Vertigo and Dizziness: Causes, Treatment and Prevention

What is vertigo?

Vertigo is a loss of balance that can take several forms and often manifests itself as dizziness, or the false sense that you or your world is spinning. Vertigo is a symptom of underlying balance disorders rather than a specific disease in and of itself. 

Symptoms of vertigo:

• Feeling that the room is spinning
• Feeling that you are spinning
• Feeling that the floor is coming up and over your head
• Feeling that you are falling or dropping
• Feeling that your are on a rocking boat
• A general “floating” feeling
• Feeling light-headed
• Motion sickness or sensitivity
• A non-specific history of "balance problems" or being clumsy

Dizziness is one of the most frequent causes of doctor visits, and it can significantly impact your life. It should be noted that dizziness is a symptom that can arise from many different causes, including inner-ear disturbances like vertigo, poor circulation, medications, etc. The nature of the feeling will guide your physician or audiologist in shaping what diagnostic tests and treatment approaches you need, and this article focuses exclusively on vertigo.

Frequently Asked Questions

How normal balance function works

Human balance is a carefully coordinated interaction between three systems:

• The inner ear, part of which consists of the left and right labyrinths—which are the inner ear organs responsible for your sense of balance,
• Eye movement mechanisms, and
• Our body awareness system (called proprioception or kinesthesia) which matches movement, motion, and bodily location.

Information from these input systems is coordinated in the brainstem. Consider the following common example:

You’re sitting at the kitchen table browsing articles on HearingTracker as you enjoy your morning coffee. Your brain knows you’re sitting still because the fluid and crystals (otoconia) in your labyrinthine structures are still and your proprioceptive system is reporting that about 80% of your weight is on your keister and 10% on each foot. You hear some noise outside your window and turn your head to check it out.

At that point, your brain gets a report of a 90-degree positive response from your right labyrinth, and an equal and opposite response from the left labyrinth. Your eyes move 90 degrees to the left to prevent a visual “whoosh,” and your proprioceptive system reports that the “tuchus-footus” ratio is unchanged. All this means that the only possible option is that you must have moved your head 90 degrees to the right while your body remained still.

Using this basic understanding of how things should work, let’s look at some common causes of vertigo.

Two main types of vertigo

Vertigo is characterized by the probable location of the problem.

Peripheral vertigo

This type of vertigo results from dysfunction in the labyrinth, or inner ear balance organs. These include the semicircular canals/ducts, the utricle, and the saccule. These fluid-filled structures within the temporal bone contain small crystals called otoconia. When we move our head or body, very small sensory “hair cells” detect the movement of the otoconia and let our brain know which direction we moved.

Central vertigo

If the structures of the labyrinth are working normally, the cause of your vertigo may be central. This can include disruptions of the nerve signal between the ear and brain along the vestibular nerve or within the brain’s coordination center called the cerebellum. Other causes of central vertigo include disorders involving blood pressure, blood sugar, or medication interactions.

Diagnosing and treating vertigo

Vertigo can be evaluated by several healthcare specialties, including audiology, primary care, otolaryngology (ENT), neurology, or physical therapy. In general, the exam will include a careful case history, including an inventory of all medications you are taking, how many episodes of vertigo you've experienced, and a general physical examination. Audiologists will usually perform a hearing evaluation (audiogram) and possibly some specialized balance tests such as videonystagmography (VNG), rotary chair, and posturography. ENTs will read these results and may add a neurological exam and maybe a Magnetic Resonance Imaging (MRI) scan. Depending on the results of these tests, a referral to Neurology may be made to better define the source of the vertigo.

Types of Vertigo

Benign Paroxysmal Positional Vertigo (BPPV)

One of the most common causes of vertigo (about 2.4% of people) occurs when the otoconia get “stuck” in one of the semicircular canals and causes an exaggerated response to a particular head position, usually looking up or laying back. The classic presentation of BPPV is a rapid onset of spinning vertigo where the room appears to spin up and toward the affected ear, then down toward the floor. This sensation usually lasts 30 to 45 seconds and may be accompanied by nausea and possibly vomiting. During the attack, your eyes rapidly move to try to keep up with the perceived spinning. This eye movement is called nystagmus and is typical during vertigo episodes. In BPPV, the nystagmus is unique in that it is rotary in nature (rotary nystagmus).

Diagnosing and Treating BPPV

The classic test for BPPV is called the Dix-Hallpike maneuver. This can be performed by primary care healthcare providers, audiologists, or specially trained health technicians using only a simple examination table or reclining chair.

During the test, you will sit upright so that when lying down, your head will be just off the edge of the table. While supporting your neck and upper back, the tester will quickly lie you back and turn your head to the right so that your head is hanging off the edge of the table. With your head in this position, they will carefully look at your eyes checking for rotary nystagmus. After about 45 seconds, they will sit you back up and watch your eyes again. In some settings, they will have you wear special magnifying goggles or glasses to make your eye movements easier to see and record.

If you have BPPV in a given ear, you will slowly feel the room begin to spin about 15 seconds after your head is in the down position. The dizziness will peak in intensity about 15 seconds later, then begin to ease off. When you sit up, the pattern will repeat in the opposite direction. If you have a positive response, the tester will usually repeat the maneuver. In classic BPPV, the second trial will result in a notably less intense reaction.

The maneuver should be performed on both sides.

In addition to being quite common, BPPV is also very treatable. Following a positive result, the tester may move immediately to the Epley Maneuver, one of several canalith repositioning maneuvers. This series of head and body movements attempts to realign the “stuck” otoconia, as well as make it easier for your brain to adapt to the sensation. In most cases, two or three repetitions of the Epley Maneuver will resolve the symptoms of BPPV. Your provider should give you a worksheet and teach you how to perform the Epley at home in case symptoms recur.

Meniere's Disease

First described by Prosper Meniere, this disorder presents as episodes of spinning vertigo, fluctuating hearing loss (usually greater in low pitches), and low pitched roaring tinnitus (ringing in the ears). Meniere’s generally begins in one ear and tends to have an initial “active” phase where symptoms are more intense and more frequent, followed by a less active phase of gradual decrease in hearing and balance symptom changes.

HearingTracker published a recent in-depth article on Meniere’s disease.

Viral and Bacterial Labyrinthitis

Labyrinthitis is a bacterial or viral infection or inflammation of the inner ear’s balance organs. This can be associated with a cold, the flu, or other upper respiratory infection. Symptoms may include rapid onset vertigo of the spinning type, hearing loss, or tinnitus.  There is no specific test for labyrinthitis; however, some of the following tests may be ordered in order to rule out other causes:

• Hearing evaluation (audiogram)
• Balance testing (Videonystagmography or VNG)
• MRI (magnetic resonance imaging)
• Cardiac tests like an echocardiogram or an EKG

In most cases, viral labyrinthitis symptoms resolve on their own between a few weeks and a few months from onset. If the infection is bacterial, then an antibiotic may be prescribed and symptoms should begin to fade after a few weeks as the infection is resolved.

A similar disorder, vestibular neuritis (sometimes called neuronitis), occurs when the inner ear is inflamed, but there is no specific infection. Symptoms, diagnosis, and timeline for resolution are similar to Labyrinthitis, with the exception of hearing loss.

Other Causes of Vertigo

In addition to the above, vertigo can occur when the brain gets incomplete or confusing information from one or more of the parts of the vestibular system. It can also happen when there is an interruption or restriction of oxygen to the brain. Some of these non-ear-related forms of vertigo include:

Orthostatic Hypotension

This occurs when lower than average blood pressure causes a delay in blood reaching the brain when rising from sitting or lying down. It generally takes the form of a light-headed or woozy feeling and may include “seeing stars.” While this usually passes quickly, it is important to steady yourself before walking to lessen the risk of falling.

Peripheral Neuropathy

This reduction of feeling in the hands and feet places you at risk for vertigo because the proprioceptive system (the tuchus-footus system from earlier in this article) provides reduced or missing information to the brain. Without all three parts of the balance system—the inner ear, vision, and the feeling in your hands and feet—reporting for duty, the brain needs to estimate body position and can often over-correct. This leads to veering, stumbling, or falling particularly when walking on soft surfaces like carpet or grass.

Hypoglycemia (low blood sugar)

Our brain and nervous system need calories to operate properly. When your blood sugar levels are too low the entire system, including the coordination of balance, can be affected. This tends to present similar to peripheral neuropathy, but will fluctuate more as your glucose (sugar) levels change throughout the day.

Neurological Disorders

Disorders of the central nervous system like Multiple Sclerosis, Parkinson's disease, or Cerebral Palsy can affect all parts of the balance system. However, in general, the inner ear is less affected than the proprioceptive system and cerebellum, the brain’s control center for balance.

Vestibular Schwannoma (acoustic neuroma)

These non-cancerous (benign) tumors grow very slowly near the vestibular branch of the 8th cranial nerve and can cause a “drunken sailor” type of vertigo along with hearing loss and tinnitus. Diagnosis includes hearing and balance testing and usually an MRI. Depending on several factors including age, size, and position of the tumor, treatment ranges from “watch and wait” to radiotherapy (also called Gamma knife) to surgery.

Migraine Headaches

While not a direct cause of vertigo, many people with migraine experience vertigo, tinnitus, and light sensitivity during a migraine. This is often referred to as vestibular migraine. Be sure to report this to your treating healthcare provider if this is what you’re experiencing.

Head Injury (Traumatic Brain Injury)

Even mild concussions can disturb the brainstem's ability to coordinate balance and may cause vertigo.

Common Treatments for Vertigo and Dizziness

There are a number of treatments for vertigo, including physician-led strategies as well as some that are more self-directed.

Traditional Treatments

After your vertigo is diagnosed, you may be referred to a specially-trained physical therapist for vestibular rehabilitation. This generally includes functional tests to better identify exactly which parts of the balance system are weak or misbehaving, and then a customized set of exercises to improve the function of those weak components.

It’s common to have a few sessions a week with the therapist in addition to daily at-home practice. Generally, vestibular rehab will last for 6 to 12 weeks with several re-checks of function and strength along the way. In most cases, if the referral comes from your primary care provider, these costs of vestibular rehab are covered at least partially by insurance.

For acute symptoms, your physician may prescribe an anti-vertigo medication like Meclizine which essentially “turns off” the signals coming from the affected inner ear. It’s very important to take this as prescribed, because this and other anti-vertigo drugs may have side effects including drowsiness which make it difficult to get around. Another danger of over-using medication designed for acute symptom care is that your brain becomes accustomed to it, making it less effective when you actually need it. Finally using these drugs chronically can interfere with your body’s ability to compensate to the vertigo.

How to Ease Symptoms at Home

If you don’t have access to formal vestibular rehab, you can improve your balance using a few simple tips and tricks.

• Make sure your general health is on point. Schedule a physical and make sure that your cholesterol, blood pressure, and blood glucose (sugar) levels are well controlled and that any medications you are taking are well managed.
• Review the reports of any vestibular testing to see if they included at-home exercises.
• Visit the Vestibular Disorders Association website. This great resource includes links to professionals familiar with vestibular disorders as well as an entire section on at-home exercises.