Vertigo is a medical condition where a person feels as if the or the objects around them are moving when they are not. Often it feels like a spinning or swaying movement. This may be associated with nausea, vomiting, sweating, or difficulties walking. It is typically worsened when the head is moved. Vertigo is the most common type of dizziness.

The most common diseases that result in vertigo are benign paroxysmal positional vertigo (BPPV), Ménière’s disease, and labyrinthitis. Less common causes include stroke, brain tumors, brain injury, multiple sclerosis, migraines, trauma, and uneven pressures between the middle ears. Physiologic vertigo may occur following being exposed to motion for a prolonged period such as when on a ship or simply following spinning with the eyes closed.Other causes may include toxin exposures such as to carbon monoxide, alcohol, or aspirin. Vertigo is a problem in a part of the vestibular system. Other causes of dizziness include presyncope, disequilibrium, and non-specific dizziness

Epidemiology

• The majority of cases seen in primary care are viral or benign positional vertigo.
• Prevalence estimates for vertigo are 4.9%, with migrainous vertigo 0.89%, and BPPV 1.6%. A recently reported prevalence of Ménière’s disease of 0.51% is much higher than in previous estimates.
• The prevalence of vertigo and dizziness in people aged more than 60 years reaches 30%.
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Classification

Vertigo is classified into either peripheral or central depending on the location of the dysfunction of the vestibular pathway, although it can also be caused by psychological factors.

Vertigo can also be classified into objective, subjective, and pseudovertigo. Objective vertigo describes when the person has the sensation that stationary objects in the environment are moving.Subjective vertigo refers to when the person feels as if they are moving. The third type is known as pseudovertigo, an intensive sensation of rotation inside the person’s head. While this classification appears in textbooks, it has little to do with the pathophysiology or treatment of vertigo.

Causes and Types

There are different types of vertigo, depending on what causes them.

• Peripheral vertigo happens when there is a disturbance in the balance organs of the inner ear.
• Central vertigo happens when there is a disturbance in parts of the brain known as sensory nerve pathways.
• Peripheral vertigo

Peripheral vertigo is linked to the inner ear.

The labyrinth of the inner ear has tiny organs that enable messages to be sent to the brain in response to gravity.

These messages tell the brain when there is movement from the vertical position. This is what enables people to keep their balance when they stand up.

Disturbance to this system produces vertigo.

This can happen because of an inflammation, often due to a viral infection.

Various conditions are associated with peripheral vertigo.

• Labyrinthitis: This is an inflammation of the inner ear labyrinth and vestibular nerve, the nerve that is responsible for encoding the body’s motion and position. It is usually caused by a viral infection.
• Vestibular neuronitis: This is thought to be due to inflammation of the vestibular nerve, usually due to a viral infection.
• Cholesteatoma: A skin growth occurs in the middle ear, usually as a result of repeated infection. If the growth becomes larger, it can damage the ear, leading to hearing loss and dizziness.
• Ménière’s disease: A buildup of fluid in the inner ear can lead to attacks of vertigo. It tends to affect people between the ages of 40 and 60 years.

According to The National Institute on Deafness and Other Communication Disorders (NIDCD), 615,000 people in the United States (U.S.) are currently receiving treatment for this condition. It may stem from blood vessel constriction, a viral infection, or an autoimmune reaction, but this is not confirmed.

• Benign paroxysmal positional vertigo (BPPV): This is thought to stem from a disturbance in the otolith particles. These are the crystals of calcium carbonate within inner ear fluid that pull on sensory hair cells during movement and so stimulate the vestibular nerve to send positional information to the brain.

In people with BPPV, normal movement of the endolymph fluid continues after head movement has stopped.

BPPV usually affects older people and the cause is usually unknown, or idiopathic. It has been linked to dementia. It is twice as common in women as in men.

However, it can also follow:

• a head injury
• reduced blood flow in part of the brain, known as vertebrobasilar ischemia
• labyrinthitis
• ear surgery
• prolonged bed rest

Drug toxicity and syphilis can also lead to inner ear disturbances.

Other, rarer causes of peripheral vertigo are:

• perilymphatic fistula, a tear in one or both of the membranes separating the middle and inner ear
• herpes zoster oticus, a viral infection of the ear, also known as Ramsay Hunt syndrome
• otosclerosis, a genetic ear bone problem that causes hearing loss
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Central vertigo

Central vertigo is linked to problems with the central nervous system.

It involves a disturbance in one of the following areas

• the brainstem and cerebellum, which are the parts of the brain that deal with the interaction between the senses of vision and balance
• sensory messages to and from the part of the brain known as the thalamus

A migraine headache is the most common cause of central vertigo. An estimated 40 percent of patients with a migraine have some vertigo, which can involve disrupted balance, dizziness, or both, at some time.

Uncommon causes are:

• stroke
• transient ischemic attack
• cerebellar brain tumor
• acoustic neuroma, a benign growth on the acoustic nerve in the brain
• multiple sclerosis

The frequencies of various causes are as follows:

• 39% idiopathic
• 21% trauma
• 29% ear diseases
• 9% chronic otitis media
• 7% vestibular neuronitis
• 7% Ménière disease
• 4% otosclerosis
• 2% sudden sensorineural hearing loss
• 11% CNS disease
• 9% vertebrobasilar insufficiency
• 2% acoustic neuroma
• 2% cervical vertigo

A condition that Caused  after being affected  of Vertigo

 

Vertigo can be caused by problems in the brain or central nervous system (central vertigo) or the inner ear (peripheral vertigo). Vertigo is a symptom of other conditions and is not in itself contagious.

• Benign paroxysmal positional vertigo (BPPV) is the most common form of vertigo and is characterized by the brief sensation of motion lasting 15 seconds to a few minutes. This may be described as a sudden attack of vertigo. It may be initiated by sudden head movements or moving the head in a certain direction, such as rolling over in bed. This type of vertigo is rarely serious and can be treated.
• Vertigo may also be caused by inflammation within the inner ear (labyrinthitis or vestibular neuritis), which is characterized by the sudden onset of vertigo and may be associated with hearing loss. The most common cause of labyrinthitis is a viral or bacterial inner ear infection. The duration of symptoms can last for days until the inflammation subsides. Viruses that may cause labyrinthitis or vestibular neuritis include herpes viruses, influenza, measles, rubella, mumps, polio, hepatitis, and Epstein-Barr virus (EBV).
• Meniere’s disease is composed of a triad of symptoms including episodes of vertigo, ringing in the ears (tinnitus), and hearing loss. People with this condition have the abrupt onset of severe vertigo and fluctuating hearing loss as well as periods in which they are symptom-free. The cause of Meniere’s disease is not fully understood but is thought to be due to viral infections of the inner ear, head injury, a hereditary factors, or allergies.
• Acoustic neuroma is an uncommon cause of vertigo related to a type of tumor of the nerve tissue of the inner ear that can cause vertigo. Symptoms may include vertigo with one-sided ringing in the ear and hearing loss.
• Vertigo can be caused by decreased blood flow to the base of the brain. A blood clot or blockage in a blood vessel in the back of the brain can cause a stroke (cerebral vascular accident or CVA). Another type of stroke consisting of bleeding into the back of the brain (cerebellar hemorrhage) is characterized by vertigo, headache, difficulty walking, and inability to look toward the side of the bleed. The result is that the person’s eyes gaze away from the side with the problem. Walking is also extremely impaired.
• Vertigo is often the presenting symptom in multiple sclerosis. The onset is usually abrupt, and examination of the eyes may reveal the inability of the eyes to move past the midline toward the nose.
• Head trauma and neck injury may also result in vertigo, which usually goes away on its own. Cervical vertigo can be caused by neck problems such as impingement of blood vessels or nerves from neck injuries.
• A migraine, a severe form of a headache, may also cause vertigo. The vertigo is usually followed by a headache, although not always. There is often a prior history of similar episodes but no lasting problems.
• Complications from diabetes can cause arteriosclerosis (hardening of the arteries) which can lead to lowered blood flow to the brain, causing vertigo symptoms.
• Changes in hormones during pregnancy along with low blood sugar levels can cause pregnant women to feel dizziness or vertigo, especially during the first trimester. In the second trimester, dizziness or vertigo may be due to pressure on blood vessels from the expanding uterus. Later in pregnancy dizziness and vertigo may be caused by lying on the back, which allows the weight of the baby to press on a large vein (vena cava) that carries blood to the heart.
• Anxiety or panic attacks may also cause people to feel the sensation of vertigo. Stress may worsen symptoms, though it usually does not cause them.
• Mal de Debarquement, which means “sickness of disembarkation,” is the medical term for the dizziness and vertigo felt after travel by ship or boat. This is commonly felt after a cruise. In some cases people experience this sensation after getting out of a plane, car, or train.

Symptoms vertigo

Descriptions of dizziness may include:

• a sensation of movement (including spinning), either of yourself or the external environment
• unsteadiness, including finding it difficult to walk in a straight line
• light-headedness
• feeling faint.

Other symptoms that may accompany dizziness include

• headache
• nausea and vomiting
• ringing or other sounds in the ears (tinnitus)
• difficulty hearing
• staggering gait and loss of coordination (ataxia)
• unusual eye movements, such as flitting of the eyes (nystagmus)
• finding it difficult to see clearly when moving, for example, when reading a sign while walking or driving.
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Tests and diagnosis

Assess any relevant medical history

• Recent upper respiratory tract infection or ear infection (may suggest a diagnosis of vestibular neuronitis or labyrinthitis).
• History of migraine.
• Head trauma or recent labyrinthitis suggests BPPV.
• Direct trauma to the ear, which may indicate possible perilymph fistula.
• Both anxiety or depression can aggravate dizziness or vertigo.
• Cardiovascular risk factors increase the likelihood that stroke may be the cause of vertigo.
• Some drugs (eg, aminoglycosides, furosemide, antidepressants, antipsychotics, anticonvulsants) may cause vertigo.
• Acute intoxication with alcohol may cause vertigo.

Examination

• Neurological examination, including gait and their ability to stand unaided, cranial nerves, cerebellar function, signs of peripheral neuropathy and any indication of a cerebrovascular event.
• Ear examination, including signs of infection, discharge and cholesteatoma.
• Eye examination: nystagmus (common in acute vertigo), fundoscopy.

The doctor will ask about ask about the patient’s medical history, including any history of migraine or a recent head injury or ear infection.

The person may undergo a CT or MRI scan.

Nystagmus test

The doctor may also provoke an eye movement known as nystagmus, as this can occur with vertigo.

Nystagmus is an uncontrolled eye movement, usually from side to side. It can happen when a person has vertigo, due to the brain thinking there is a rotational movement when there is not.

Similar eye movement happens when you try to fix your eyes on one position while looking at something that is passing quickly by, for example, when looking out from a train window.

To check for nystagmus, the doctor may carry out the following exercise:

• The doctor rapidly moves the patient from a sitting position to lying down on the examination bench.
• The head is turned and held 45 degrees toward the affected side before this quick maneuver, and moved 30 degrees down at the end of it, over the end of the bench, below the horizontal position of the rest of the body.
• If the patient experiences vertigo shortly after, and if the doctor observes specific eye movements, or nystagmus, this can indicate that the patient has vertigo.

Electronystagmography (ENG) can electronically record the nystagmus. The patient wears a headset that places electrodes around the eyes. The device measures eye movements.

Videonystagmography (VNG) is a newer technology can provide a video recording of the nystagmus.

The patient puts on a pair of special glasses that contain video cameras. These record horizontal, vertical and torsional eye movements using infrared light. Computer processing can analyze the data collected.

Specific clinical tests

Romberg’s test
This is used to identify instability of either peripheral or central cause:

• The patient stands up straight with feet together (or at a distance for them to be steady) with arms outstretched. Then ask them to shut their eyes.
• If they are unable to maintain their balance with their eyes closed, the test is positive (usually fall to the side of the lesion so stay close by to prevent them falling).
• A positive test suggests a problem with proprioception or vestibular function. Romberg’s test can also be positive in neuromuscular disorders and may not be reliable in very elderly people.

Dix-Hallpike manoeuvre
Can be used to confirm BPPV.

Head impulse test
This is used to help determine whether the cause of vertigo is peripheral or central (although it is not a sensitive test):

• Be very cautious if the patient has neck pathology, as it involves rapid repositioning of the head. Ask the patient to rotate their neck to assess for any limitation of neck movement. If in doubt about the safety of the manoeuvre, seek specialist advice or refer the person to a balance specialist.
• The patient should sit upright and fix their gaze on the examiner.
• Rapidly turn their head 20° to one side and watch the eyes for corrective abnormal movements.
• Repeat several times to the same or opposite side (at random) until satisfied as to the consistent presence or absence of the corrective abnormal movements.
• Corrective abnormal movements represent a positive test and imply moderate to severe loss of function of the horizontal semicircular canal on the side to which the test is positive.

Unterberger’s test
This is used to identify damage to one of the labyrinths:

• The patient should march on the spot for 30 seconds with their eyes closed; observe them for lateral rotation:
  • If there is no rotation, there is symmetrical labyrinthine function.
  • If there is labyrinthine damage, the person will rotate to the side of the affected labyrinth.

• Inner ear problems – disorders of the inner ear account for about half of all cases of persistent (ongoing) dizziness. Disorders include Meniere’s disease, benign paroxysmal positional vertigo (BPPV) and vestibular neuritis.
• Anxiety disorders – stress or anxiety may play a role in causing dizziness or, more commonly, may be a contributing factor in dizziness from other causes, such as inner ear disease.
• Brain disorders – a common cause of dizziness is migraine, even without the headache that most people associate with a migraine. Very rarely, other causes of dizziness can include stroke or other brain diseases.
• Other conditions – some cases of dizziness are due to underlying medical conditions such as low blood pressure, infection, some heart problems (such as cardiac arrhythmias) and hypoglycaemia (low blood sugar). Drugs that are used to treat conditions such as epilepsy, coronary heart disease and high blood pressure can also cause dizziness in some people.
• Unknown causes – although a cause may not be found in some people, it does not necessarily mean that these people cannot be helped by the appropriate treatment.

Treatment

Definitive treatment depends on the underlying cause of vertigo. Ménière’s disease patients have a variety of treatment options to consider when receiving treatment for vertigo and tinnitus including: a low-salt diet and intratympanic injections of the antibiotic gentamicin or surgical measures such as a shunt or ablation of the labyrinth in refractory cases. Common drug treatment options for vertigo may include the following:

• Anticholinergics such as hyoscine hydrobromide (scopolamine)
• Anticonvulsants such as topiramate or valproic acid for vestibular migraines
• Antihistamines such as betahistine, dimenhydrinate, or meclizine, which may have antiemetic properties
• Beta blockers such as metoprolol for vestibular migraine
• Corticosteroids such as methylprednisolone for inflammatory conditions such as vestibular neuritis or dexamethasone as a second-line agent for Ménière’s disease.
• Drugs can relieve symptoms of some kinds of vertigo, for example, vestibular suppressants or anti-emetics to reduce motion sickness and nausea.
• Patients with acute vestibular disorder linked to a middle ear infection may be prescribed steroids (such as prednisone), antiviral drugs (such as acyclovir) or antibiotics (such as amoxicillin).
  • prochlorperazine
  • antihistamines

• Prochlorperazine

  Prochlorperazine can help relieve severe nausea and vomiting associated with vertigo. It works by blocking the effect of a chemical in the brain called dopamine.

  AntihistaminesAntihistamines can be used to help relieve less severe nausea, vomiting and vertigo symptoms. They work by blocking the effects of a chemical called histamine.

  Possible antihistamines that may be prescribed include:

  • cinnarizine
  • cyclizine
  • promethazine teoclate
• All cases of decompression sickness should be treated initially with 100% oxygen until hyperbaric oxygen therapy (100% oxygen delivered in a high-pressure chamber) can be provided. Several treatments may be necessary, and treatment will generally be repeated until either all symptoms resolve, or no further improvement is apparent.
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Exercises for Vertigo