What is vertigo, and how can it be treated?

Approximately 40% of adults experience vertigo at least once in their life, with women being slightly more likely to get it than men. Vertigo is a sensation of spinning that can be associated with dizziness and feeling off balance. Other symptoms associated with vertigo are nystagmus (abnormal jerking eye movements) and nausea/vomiting. Contrary to what you may think, vertigo is not a condition, but a symptom of an underlying problem. Vertigo can be classified as central or peripheral based on the origin of the symptoms. Pathology originating from the cerebellum or brainstem are classified as central, while symptoms arising from the inner ear or the vestibular nerve are classified as peripheral.

Causes

Vertigo is often caused by a problem in the inner ear. The most common causes include Benign Paroxysmal Positional Vertigo (BPPV), Meniere’s Disease or Vestibular Neuritis or Labyrinthitis.

BPPV occurs when very small calcium particles called otoconia or canaliths are dislodged from their normal location (known as the utricle) and collect in the semicircular canals. These inner ear structures are responsible for sending signals to the brain about head position and movement relative to gravity. Malfunctions in this system can result in symptoms of vertigo. These symptoms usually last for a brief period of time and are related to changes in head or body position. While there is no well-known cause for this condition, and it can occur at any age however it is more common in older adults.

Meniere’s disease is thought to result from a buildup of fluid and changing pressure in the ear. This will typically result in episodes of vertigo that last longer than BPPV and are associated with tinnitus (ringing in the ears) and hearing loss.

Vestibular Neuritis or Labyrinthitis is related to an infection, usually viral, that results in inflammation in the inner ear around the nerves that allow the transmission of signals carrying information about head/body position to the brain.

Less common causes of vertigo include head/neck injury, brain tumors/stroke, migraine headaches and side effects of certain medications.

Treatment

Treatment for vertigo depends on what the cause. Oftentimes, vertigo will subside without treatment but vestibular rehabilitation is used in many cases to help strengthen the vestibular system and restore equilibrium.

Canalith repositioning maneuvers are recommended by the American Academy of Neurology to treat vertigo caused by BPPV. If your therapist diagnoses BPPV, he/she may treat you by taking your body through a series of movements that are designed to move the dislodged otoconia/canalith from the semicircular canals back to the utricle where they originated. Symptoms of vertigo occur during this maneuver but subside following. This should significantly reduce symptoms. Exercises that stress the vestibular system will be prescribed by your physical therapist following in order to “re-calibrate” your system.

Currently, there is no known cure for Meniere’s disease. However, you can take medications to treat the symptoms such as meclizine (for motion sickness) and promethazine (anti-nausea). Physical therapy is also recommended in the treatment of Meniere’s disease to improve vestibular function and balance. Alternatively, physicians can perform a number of injections to the middle ear such as dexamethasone (steroid) to reduce inflammation and mitigate symptoms.

If symptoms persist and are debilitating in nature, there are a number of surgical options available that are used as a last resort. One involves endolymphatic sac procedures, which decompress a part of the ear that is responsible for fluid levels. A shunt may also be placed to drain excess fluid that is causing symptoms. Yet another, labyrinthectomy, is a more aggressive procedure that removes the balance and hearing portion of the affected inner ear. Due to the invasive nature of the procedure, this is only performed in cases where the patient already has near or complete hearing loss.

Finally, some doctors may perform a vestibular nerve section, which  involves cutting the nerve that sends signals about balance and movement to the brain while preserving hearing function. This requires general anesthesia and overnight hospital stay.

Vestibular Neuritis (or Labyrinthitis) has simpler treatments, including antibiotics, prednisone, and antihistamines as well as medications to treat symptoms such as dizziness and nausea.

Vestibular therapy

Vestibular rehabilitation is a common part of a multimodal treatment for various vestibular conditions including those mentioned above. Exercises prescribed by your physical therapist will be divided into three main categories: habituation, gaze stabilization and balance/postural control.

Habituation involves exercises that provoke symptoms using graded exposure to specific movements or visual stimuli. The goal is to provoke mild symptoms that allow the central nervous system to acclimate the body to the stimulus. An increase in symptoms should be temporary and return to baseline after 15 minutes.

Gaze stabilization is performed with the goal of improving visual acuity during head and eye movements. Common exercises include fixing your gaze on an object while repeatedly moving the object, your head, or both. Head movement can be vertical or horizontal. This can be progressed by changing the environment, body position, speed of movement and duration of exercise.

Balance or postural control exercises may be prescribed to improve steadiness during a variety of tasks in order to promote functional return to activities of daily living, work or leisure. After determining what aspects of balance are impaired, your therapist will provide exercises that are challenging — but safe — so that you are not at risk of falling. These can be progressed by introducing uneven ground, low lighting, narrow base of support, single leg standing, external perturbations, etc.

If you are experiencing vertigo-like symptoms, please contact your physical therapist to determine the appropriateness of treatment. They will be able to assist you in discerning the cause of symptoms, setting up a treatment plan, and referring to another provider if needed.