Overview of dizziness and vertigo?
Dizziness is a feeling of being lightheaded, unsteady, and faint. It can make you feel like the world is spinning. Sometimes the feeling is mild and goes away quickly. Other times it can be severe and come along with other symptoms, like a headache and nausea/vomiting.
Vertigo is the feeling that you, or your environment, is moving or spinning. It can be associated with nausea or vomiting. It can sometimes be severe enough to cause imbalance and fall.
What are the causes of dizziness or vertigo?
Some of the important causes of dizziness are —
1) Inner ear problems, like vertigo (BPPV)
2) Brain problems e.g. brain stroke, demyelination infections
3) Dehydration
4) Stress and anxiety
5) Inner ear infections
6) Low blood sugar
7) B12 deficiency
8) Heart problems
9) Concussion
10) Medication side effect
11) Motion sickness
12) Vestibular migraine
Important facts regarding BPPV — Benign paroxysmal positional vertigo or BPPV is a common inner ear disorder. In BPPV, tiny bits of calcium in part of inner ear becomes loose and gets dislodged. This breaks the normal connection between inner ear and brain, sends incorrect signal to brain.
Common triggers for BPPV includes head injury, abnormal neck position, prolonged travel, inner ear infection.
Dizziness is usually maximum when head is tilted towards one side or when you roll over in bed or sit up. BPPV isn’t serious and usually goes away with medications. If not – it can be treated with special head exercises to get the pieces of calcium back in place. Your doctor can help you perform these exercises.
Neurological causes of Dizziness — 5 important neurological causes of dizziness are:
1) Stroke – mainly posterior circulation stroke
2) Head injury
3) Vestibular migraine
4) CNS tumours
5) Neurodegenerative diseases – most common being Parkinsons disease
How to evaluate a patient with dizziness or vertigo?
History — History is very important to determine the cause of vertigo
Duration of vertigo — Vertigo can occur as single or recurrent episodes and may last seconds, hours, or days. This time course of symptoms provides one of the best clues to the underlying pathophysiology of vertigo.
1) Recurrent vertigo lasting under one minute is usually benign paroxysmal positional vertigo (BPPV)
2) A single episode of vertigo lasting several minutes to hours may be due to migraine or to transient ischemia of the labyrinth or brainstem
3) The recurrent episodes of vertigo associated with Meniere disease or vestibular migraine also typically last hours
4) More prolonged, severe episodes of vertigo that occur with vestibular neuritis can last for days. This is also characteristic for vertigo originating from multiple sclerosis or infarction of the brainstem or cerebellum
Associated symptoms — A number of associated symptoms may help to distinguish the cause of vertigo:
1) Acute vertigo due to a vertebrobasilar stroke is almost always accompanied by other evidence of brainstem ischemia such as diplopia, dysarthria, dysphagia, weakness, or numbness. However, infarction of the cerebellum may present as vertigo with no other symptoms. Focal neck pain may suggest vertebral artery dissection.
2) Vertigo in patients with multiple sclerosis may also be preceded by or associated with other neurologic dysfunction, depending on the locus of demyelination.
3) Deafness and tinnitus suggest a peripheral lesion of the inner ear. A sensation of aural fullness typically accompanies attacks of Meniere disease.
4) Headache, photophobia, and phonophobia suggest migrainous vertigo. Many patients with migrainous vertigo will also experience visual aura in at least some of their attacks.
5) Shortness of breath, palpitations, and sweating may suggest a panic attack but can occur with vertigo too. Vertigo is often so terrifying that such symptoms are not uncommon with vestibular disease
Neurological examination — Your doctor will perform a detailed neurological examination to ascertain the cause of vertigo. It includes checking nystagmus, gait, power, speech, sensory system, posterior column.
There are certain manoeuvres that helps in establishing the cause as central vs peripheral, e.g. Dix-Hallpike manoeuvre, HINTS test, Head impulse test.
Brain imaging — MRI of the brain is indicated in selected patients when the history and examination suggest either a central cause of vertigo. Some important findings where an MRI is indicated includes:
1) Bidirectional nystagmus
2) Severe postural instability
3) Other neurological signs e.g., diplopia, ataxia, dysarthria, dysphagia, focal or lateralized weakness
What is the treatment of dizziness or vertigo?
Appropriate management of dizziness depends upon the underlying cause. Vertigo treatment can be divided into three categories: those specific to the underlying vestibular disease, those aimed at alleviating the symptoms of vertigo, and those aimed at promoting recovery.
Treatment of the underlying disease may diminish the symptoms of vertigo or alter the disease course in the following conditions:
1) Vestibular neuritis
2) Vestibular migraine
3) Benign paroxysmal positional vertigo
4) Meniere disease
5) Multiple sclerosis
6) Vertebrobasilar ischemia
Symptomatic treatment: Medications to suppress vestibular symptoms are best used for alleviating acute episodes of vertigo that last at least a few hours or days. Three general classes of drugs can be used to suppress the vestibular system and/or reduce associated nausea and vomiting:
1) Antihistamines – meclizine, dimenhydrinate, diphenhydramine, betahistine
2) Benzodiazepines – diazepam, lorazepam, clonazepam, alprazolam
3) Antiemetics – ondansetron, prochlorperazine, promethazine, metoclopramide, domperidone
Vestibular Rehabilitation – Vestibular rehabilitation (physical therapy) promotes recovery in patients with permanent unilateral or bilateral peripheral vestibular hypofunction. Certain neck exercises are recommended both for acute and chronic causes of vertigo. Your doctor can guide you regarding the exercises that best suits your clinical condition and diagnosis.