluid balance and vestibular function.
• Surgery:
  – Endolymphatic Sac Decompression: This procedure involves relieving pressure within the endolymphatic sac, which can help control vertigo attacks.
  – Vestibular Nerve Section: In more severe cases, cutting the vestibular nerve can prevent vertigo by stopping the transmission of balance signals from the inner ear to the brain, though it typically does not affect hearing.

Labyrinthitis

Labyrinthitis is an inflammatory condition affecting the labyrinth, a part of the inner ear that controls balance and hearing. This inflammation is usually caused by a viral infection, such as a cold or flu, but can also result from bacterial infections. The inflammation disrupts the transmission of sensory information from the ear to the brain, causing vertigo, hearing loss, and other symptoms. The vertigo usually resolves within a couple of days; however, milder symptoms may persist for several weeks. The condition can be acute or chronic, and while it often resolves on its own, it can sometimes lead to long-term balance issues.

Symptoms:

• Sudden onset of severe vertigo (usually continuous, disabling and requires bed rest).
• Hearing loss.
• Tinnitus.
• Nausea and vomiting.
  

Diagnosis and Treatment:

• Physical Examination:
  To assess balance and hearing.
• Medications:
  Antibiotics (if bacterial), corticosteroids to reduce inflammation.
• Vestibular Rehabilitation:
  Exercises to improve balance and reduce symptoms.

Persistent Postural-Perceptual Dizziness (PPPD)

Persistent Postural-Perceptual Dizziness (PPPD) is a chronic condition that manifests as persistent sensations of rocking or swaying unsteadiness and/or dizziness without vertigo. This condition is often triggered by movement, complex visual environments, or visual patterns and can significantly impact daily activities and quality of life. PPPD is thought to result from a combination of vestibular and psychological factors, typically following an initial vestibular disorder such as BPPV, vestibular neuritis, or vestibular migraine.

Symptoms:

• Persistent sensations of dizziness and unsteadiness lasting for 3 months or more.
  
• Symptoms are present on more days than not, with many patients experiencing daily symptoms.
  
• Symptoms typically worsen with:
  • Upright posture (standing or sitting upright)
  • Head or body motion
  • Exposure to complex or motion-rich environments
• Feeling of swaying or rocking.
  
• Brain fog and difficulty concentrating.
  

Triggers:

PPPD typically starts shortly after an event that causes acute vertigo, unsteadiness, dizziness, or disruption of balance, such as:

• A peripheral or central vestibular disorder (e.g., BPPV, vestibular neuritis, Meniere’s disease, stroke)
  
• Vestibular migraine
  
• Panic attacks with dizziness
  
• Mild traumatic brain injury (concussion or whiplash)
  
• Dysautonomia (disease of the autonomic nervous system)
  
• Other medical problems, such as dysrhythmias and adverse drug reactions, although these are less common triggers.
  
• PPPD rarely starts slowly and gradually without a triggering event, although it is not always possible to sort out the cause.

Comorbidities and Psychological Impact:

• Anxiety or mild depression may be present as comorbidities but are not considered symptoms of PPPD itself.
  
• PPPD may coexist with other vestibular disorders, which can complicate the diagnosis as patients may exhibit other symptoms, including vertigo.
  
• Patients with PPPD often have a history of vertigo, indicating previous vestibular dysfunction. Chronic symptoms due to accumulated exposure to motion stimuli make them more susceptible to recurrence of symptoms.
  
• Patients tend to avoid situations that may exacerbate symptoms due to fear of worsening physical symptoms or anxiety that something terrible might happen. Thus, PPPD is a physiological disorder that can have significant psychological consequences.
  
  

Diagnosis and Treatment:

Vestibular Rehabilitation Therapy:
Exercises designed to help the brain readjust and improve balance.

Symptom History:
A detailed patient history is crucial for diagnosing PPPD, focusing on the persistence and triggers of symptoms.

Medications:
Selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs) can help manage symptoms.

Cognitive Behavioral Therapy (CBT):
CBT is used to address anxiety and stress associated with PPPD.

Mal de Débarquement Syndrome (MdDS)

Mal de Débarquement Syndrome (MdDS) is characterized by a persistent sensation of rocking, swaying, or bobbing, typically occurring after exposure to passive motion, such as a sea voyage or long car ride. The exact cause of MdDS is not well understood, but it is believed to involve a maladaptation of the brain’s balance systems to prolonged motion. Unlike other forms of vertigo, the symptoms of MdDS often improve when the person is in motion and worsen when stationary.

Symptoms:

• Feeling of rocking, swaying, or bobbing.
• Symptoms improve with motion and worsen when stationary.
• Difficulty concentrating and fatigue.

Diagnosis and Treatment:

• Symptom History: Diagnosis based on symptom pattern.
• Vestibular Rehabilitation Therapy: Exercises to help the brain readjust.
• Medications: Clonazepam or amitriptyline for symptom relief.

Cervicogenic Dizziness

Cervicogenic dizziness is a form of vertigo that originates from neck problems, often due to injury or chronic neck pain, such as whiplash or cervical spine disorders. The condition is thought to arise from abnormal sensory input from the neck affecting the vestibular system. Cervicogenic dizziness can be challenging to diagnose because its symptoms overlap with other types of vertigo and dizziness. Proper diagnosis typically involves ruling out other causes and confirming the neck as the source of dizziness through specific physical examinations.

Symptoms:

• Dizziness and unsteadiness that can last minutes to hours.
• Neck pain and stiffness.
• Headache.
• Limited range of motion in the neck.

Diagnosis and Treatment:

• Physical Examination: To assess neck movement and pain.
• Diagnostic Tests: Imaging studies, such as MRI or X-rays, are used to evaluate degenerative changes in the cervical spine. These tests often reveal a loss of normal cervical curvature, which can indicate underlying muscular imbalance or spasm in the neck.
• Physical Therapy: Exercises to improve neck strength and flexibility, ensuring that the entire back, including the mid and lumbar spine, are worked on, as muscles interact along the entire axial skeleton.
• Medications: Pain relievers and muscle relaxants.
• Manual Therapy: Techniques like osteopathic manipulation (avoid chiropractic adjustments).

Additional Considerations

Chronic B12 Deficiency: Chronic B12 deficiency can contribute to a sense of disequilibrium.

Overlap with Anxiety: Anxiety can exacerbate dizziness, creating a cycle of stress and dizziness. Addressing anxiety through therapy and stress management techniques is crucial for comprehensive treatment.

Conclusion

Understanding dizziness and vertigo requires distinguishing between various underlying causes, from benign inner ear disorders to more complex chronic conditions. Accurate diagnosis is crucial and involves detailed patient history, physical examinations, and diagnostic imaging. Effective management typically includes a combination of medications, lifestyle modifications, physical therapy, and targeted therapeutic exercises. Tailoring the treatment to the specific type and cause of dizziness or vertigo can significantly improve patient outcomes and quality of life.