Vertigo

Vertigo is not an actual condition, but is instead the symptom of a balance disorder.

Although people with vertigo sometimes mistakenly describe it as dizziness, they are not the same symptom. Vertigo combines disorientation with a sensation of motion, which can make the room feel as though it is spinning.

Causes
The eyes, muscles, and joints constantly provide information about the body’s orientation to the brain. The vestibular system in the inner ear is involved with equilibrium. It helps you stay oriented in space and plays a big part in the sensation of balance. This system includes a series of fluid-filled passageways called the labyrinth, which helps the body stay properly positioned.

Inside the labyrinth are fluid-filled rings called semicircular canals. The movement of fluid within these canals tells your body that you are moving, and in which direction. The semicircular canals come together in a cavity called the vestibule.

Health conditions that affect any one of these systems can lead to a balance disorder and vertigo.

There are several different types of vertigo, each with its own cause:

Benign paroxysmal positional vertigo: This is the most common type of vertigo. It usually comes on when people change position, such as bending over to pick something up, turning over in bed, or moving their head quickly. The cause may be unknown or it may be due to:

• Age
• Ear infection
• Dirt or other debris in the ear
• Head trauma

Acute vestibular neuritis: This condition is a dysfunction with the vestibular system that lasts for a few days but is not associated with any hearing or neurological symptoms. Researchers believe it may be triggered by a virus.

Labyrinthitis: This is a bacterial or viral infection of the inner ear.

Meniere's disease: This condition is caused by a change in fluid volume in the labyrinth, and it accounts for about 10% of all vertigo cases.  It also may cause hearing loss and tinnitus (ringing or roaring sound in the ear) in one or both ears.

Other causes of vertigo:

• Acoustic neuroma (a benign tumor of the acoustic nerve that travels from the ear to the brain)
• Aging
• Anxiety disorders
• Certain medications (such as anti-convulsants, alcohol, or quinine)
• Foreign object in the ear
• Hemorrhage in the brain
• Migraine headaches
• Multiple sclerosis
• Reduced blood flow to the cerebellum and brain stem (this can occur during a stroke)
• Trauma/injury to the inner ear or head
• Underactive thyroid gland (hypothyroidism)
• Viral or bacterial infections (such as an ear infection, encephalitis, or meningitis)

Risk Factors
One of the biggest risk factors for vertigo is increasing age. Other risks include:

• Blood circulation problem or hemorrhage in the brain
• Infection
• Injury to the head or neck
• Migraines
• Multiple sclerosis

Symptoms and Signs
Vertigo is not the same as dizziness, although many patients describe it that way. It combines the sensation of movement with the feeling of disorientation.

Symptoms of vertigo include:

• A feeling that the room is spinning
• Lightheadedness
• Disorientation

These symptoms may be accompanied by:

• Abnormal eye movements
• Hearing loss
• Nausea
• Pale skin
• Ringing in the ears
• Sweating
• Vomiting
• Walking (gait) problems

Depending on the cause of the vertigo, the symptoms can last from a few seconds to several days. For example, benign paroxysmal positional vertigo usually lasts for a few minutes. A migraine may cause vertigo for a few seconds to hours. Vertigo from labyrinthitis can last for several days.

When to Seek Medical Advice
Although vertigo is usually benign and temporary, it’s important to get evaluated by your doctor, especially if your symptoms persist, because some conditions that cause vertigo can be serious.

Seek emergency help (call 911 or go to your local emergency room) if you have any of the following symptoms, as they may be a sign of stroke:

• A change in consciousness
• Difficulty speaking or walking
• Double vision
• Weakness

Diagnosis
The doctor will take a medical history, and will ask about your vertigo-including when it began, what causes it (for example, changing position), and what makes it better or worse. You will also be asked about any symptoms you are experiencing in addition to vertigo, including nausea or sweating. Knowing these things will help the doctor determine whether you have actual vertigo or another condition with similar symptoms.

The exam may include:

• Ear exam to see if there are any foreign objects, build-up of fluid behind the eardrum (from an ear infection), or perforated eardrum
• Vision test to check for abnormal eye movements
• Blood pressure measurement in both arms
• Neurologic (nervous system) exam
• Positional testing (moving you from one position to another in an attempt to trigger the vertigo)

Other tests may include:

• Blood sugar (glucose) test to rule out low blood sugar (hypoglycemia)
• Computed tomography (CT) or magnetic resonance imaging (MRI) scan of the head to look for problems with blood flow
• Echocardiogram (EKG) or electrocardiogram (ECG) to see how well the heart is functioning
• Hearing testing (audiology)
• Tests of balance and gait
• X-ray of blood vessels using contrast dye (angiography)

Treatment
Treatment for vertigo targets the underlying cause of the problem.

Some possible treatments are:

• Antibiotics (for bacterial infections)
• Semont or Epley maneuver – a series of head-turning maneuvers done in the doctor’s office to move debris particles from one part of the inner ear to an area where they will not affect balance (for benign paroxysmal positional vertigo)
• Debridement – to remove any dirt or debris in the ear
• Low-salt diet and diuretics – medications that rid the body of excess fluid and salt may be used as treatment for Ménière's disease
• Fluid draining if fluid has accumulated within the ear
• Medications such as Valium, Dramamine, Reglan, and Ativan (for acute vertigo that lasts from a few hours to a few days)
• Medications such as tricyclic antidepressants or beta blockers (for migraines)
• Vestibular rehabilitation therapy – training the brain to look for other visual clues to stay balanced
• Vestibular suppressant medications (for vestibular neuronitis and labyrinthitis)

Self-Care
Vertigo can cause you to fall if you’re not careful. These steps can help reduce your chances of falling:

• Avoid changing position (such as standing up or bending over) too quickly. When you get up from a chair or the bed, sit on the edge for a second or two and then ease up slowly.
• Ask your doctor about exercises that can help improve your balance and reduce vertigo symptoms.
• Sit down if you start feeling as though the room is spinning.

Prognosis
How well you do will depend on the condition that is causing your vertigo and how effectively it is treated.

Vertigo caused by problems with the inner ear can be effectively treated with medication and exercises. A brain tumor or blood vessel problem can be more serious and will need to be evaluated by a neurologist.

Sources:
NIDCD. Balance Disorders. http://www.nidcd.nih.gov/health/balance/balance_disorders.asp
Cummings CW, et al. Cummings: Otolaryngology: Head & Neck Surgery. 4th ed. Philadelphia, Pa; Mosby: 2005.
Goldman L, Ausiello D. Goldman: Cecil Medicine. 23rd ed. Philadelphia, Pa; Saunders Elsevier; 2007: chap 454.
Marx, JA. Marx: Rosen’s Emergency Medicine: Concepts and Clinical Practice. 6th ed. Philadelpia, Pa: Mosby;2006:chap 13.
Swartz R, Longwell P. Treatment of vertigo. American Family Physician. 2005; 71.