An Overview of Vertigo

Vertigo is the dizzy sensation associated with spinning around in a circle too fast, or as if the world is spinning around you. It may be described in different ways—dizziness, spinning, swaying, or tilting—and can be mild or severe enough to cause walking difficulties and even falls. Depending on the underlying cause of vertigo (for example, inner ear or nerve problem or migraine), other symptoms may be present, such as nausea, vomiting, headache, or hearing loss.

Diagnosing the "why" behind a person's vertigo requires a detailed medical history and physical examination. Sometimes, imaging, blood, or other tests are needed. Treatment of vertigo may involve multiple therapies, depending on the cause, such as medication, lifestyle changes, and/or vestibular rehabilitation.

Vertigo-related diagnoses can be divided into those related to the peripheral nervous system versus the central nervous system.

The peripheral nervous system consists of nerve cells outside of the brain and spinal cord, such as the cranial nerves and spinal nerves.

Benign Paroxysmal Positional Vertigo

Benign Paroxysmal Positional Vertigo (BPPV) is believed to be caused by calcium debris within the inner ear. Typically, a person with BPPV will describe a brief spinning sensation when moving their head in certain ways (e.g., tilting the head back to look up at the sky). Nausea may also be present, but rarely vomiting.

Vestibular Labyrinthitis

Vestibular labyrinthitis, also called vestibular neuronitis, is a viral or postviral inflammatory condition that affects the eighth cranial nerve. This condition causes sudden, severe vertigo along with nausea, vomiting, and unstable walking.

Meniere's Disease

Meniere's disease results from abnormal fluid buildup in the inner ear. It's associated with episodes of severe vertigo that last for minutes to hours, in addition to one-sided tinnitus, hearing loss, and ear fullness. Nausea, vomiting, and imbalance also commonly occur during the vertigo episodes.

Otitis Media

Otitis media (infection of the middle ear) may cause nonspecific dizziness, in addition to ear pain and decreased hearing.

Rare Conditions

There are a few rare peripheral nervous system conditions that may cause vertigo, such as:

• Otosclerosis: A condition that results from abnormal bone growth within the middle ear, causing hearing loss and sometimes, vertigo and tinnitus.
• Labyrinthine Concussion: A condition that causes hearing loss and sometimes, vertigo, as a result of head trauma to the inner ear
• Perilymphatic Fistula: A condition in which a fistula (an abnormal connection) develops in one or more membranes that separate the air-filled middle ear from the fluid-filled inner ear. Vertigo occurs as a result of middle-ear pressure changes that are transferred to the inner ear, often when a person strains or sneezes.
• Ramsay Hunt Syndrome: This syndrome results from an infection of the facial nerve with the herpes zoster virus. In addition to a painful red, blistering rash along the ear or within the ear canal, a person experiences one-sided facial weakness, ear pain, hearing loss, and vertigo.

The central nervous system consists of your brain and spinal cord.

Examples of diseases that affect your central nervous system and may cause vertigo include the following:

Vestibular Migraine

Vestibular migraine refers to vertigo that occurs as a result of a migraine, which is classically a one-sided, throbbing headache. In addition to vertigo and headache, other symptoms may occur with vestibular migraine, such as nausea and sensitivity to light and/or sound.

Stroke

A stroke, especially in the brainstem or cerebellum, may cause vertigo; although, usually other symptoms are present. For example, a brainstem stroke may also cause double vision and slurred speech.

Vestibular Schwannoma

Vestibular schwannoma, also called acoustic neuroma, is a benign (non-cancerous) tumor that develops on the eighth cranial nerve, which connects your inner ear to your brain. In addition to vertigo, tinnitus and hearing loss may occur.

Of note, because this type of tumor is slow growing, a person's vertigo may be subtle, often described as a vague feeling of swaying, tilting, or imbalance.

Multiple Sclerosis

Multiple sclerosis is an autoimmune, neurological disease in which a person's immune system misguidedly attacks the protective coating of nerve fibers (called myelin) within the brain and/or spinal cord. If myelin damage occurs within certain areas of the brainstem or cerebellum, vertigo may result.

Epileptic Vertigo

Epileptic vertigo refers to vertigo that occurs as a result of a seizure disorder.

It's important to keep in mind that heart problems, such as abnormal heart rhythms or vasovagal presyncope, can cause vertigo.

While vertigo related to heart problems is often reported as more of a lightheaded than spinning or dizzy sensation, the distinction can be subtle, which is why a doctor will often investigate a heart problem with any complaint of vertigo or dizziness.

Besides heart problems, other possible causes of vertigo, include the following:

• An adverse effect of taking certain medications (e.g., aminoglycoside toxicity)
• Psychiatric (e.g., depression or anxiety)
• Orthostatic hypotension from a variety of causes (e.g., dehydration, anemia, or pregnancy)

Due to the plethora of causes behind vertigo—some of which are serious—it's important to make an appointment with your doctor for this symptom.

Diagnosing the "why" behind your vertigo often takes a multifaceted approach—one that entails a detailed medical history, physical examination, and sometimes imaging or blood tests, depending on your doctor's suspicion for certain diagnoses.

During your appointment, your doctor will ask you several questions related to your vertigo, such as:

• Is your vertigo triggered by a sudden change in head position?
• How long do your vertigo episodes last, or is your vertigo continuous?
• What medications are you taking?
• Have you experienced any form of head trauma?
• Are you experiencing any additional symptoms (for example, hearing loss, tinnitus, ear pain, headache, or other neurological symptoms such as weakness, numbness, or slurred speech)?

Your doctor will perform a physical exam that will include a heart, neurological, head/neck, eye, and ear exam.

More specifically, in order to thoroughly evaluate your vertigo, your doctor may perform one or more of the following tests or maneuvers:

• Dix-Hallpike maneuver 
• Head Impulse test
• Nystagmus test
• Fukuda test
• Romberg test

Blood tests may be ordered if your doctor suspects an underlying process as the culprit behind your vertigo, such as anemia or an electrolyte abnormality from dehydration. Likewise, if your doctor is concerned about or simply wants to rule out a heart problem, an electrocardiogram (ECG), or Holter monitor may be ordered.

An imaging test, usually a magnetic resonance imaging (MRI), is warranted if a central nervous system cause of vertigo is suspected, such as a stroke, multiple sclerosis, or vestibular schwannoma.

The treatment of vertigo depends on the underlying cause. While many diagnoses are benign, some are very serious and require emergent medical attention, most notably a stroke.

For most other diagnoses, lifestyle changes, medications, and/or vestibular rehabilitation remain the mainstay of treatment.

Lifestyle changes are important for treating certain diagnoses. For instance, for vestibular migraine, your doctor may recommend keeping a migraine diary and avoiding potential migraine triggers, such as sleep deprivation or excess stress.

Lifestyle changes are also the primary treatment for Meniere's disease and include limiting salt, caffeine, and alcohol intake.

For vertigo related to a stroke, in addition to emergent care, your doctor will recommend smoking cessation and addressing any underlying health problems like high blood pressure, diabetes, and high cholesterol.

Various vertigo-related diagnoses may be treated with medication. For instance, for vestibular labyrinthitis, your doctor may recommend an antihistamine called Antivert (meclizine) and an anti-nausea medication like Phenergan (promethazine). Sometimes, a benzodiazepine, like Valium (diazepam), is prescribed to help ease vertigo.

For Meniere's disease (in addition to lifestyle changes), a thiazide diuretic may be recommended.

For vestibular migraine, a preventive migraine medication may be recommended, especially if the migraines are severe and/or frequent.

A technique called the Epley maneuver is used to treat people with BPPV. The purpose of this maneuver is to remove the calcium debris from the semicircular canal, located in the inner ear.

Research published in 2014 suggests that this maneuver is safe and effective; although, there is a high rate of recurrence of BPPV after treatment (around 36 percent).

Vestibular rehabilitation is a type of physical therapy in which patients with certain diagnoses of vertigo related to the peripheral nervous system (e.g., vestibular labyrinthitis) engage in various head, eye, and balance exercises to ease their dizziness and improve their stability and steadiness.

Some people incorporate complementary therapies, most notably, acupuncture, into their treatment plan. In fact, for people with benign diagnoses—BPPV, vestibular labyrinthitis, and Menier's disease—acupuncture has been found to be an effective therapy for obtaining immediate relief from their dizziness.

Vertigo is an unpleasant symptom that can be debilitating. If you are experiencing vertigo, be sure to seek out an evaluation by a healthcare professional. While most cases of vertigo are benign, there are some serious ones—so getting it checked out is important. Moreover, a doctor can provide you with the guidance and tools you need to start feeling well and steady again.