Vertigo is the illusion of movement. You may experience the room spinning around and around when your eyes are open. It is often related to a problem with the inner ear. It is to be distinguished from other types of dizziness such as feeling faint and lightheaded, which may be related to drops in blood pressure or problems with the heart pumping blood to the brain.
There are different types of vertigo. The main way to differentiate them is how long they last:
30 – 60 seconds Benign Paroxysmal Positional Vertigo
6 – 8 hours Ménière’s disease
Weeks – months Labyrinthitis or vestibular neuronitis
When you come to see me I would ask in detail about the type of dizziness you have, its duration, noises in the ear (tinnitus), loud noise exposure, and if you have taken any medication that might have affected your hearing or balance. I would examine your ears, check all your nerves are working and move your head in different positions to check if that triggers the vertigo. After that I would order a hearing test. This is the minimum investigation for vertigo, as the shape of the graph may indicate certain diagnoses, and if it is asymmetrical between the 2 ears, it may be an indication to order an MRI scan of inner ears/brain to exclude any other cause for the vertigo.
Benign Paroxysmal Positional Vertigo (BPPV)
This causes bouts of spinning which are triggered by head movement. Typically tipping the head back or rolling in bed triggers it. It can sometimes be precipitated by a head injury. It can come and go. It is not normally associated with a hearing loss or tinnitus (noises in the ears). It happens when crystals get stuck in the middle of the semicircular canals. The semicircular canals contain fluid which moves when you move your head. This fluid movement sends messages to the brain along the nerves telling the brain of the head’s rotation and position in space. The crystals are normally in the end of the canals, but when they drift into the middle of the canal, they impede the free movement of fluid when the head rotates, which sends error messages to the brain causing the eyes to spin, causing vertigo.
I would move your head in different positions to see if I can trigger the vertigo, in order to identify which semicircular canal is affected. The treatment is a positional manoeuvre e.g. the Epley manoeuvre, which will depend on the canal affected. This particle repositioning manoeuvre aims to move the crystals back into the end of the affected canal where they do not cause obstruction to the free movement of fluid. You might be more dizzy 48 hours after the treatment, so be sure to come with a friend or member of your family to hospital to drive you back home if necessary. The BPPV can recur and the manoeuvre can be repeated.
Ménière’s disease
A typical attack of Ménière’s disease is associated with vertigo, a drop in hearing, tinnitus and a feeling of fullness in one ear. It can be quite bad and you might need to lie down in a bed to let the attack pass. It can recur at random times. It might happen tomorrow and then the next day, and not happen again for 6 months. Over time it can damage the hearing. The diagnosis is made using the description of the attacks along with repeating a hearing test over several months and noticing a fluctuating hearing loss on the graphs. Once diagnosed with Ménière’s disease, there is a ladder of interventions which I can use, starting with medications.
Labyrinthitis or vestibular neuronitis
This is caused by a viral infection of the inner ear. It causes very severe vertigo and patients can end up in hospital, incapacitated with vomiting. The severe vertigo lasts for days and takes weeks and months to settle down. If the hearing is damaged it is called labyrinthitis. If the hearing is preserved it is called vestibular neuronitis. In the acute phase, tablets called vestibular sedatives e.g. prochlorperazine may be required to suppress the vertigo.
One can consider the inner ear, on each side, is like a plane’s engine. Normally, a plane flies level with two engines - one on either side. Having either condition is like blowing an engine and flying with one engine. Likewise, initially the vertigo is severe but over time the body compensates and “learns to fly with one engine” or one inner ear. This process of compensation may take many months until the patient feels like they have regained their balance. The process of compensation can be delayed if you use the vestibular sedative tablets for too long. Alternatively, it can be accelerated by doing exercises which challenge the balance system e.g. Cawthorne Cooksey exercises.
Persistent Postural Perceptual Dizziness (PPPD)
This causes persistent imbalance rather than vertigo, and can coexist with the above types of vertigo. If becomes difficult to scroll on your phone or computer screen. You can feel a bit detached from reality and feel like you are looking down upon yourself. It becomes difficult to navigate supermarkets because of the sensory overload. Anxiety intervenes which makes the problem worse. There is a crossover with migraine. The treatment consists of migraine preventative tablets or vestibular rehabilitation (physiotherapy for the balance system). You can read more about PPPD on the neurosymptoms.org website.