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Vertigo: spinning out of control

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Vertigo is a disorienting symptom with numerous causes, but you can stop it from sending you into a spin. Cate Montana reports

It comes out of nowhere. Suddenly, the room—the whole world—spins sickeningly round and round. You feel like you’re at the center of a tornado, falling, with no sense of balance or support.

That’s vertigo, a dramatic and debilitating symptom that accompanies many different kinds of illnesses and injuries affecting approximately 20 percent of the adult population every year. As you age, your chances of experiencing vertigo increase. If you’re a woman, you have two to three times greater chances of experiencing it than a man.

Distinctly different from dizziness, vertigo is characterized by sudden onset and, just as often, sudden cessation after a relatively short duration of a few minutes. Dr Josh Lurie, owner of Balance & Vestibular Center Physical Therapy in Northridge, California (bvcphysicaltherapy.com), describes the difference between vertigo and dizziness this way: “True vertigo is where somebody feels like the room is spinning around them. It’s very intense, debilitating and short lasting. You aren’t able to stand up as it is happening, and it often happens when you’re turning over in bed.

“Dizziness is more like you’ve stood up really fast and you get that rush feeling in your head—except [with vertigo,] the feeling doesn’t necessarily go away. It waxes and wanes throughout the day. Basically, with vertigo the world seems like it’s spinning around you. Dizziness is felt to be contained within your head.”

Vertigo occurs when the vestibular system— the sensory balancing system based within the inner ears—gets out of whack via illness, infection, injury or sometimes an inherited problem such as Usher syndrome, which negatively affects both hearing and vision. The vestibular system is one of three balancing systems in the body, including our proprioceptive system, which is responsible for coordinating sensory information from our feet, up our legs and through our joints to the brain. It tells the body how to adjust depending on what type of surface we’re standing on and our visual system, which also helps us to balance.

“The vestibular system is kind of like a gyroscope in your head,” says Lurie, who is a doctor of physical therapy. “It always keeps us centered, and whatever position our body is in, we can always sense which way is up, down, left and right. The vestibular system’s job is to keep us balanced and upright. Its other job, which is even more complex, is that it coordinates our head and eye movements together.”

Vertigo: types and causes

There are two types of vertigo. The more common is peripheral vertigo, which arises from inner ear problems, better known as disorders of the vestibular system. Central vertigo arises within the central nervous system and is caused by a disease or injury to the brain.

Peripheral vertigo quite often has a rapid onset triggered by changes in position while lying down and can just as quickly vanish. That said, it can also last for months on end. Michael Malone, 48, of Chatsworth, California, was diagnosed with vestibular neuritis and had this to say.

“The extreme disorientation, feeling like I was out of my body and totally out of control, lasted for about five months, 24 hours a day, seven days a week. It is the most frightening feeling that you could possibly have.”

Peripheral vertigo is frequently accompanied by nausea, vomiting, sweating, tinnitus (ringing in the ears) and hearing problems. If the root cause is an inner ear infection, there may be pain and the sense that the ear is stuffed up or blocked. The following are the main causes of peripheral vertigo:

  • Vestibular hypofunction: reduced ability of the inner ear to maintain balance. It can be one sided (unilateral) or affect both ears (bilateral). Bilateral dysfunction is more difficult to treat because it depends upon training other body systems, such as the cervical-ocular reflex to sense head movements and coordinate those movements with the eyes as compensation.
  • Labyrinthitis: inflammation of the inner ear often caused by a virus (and some medications). May be accompanied by tinnitus and hearing difficulties/loss.
  • Vestibular neuritis: inflammation of the auditory nerve’s vestibular portion.
  • Vestibular schwannoma or acoustic neuroma: a noncancerous, mostly slow-growing tumor on the vestibulocochlear nerve.
  • Meniere’s disease: a disease not well understood and thought to be caused by viral infection, stress, constriction of localized blood vessels and possibly autoimmune issues. May be accompanied by tinnitus and hearing loss.
  • Benign paroxysmal positional vertigo (BPPV): the most common cause of peripheral vertigo, and often the most easily cured. BPPV occurs when tiny calcium crystals build up and come loose from their normal location in the inner ear. It can also result from fluid buildup in the inner ear or from viral infection and inflammation.
  • Superior semicircular canal dehiscence syndrome (SSCDS): an abnormal thinness, hole or incomplete closure of one of the bony canals in the inner ear. Frequently accompanied by sound distortion and hearing loss.

Central vertigo can last weeks or months, is more violent than peripheral vertigo, resulting in the inability to stand or walk without external support, and takes longer to treat. It is characterized by sudden onset, usually following an event such as illness or injury to the central nervous system resulting in trauma and subsequent hemorrhage. Symptoms are typically worse when standing or sitting upright as opposed to lying down, and when exposed to complicated, busy or motion-filled environments, with or without head and/or body motion.

These are the main causes of peripheral vertigo:

  • Traumatic brain injury
  • Tumors
  • Infection
  • Ischemia (a blockage in arteries) in the brain
  • Multiple sclerosis

Damage to the brain stem can result in an impaired vestibulo-ocular reflex, a condition in which the speed of eye movement doesn’t match head movement. Vertigo is often accompanied by brain fog and dizziness, tinnitus and hearing loss. The following can accompany both peripheral and central vertigo:

  • Vestibular migraine
  • Panic attacks with dizziness

Persistent postural perceptual dizziness (PPPD) is dizziness and unstable balance without vertigo and occurs mostly in an upright body posture (standing and/or walking). It is often triggered by an overactive parasympathetic system caught in a flight-or-flight response. Busy social situations, crowds, daylight, darkness and lots of movement are common triggers. PPPD may last over six months.

Missed diagnoses

Unfortunately, vestibular issues, in particular the symptom of vertigo, are often misdiagnosed. Vertigo itself is often dismissed as a hallucination or marginalized as a side effect of anxiety and panic attacks. Many patients see multiple doctors and receive multiple diagnoses before the actual underlying issue is ascertained.

“I’ve heard so many stories of patients who have gone to five or more different places with no proper diagnosis,” says Dr Payal Anand, an audiologist at the Balance and Falls Center in San Francisco (ucsfhealth.org/clinics/balance-and-falls-center). “One story in particular just broke my heart, and that was a 74-year-old patient I treated who had been sleeping on a recliner for the last 10 years because she had BPPV and nobody diagnosed it and treated it.”

The most common cause of vertigo, BPPV is a mechanical issue in which tiny calcium crystals called otoliths get dislodged from the gelatinous material in the inner ear and end up floating through the inner ear canals. The presence of the crystals triggers nystagmus, a neurologic response in the nerve that controls the eyes and eye movement. The rapid eye movements then trigger the vertigo, which usually occurs when the patient is lying down.

According to Lurie, approximately 80 percent of patients he sees and diagnoses with BPPV get complete relief from just one session using the Epley maneuver.

Anand concurs. “It’s often very simple to treat. Even if you go to the emergency room, you can get treated for BPPV. But you have to be able to diagnose it. There’s absolutely a need for training our residents and physicians to be able to identify this condition.”

Who should you see?

If you suffer from vertigo, a good place to start getting a proper causal diagnosis is an ear, nose and throat specialist (ENT) or an audiologist who specializes in hearing disorders and can conduct the proper tests. Once a correct diagnosis has been made, the next step is working with a physical therapist who specializes in mitigating vertigo while helping patients regain body balance and stability.

“Physical therapists assess how you’re doing from a functional standpoint—how are you moving, how are you walking, which is also part of what the audiologist does,” says Anand. “But audiologists use very sophisticated tests that are looking at different parts of the vestibular system itself. Is your inner ear system working okay? Is it functioning the same on both sides? Is it reduced on both sides? Is there a deficit or hyperactivity in the vestibular system?

“Getting a vertigo patient’s history is really important. I can often narrow down my diagnosis just based on history alone. What are your symptoms? How long have you had them? What triggers are there? Do you have headaches? Do you get light sensitivity? Do you have sound sensitivity? Are you triggered in crowds? By certain foods? Medication? Intake history is extremely critical in defining this condition.”

Anand tells the story of a musician who came to her for help with vertigo that would sometimes hit him while he was performing. “Nobody could figure out what was going on,” she says. “We went through all our normal protocols and didn’t find anything. So, we had him bring in his guitar and we had him sing while recording and measuring his eye movements. Turns out certain pitches and frequencies were triggering nystagmus, which was, in turn, related to an issue with his superior semicircular canal.”

The constant movement of inner ear fluid had apparently thinned the bony canals in the musician’s inner ears. Diagnosed with SSCDS, he went on to have a successful surgery to correct the condition.

“He was so relieved,” says Anand. “Sometimes people just need to know what’s going on in there. They need to know that they’re not going crazy and that somebody understands what they’re going through and that there is an explanation and the possibility of treatment. That, in itself is extremely calming and relieving to a lot of people.”

Diagnostic tools

Considering how often vertigo is misdiagnosed or goes undiagnosed, getting to the correct specialist and getting tested correctly is vital. Also, considering how closely the eyes and ears work together to maintain stability and balance in the body, diagnostic tests involve both the ocular and vestibular systems. If you are experiencing vertigo, prolonged dizziness, balance issues and/or hearing loss, you may need the tests below.

Audiometric test battery: hearing tests in which words, tones and pitches are presented through headphones and the patient is prompted to a response.

Tympanometry: test for problems between the eardrum and the inner ear.

ENG tests: Electronystagmography or electrooculography evaluates people suffering from vertigo, dizziness, and hearing and vision problems by determining the health and function of the ocular (eye) motor nerve and the vestibulocochlear (ear) nerve. Electrodes set below and above the eye can detect nystagmus, a totally involuntary side-to-side, rapid eye movement.

If nystagmus does not present after electrical stimulation of the eye, that narrows the problem down to the inner ear and the vestibular system. Many different types of ENG tests may be used, depending on symptoms and case history:

  • Calibration test: measures the movements of the pupil of the eye by tracking a light with the eyes
  • Caloric test: tracks involuntary eye movement as water introduced into the ear canal reaches the eardrum
  • Gaze nystagmus test: measures the eyes’ ability to hold a steady focus on an object without involuntary movement
  • Optokinetics test: measures the eyes’ ability to track an object across and out of the field of vision and then back again without moving the head
  • Pendulum-tracking test: measures the eyes’ ability to track an oscillating object or light
  • Positional test: measures the amount of involuntary eye movement when turning or sitting up quickly

ENG tests should also be administered if you have been diagnosed with the following:

  • Acoustic neuroma: a benign tumor on the vestibulocochlear nerve
  • Labyrinthitis: inner ear inflammation
  • Meniere’s disease: inner ear disorder that affects balance and hearing
  • Usher syndrome: inherited disorder affecting hearing, vision and balance

VNG tests: Videonystagmography uses a camera inset within goggles to record various eye movements.

  • Rotarychair test: assesses and compares eye and head movement speed to determine the health of the vestibulo-ocular reflex. It is best used to detect bilateral (in both ears) vestibular losses. The three most common rotary chair tests are: the sinusoidal harmonic acceleration (SHA) test, the vestibulo-ocular reflex suppression test, and the velocity step test.
  • Head impulse testing: assesses the health of the vestibulo-ocular reflex. The examiner (ENT doctor, physical therapist, audiologist) moves the patient’s head quickly and unpredictably to 10 to 15 degrees of neck rotation while taking care not to overly manipulate the cervical spinal region. This test works well for those with complete vestibular loss but is less sensitive for detecting mild to moderate losses.

VEMP test: If SCDS is suspected, a computed tomography (CT) scan may be done as well as a vestibular evoked myogenic potential (VEMP) test that measures muscular reactions in neck and eye muscles. Hearing tests are also crucial.

Computerized dynamic posturography (CDP): Tests the relationship between the body’s eyes, inner ears and muscles/joints and the body’s ability to keep standing upright under differing conditions in the environment.

Electrocochleography (eCog): This test uses earphones and electrodes placed on the body to measure the nervous system’s response to sound.

Auditory brainstem response test (ABR): Similar to the eCog, the ABR test measures the nervous system’s response to sound.

Magnetic resonance imaging (MRI): A brain scan can reveal tumors, blood clots, stroke damage and other problems that might contribute to vertigo or dizziness.

How to treat vertigo

Benign paroxysmal positional vertigo (BPPV) occurs when calcium crystals end up inside the semicircular canals of the inner ear and improperly signal your brain about your body’s position in space, which causes the false impression that the world is whirling around you.

Epley and Lempert maneuvers

The Epley maneuver, the Lempert maneuver (aka the barbecue roll) and the reverse Epley are movements that can be employed to reposition inner ear debris (such as otoliths) in the posterior ear canal, the horizontal ear canal and the anterior ear canal respectively.

The Epley maneuver begins with turning your head toward the side that’s causing the problem, then completing a series of further head and body movements to steer the otoliths out of the semicircular canals. Many websites and YouTube videos detail the Epley maneuver and the reverse Eply and claim they can be done at home.

But Lurie has reservations about that. “The maneuvers can technically be done at home,” he says. “But the problem is the patient will become very dizzy during the maneuver, and it is very difficult for them to maintain correct positioning and remember the positions in that state. That being said, we do give a handout to certain patients who may be able to complete it at home if symptoms reoccur. However, another drawback is, if it’s done incorrectly, the crystals may migrate into another canal, causing increased symptoms.”

The Lempert maneuver, which requires head support while the patient turns over (often several times) and frequent assessment of eye movements by an observing physical therapist or doctor, cannot be done at home.

VRBT

Vestibular/balance rehabilitation therapy (VBRT) is an exercise program specifically designed to help desensitize patients suffering from vertigo, dizziness and physical instability to various motion stimuli. The goal is to reduce symptoms, increase gaze instability and make everyday functioning more possible. With one or more short training periods every day, most VRBT programs run at least three to six months to be effective.

A VRBT program might include the Epley and Lampert maneuvers. (The Reverse Epley is seldom used because crystals in the inner ear canals rarely make it as far as the anterior canal.) Positional maneuvers that trigger or initially exacerbate vertigo and dizziness help the body learn to compensate and adjust to environmental triggers. Balance training and strength training are also standard.

Supplements

A few prescription medications and some over-the-counter supplements can help mitigate vertigo.

  • Vitamin D: Studies show that supplementing with vitamin D decreases BPPV occurrences in patients with below-normal vitamin D levels.1

Dosage: Get your blood levels tested, then supplement as needed

  • Ginkgo biloba extract: A study shows ginkgo biloba helps reduce vertigo more effectively than betahistine.2

Dosage: 240 mg/day

  • Gingerroot powder: One study has shown that gingerroot powder can reduce induced vertigo.3

Dosage: 750 mg/day

  • Use supplement products withnon-GMO ingredients and no additives.

Michael Malone’s story

On May 28, 2022, Michael, 48, was driving down Highway 101 in California with a friend after finishing a job. All of a sudden, vertigo hit him, and he felt like he was going to pass out. He’d had vertigo symptoms in the past—episodes that lasted up to three weeks. But this was something else.

“I literally thought I was going to die,” he says. “I thought I was having a stroke or something. I couldn’t control my body movements. I was extremely disoriented looking around and thought I was going to pass out.” He pulled over, and his buddy drove the rest of the way home.

The next day he felt better, but in the following days, the vertigo was so severe that he went to the emergency room several times. Despite the extreme vertigo, nausea, headache, neck pain and eye pressure, his CT scans, MRIs and blood work all came up negative. Doctors sent him home with an OTC bottle of meclizine (for motion sickness) and referred him to his primary care physician “if symptoms persist.” They did, and he went to his doctor, a general practitioner, who diagnosed him with labyrinthitis.

“That didn’t match all my symptoms because I didn’t have any hearing loss or pressure in either ear,” says Michael. “So, I went online and researched, and vestibular neuritis popped up and that sounded like what I had. When I looked for treatment, physical therapy was recommended, which led me to the Balance & Vestibular Center in Encino.”

Physical therapists at the center conducted tests, confirming Michael’s self-diagnosis of vestibular neuritis. For seven months he underwent physical therapy twice a week, gradually tapering off as his brain adjusted to the bizarre signals coming from his vestibular nerve and his symptoms declined. However, the vestibular neuritis and vertigo were then replaced by similar but different symptoms of dizziness. His physical therapist suspected PPPD (persistent postural perceptual dizziness) but recommended he see a specialist, Dr Edward Cho, an ENT at Cedars-Sinai Medical Center in Los Angeles.

PPPD often follows fearful “trigger events,” activating the parasympathetic system and a fight-or-flight response, which can alter how the brain perceives motion and spatial orientation. Once the scary trigger is over, the brain doesn’t “reset” and wonky perceptions persist, causing a chronic rocking sensation that takes months to diminish—sometimes years.

“I already had an anxiety disorder,” says Michael. “Then I was so freaked out by the initial insult of the vestibular neuritis, I developed PPPD, which is no joke. People get totally housebound with it, they’re so scared to go outside because of the triggers. I couldn’t go outside. I couldn’t drive or go to the grocery store or go for a walk or be in a crowd or even talk or look at a computer screen—which was tough because I’m a software engineer.

“The most important thing I’ve learned is that you have to get to the place where you don’t fear the symptoms. You have to go into them and let them do their thing. The more you don’t care and don’t react, the quicker the brain calms down and stops interpreting everything as dangerous. And then the symptoms can die down in a matter of a few minutes instead of persisting.”

Today, Michael says his PPPD is under control. He goes to physical therapy once every two months, and his symptoms are “light” and short-lasting. “When I get triggered, things feel unsteady—like I’ve had a few beers. But now it will pass within a few minutes, and then I just go about my day. And by the way, check out the Steady Coach, Dr Yonit Arthur, an audiologist on YouTube (youtube.com/c/TheSteadyCoach). Watching her videos has helped me tremendously.”

KD’s story

KD woke up one morning with the room violently spinning. Horribly nauseous and feeling out of control, she had to hold onto furniture just to get to the bathroom. Diagnosing her with benign paroxysmal positional vertigo (BPPV), the doctor cautioned her that it might “take a while to resolve,” and it did.

“The wild, spinning vertigo part of it went away after four hellish days, and after that the dizziness persisted,” KD says. “It was an unsettling, exhausting whirling sensation. There was a very weird pressure at the back of my head and base of my neck. It felt like my head would just roll off at any minute. Basically, it took everything I had just to live. I fell into bed exhausted at the end of the day.”

When the symptoms didn’t clear up, she went to a neurologist who (eventually) diagnosed vestibular neuritis. She also went to a physical therapist who gave her vestibular/balance rehabilitation therapy (VBRT) exercises meant to help her body learn to compensate for the inner ear imbalance.

“They have helped tremendously,” she says. “I’m still dizzy. But I’m feeling much better and finding a different, more authentic way of being in my life. I make meaning out of the hard stuff and I am emerging stronger and wiser.”

Adapted with permission from vestibular.org.

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References
 
  1. Otol Neurotol. 2022 Aug 1;43(7):e704-e711
  2. Int J Otolaryngol. 2014; 2014:682439
  3. ORL J Otorhinolaryngol Relat Spec, 1986; 48(5): 282–86
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