Category Archives: Vertigo

How is the body’s balance maintained?

Nature has given us certain sensors which are spread in different parts of the body. These sensors pick up the information and constantly inform the brain about the stability of the ground and the surroundings via afferent neural pathway.

The information coming from the eyes, skin, muscle and joints is integrated with the information coming from the inner ears and processed in the brain.  Central processing of information in the brain is essential for balance.





—> In response the brain evolves a motor output via efferent nerves– thereby creating a precise and timed contraction of different body muscles to restore the stability.

—> Resulting in movement of head and neck, legs, eyes and rest of the body to maintain the balance and have clear vision while person is moving

Thus Maintenance of balance is a reflex action with the involvement of a sensory organ, an afferent neural pathway, a center of the reflex in the brain stem, an efferent neural pathway and an effector motor organ.

Afferent sensory organs–

  • Eyes – Inform brain about our position and movement.
  • Proprioceptors–Skin, muscles and joints inform the positions of our arms, legs, and other parts of body.
  • Inner Ear Vestibular organs –Movement & position of head

Center of the reflex—

Situated in the brain-stem where 4 vestibular nuclei are present

Efferent neural pathway –

Neural tracts in the brain and spinal cord and peripheral nerves

Effector motor organ–

Different muscles of the body

Skeletal Muscles of the limb, trunk and neck (Vestibulo-spinal pathway)—vestibulospinal reflex —

Small Muscles of the eye Vestibulo ocular reflex pathway

Hence in order to have a properly working balance system we basically need:–

A perfectly working vestibulo spinal reflex system

A perfectly working vestibulo ocular system

A very good cerebellar system

For good balance eyes, nerve signals from the skin muscles and joints, and inner ears should work normally.

However, if we shut our eyes, we still have a good sense of balance because of the signal from inner ears, and other parts of our body

Role of Ear—

The labyrinth of the inner ear is composed of the vestibule (utricle and saccule) and the 3 semicircular canals. These are–

  • The vestibular labyrinth is made up of three semicircular canals (lateral, posterior and superior) at right angles to each other and joining together at the vestibule (Utricle and Sacule).
  • filled with fluid called endolymph and have receptors to inform the brain about the head’s position in space
  • Semicircular canals detect direction of gravity and detect and measure movements and acceleration in all three planes of space.
  • The right and left balance organs work together, constantly sending signals via the audiovestibular nerves to the brain, about position and direction of movement.

Vertigo is caused by conflict of information between inner ear and other sensory system or defect in central integration of vesitbular information in brain.

Vertigo: Causes and Treatment

Vertigo is not a disease but a symptom of balance disorder which can be due to any number of causes. It is defined as an “illusion” or “hallucination” of movement. It is the feeling that you or your environment is moving or spinning when there is no actual movement.

image credit- flicker image


Dizziness and imbalance are common causes of visit to primary health care physician and includes a broad range of sensations from severe vertigo to momentary lightheadedness. Vertigo is most common cause of referral to otolaryngology clinic.

Vertigo should not be confused with other terms related to imbalance like lightheadedness, unsteadiness, or drop attacks.

Vertigo is not fear of heights

Even today vertigo is confused as fear of heights (Acrophobia—meaning Dizzy feeling often experienced when looking down from a high place), which is not true vertigo.

“Alfred Hitchcock’s” movie “Vertigo” (1958) shows its lead character a San Francisco detective (James Stewart) has Acrophobia but people confused it with vertigo because of the name of the movie.

Image credit- ( )

Mild Vertigo is very common, and the symptoms are not usually serious. Most patients who experience vertigo have disorder of the vestibular system.

(i.e Vestiblue and semicircular canals of the inner ear, the vestibular nerve, brain stem, and the cerebellum).

Normal Balance requires—

  • Accurate sensory information from eyes, inner ear and proprioceptors (Muscles and joints)
  • Co ordination of information by brain (brain stem and cerebellum)
  • Normal motor output to muscles and joints


Resulting in movement of head and neck, legs, eyes and rest of the body to maintain the balance and have clear vision while person is moving.

Vertigo is caused by—

conflict of information between inner ear and other sensory system or defect in central integration of vesitbular information in brain.

Causes of vertigo

Vertigo may be because of otologic, neurologic, or systemic reasons. Cause can often be diagnosed by patient’s description of the problem and thorough physical examination; other tests are sometimes needed

Causes of Otologic Vertigo

  • Benign paroxysmal positional vertigo
  • Meniere’s disease
  • Vestibular neuritis and related conditions
  • Bilateral vestibular loss (about 1%)
  • SCD and Fistula (rare)
  • Chronic otitis media
  • Eustachian tube dysfunction (the tube that links the inner ear with the space behind the nose)

Central (Neurologic) Causes of Vertigo

  • Multiple sclerosis
  • Tumor (Acoustic neuroma)
  • Vascular causes
  1. Transient Ischemic Attacks or stroke
  2. Vasculitis: SLE, PAN, Temporal arteritis

Systemic causes of Vertigo

  • Anaemia (Low Hemoglobin)
  • Hypogycemia (Low Blood sugar)
  • Hypotension (Low Blood Pressure)
  • Drugs- Medicines such as salicylates, quinine and aminoglycosides
  • Viral Infection

Benign paroxysmal positional vertigo

Benign Paroxysmal Positional Vertigo (BPPV) is the most common form of vertigo and is characterized by the sensation of motion provoked by sudden head movements or moving the head in a certain direction. BPPV is caused by detachment of otoconia to semicircular canal from utricle and is usually not due to any serious disorder.

Short, intense, recurrent attacks of rotatory vertigo (usually lasting 10-20 seconds) are often the result of benign paroxysmal positional vertigo (BPPV). There is no tinnitus, hearing impairment, neurologic signs, and the gait is normal.

The nystagmus is not spontaneous, it is fatigable, & is directed towards the lowermost ear.

Treatment of BPPV—

  • Canalith repositioning Maneuver
  • Assurance
  • Vestibular Rehabilitation Exercises
  • Medicines not used
  • Surgery—for Persistent symptoms
  1. Dissection of Nerve to posterior Semi circular canal ampulla (Singular Nerve)
  2. Or Posterior Canal obliteration

Meniere’s disease

Meniere’s disease is because of dilatation of endolymphatic space of membranous labyrinth) and characterized by triad of symptoms– episodes of vertigo, Ringing in the Ear (Tinnitus), and fluctuating hearing loss.

Sudden attacks of severe vertigo may last for several hours accompanied by nausea and vomiting with symptoms free intervals. Patient may feel pressure in the ear before attack and hearing loss and discomfort to loud noise (Hyperacusis).


  • Over production of the endolymph
  • Vasospastic theory: Autonomic imbalance in the arterioles of the stria vascularis.
  • Herniation/rupture of the membranous labyrinth
  • Metabolic disturbances, either local or systemic
  • Allergy

This is to be differentiated from Meniere’s syndrome, wherein a known cause exists, & Meniere’s-like syndrome, wherein there is no fluctuation of hearing or episodic vertigo.

Lermoyez’ syndrome is another variant, characterized by progressively increasing hearing loss & vertigo, followed by vomiting, & then complete recovery.


There is no cure to menieres so treatment aims at relieving vertigo.

  • Vasodilator (Betahistine)
  • Salt restricted diet
  • Oral or intratympanic corticosteroid are useful
  • Intratympanic injection of gentamycin is effective
  • Surgery—if medicines fail-
  1. Conservative surgery (to preserve Hearing)— Endolymphatic Sac decompression &Division of vestibular branch of Vestibulocochlear Nerve
  2. Radical surgery–Labyrinthectomy if intractable vertigo

Acute peripheral vestibulopathy

Vestibular neuritis and labyrinthitis are sometimes used interchangeably but are two separate conditions, in labyrinthitis hearing loss is an additional feature.
Patients benefit from bed rest and symptom relief treatments. In patients with suppurative labyrinthitis, hospitalization with intravenous antibiotic treatment is required. Early mobilization and Vestibular rehabilitation exercises are beneficial for compensation of vestibular function.


Vertigo may also be caused by inflammation within the Vestibular labyrinth –(ie complex fluid filled channels in the inner ear).

Viral infections such as a common cold or flu can spread to the labyrinth.  Less commonly, labyrinthitis is caused by a bacterial infection of the inner ear (otitis media).

Labyrinthitis is characterized by sudden onset of vertigo and, and may be accompanied by hearing loss, ear pain and fever.

Vestibular neuritis

A viral infection can sometimes lead to infection to vestibular nerve or vestibular neuritis.

Characterized by sudden onset rotatory vertigo with nausea and vomiting. Patients are unsteady but can usually stand and walk. There is no loss of hearing.

Sudden Vestibular Failure (Vestibular neuronitis) is damage to the sensory neurons of the vestibular ganglion). One side labyrinth suddenly stops working.

Characterized by sudden vertigo with nausea and vomiting without auditory symptoms. Vertigo is continues which gradually improves.

Causes may be-

  • Head injury
  • Viral infection
  • Blockage of blood supply on end arteries
  • Multiple sclerosis
  • Diabetic neuropathy
  • Encephalitis
  • Corticosteroids and early rehabilitation may be beneficial for long-term outcomes. An antiviral medication is not found to be helpful.

Superior canal dehiscence syndrome (SSCD)-

Presence of dehiscence (break in the continuity) in the bone covering superior canal is characterized by vertigo induced by loud noise, may be associated with conductive hearing loss, sensation of increased loudness of patient’s own voice (autophony) and pulsatile tinnitus .

Loud sound, positive pressure in the external auditory canal and valsalva maneuver results in vertigo and nystagmus.

Perilymph fistula

Leakage of inner ear fluid into the middle ear can occur after a head injury, drastic changes in atmospheric pressure (such as when scuba diving), physical exertion, ear surgery, or chronic ear infections.

Patient with perilymph fistula has dizziness, nausea and unsteadiness while walking or standing which increases with activity and decreases with rest. Sometimes it is present at birth along with congenital hearing loss.

Central Dizziness

Migraine- associated vertigo (Vestibular Migraine) is a common but under diagnosed cause of episodic vertigo. The vertigo is usually followed by a headache. Some patients have prior history of similar episodes with periods free of headaches.

There is no definitive diagnostic test for migraine and sometimes typical headache is absent; the diagnosis can only be verified by the response to the migraine treatment

Treatment is gradual cessation of pain killers (NSAIDS) along with avoidance of triggers of migraine caffeine , chocolates, cheese, red wine yoghurt and fermented food, stress. Vestibular suppressants are usually prescribed.

Vascular causes –

Stroke or TIA -The most feared diagnosis of true vertigo is a transient ischemic attack or stroke. It should always be excluded especially in patients with cardiovascular risk factors and central neurological findings.

Disruption of the blood flow to the inner ear can cause damage to balance and hearing system.

Occlusion of blood supply to cerebral cortex (Middle cerebral artery), cerebellum (Distal posterior inferior cerebellar artery) or brain stem (Proximal Posterior inferior cerebellar artery) or vertebro bacillar artery insufficiency) Cardiovascular risk factors modification and anticoagulation treatment can help prevent further episodes.

Cardiovascular Risk Factors

  • High Blood Pressure
  • Elevated cholesterol
  • Smoking
  • Family history of stroke or heart attack
  • Age
  • Overweight
  • Sedentary life style
  • Diabetes Mellitus
  • Collagen Vascular disease
  • Heart problem

Hemorrhage (Bleeding) into the cerebellum (back of the brain) (cerebellar hemorrhage) is characterized by vertigo, headache, difficulty walking, and inability to look toward the affected side.

Tumors of the posterior fossa

Vestibular schwannoma (acoustic neuroma) is an uncommon lesion with progressive, hearing loss and tinnitus in one ear.

Once suspected, the diagnosis can be confirmed with MRI.  Surgery should be considered for patients with more-than-mild symptoms.

Multiple sclerosis

Recurrent CNS demyelination due to autoimmune disorder. Symptoms include optic neuritis, ocular motor dysfunction, trigeminal neuralgia, sensorimotor deficits, myelopathy, ataxia, and bladder dysfunction.

Vertigo is often the presenting symptom in Multiple sclerosis. The onset is usually abrupt, and examination of the eyes may reveal the inability of the eyes to move past the midline toward the nose.

Careful history Physical examination combined with MRI and spinal-fluid analysis helps in reaching to the diagnosis

Psychogenic vertigo

Anxiety disorder, hyperventilation and depression can manifest as chronic vertigo. Reassurance and counseling, cognitive behavioral therapy and medication are useful

Trauma induced Vertigo

Head trauma -By direct injury to the labyrinth or by canalith dislodgement

Barotrauma- sudden atmospheric pressure changes (such as in pilots or divers) may cause perilymphatic fistula. Fistula usually heals in 2 weeks time with appropriate with bed rest and avoidance of straining and coughing. Surgical repair is required if there is progressive hearing loss.

Most disorders of the balance system are self-limiting and can be satisfactorily managed if the clinical tests and investigations point to a specific disorder but when the clinical tests and investigations point to vestibular disturbance of unknown etiology management becomes challenging task due to large number of potential underlying conditions. In theses cases Treatment for vertigo is mainly symptomatic with Reassurance to the patient, Physical therapy ,medicines. and sometimes surgery.

Vestibular Rehabilitation Therapy for Vertigo

When the vestibular organs of balance are damaged with disease or injury, there is conflict of information to the brain about the equilibrium and motion often resulting in dizziness, vertigo, and imbalance.Brain has tremendous plasticity so it usually adapts to the situation  (An amazing process called Nature’s mechanism of vestibular compensation) and many people recover from these symptoms on their own after a few weeks.

Nature’s compensation process for imbalance can be accelerated by Vestibular Rehabilitation Therapy.

In next post — See How our Balance system works?

What is Vestibular rehabilitation Therapy (VRT)?

Vestibular rehabilitation therapy (VRT) is a form of physical therapy that uses specialized exercise to enhance nature’s compensatory mechanism for imbalance due to inner ear disorder (Peripheral Vestibular System) which helps in retraining of brain to recognize and process signals from inner ear in coordination with Eye (Vision) and Muscle and joints (Proprioception). It also helps to desensitize the balance system to movements that provoke the symptoms.

VRT is effective in a variety of vestibular problems, including benign paroxysmal positional vertigo (BPPV),  Ménière’s disease, labyrinthitis, and vestibular neuritis.

What are the Benefits Of VRT

– Reduce fall risk level

– Decrease feelings of dizziness and unsteadiness

–  Improve mobility

– Increase safety and independence

– Accelarating mechanism of central adaptation and compensation

How Vestibular Rehabilitation Therapy works?

Most VRT works at three ways— Adaptation, Compensation and Habituation

Adaptation — Head-eye coordination exercises which stimulate brain help the eye-ear reflex work in a coordinated manner.  It also stimulates the balance portion of the ear.   It is critical that the head turn separately from the rest of your body in order for the ear to receive proper inputs.

Compensation— Balance retraining exercises which help to reduce unsteadiness by utilizing vision, sensory system and postural system more effectively to keep the balance.

Habituation– continually repeating the actions that bring on the symptoms of dizziness or vertigo will eventually accustom the body to those actions.

Exercise Protocols for Individual Patients

On the Basis of symptoms of individual patient Specific Vestibular Program is designed tailored to fit need of the patient.

Extent and location of damage of vestibular system, state of visual and proprioceptive systems, General physical health, motor skills, cognitive abilities, anxiety states and integrity of the cerebellum are taken into consideration.

These custom-designed exercises are to be done at home several times a day which begins at the minimal skill level and complexity is increased as compensation and habituation occur.

Patients have regular follow-up visits with the therapist until compensation and habituation are complete and optimal balance is attained.

Caution-Someone should be there by the side of the patient to support in the case of imbalance as often people experience increased dizziness shortly after starting a vestibular therapy program. Caution should be used while doing these exercises, especially standing and walking exercises.

Exercise Protocols

Vestibular rehabilitation exercises focus on gaze stability and gait stability. Gait stability includes both static and dynamic balance exercises.

I. Adaptation exercises Vestibulo-Ocular Reflex (VOR) stimulation exercises—

(Vestibule –means balance organ of Inner Ear & Ocular- means Related to eye)

When some object is moving towards one side, the eyes must also move along with it to keep it in focus, this stable gaze and visual focus (to stabilize the image of the surroundings in the retina) during active and passive head movement is maintained by Vestibulo-Ocular reflex.

When one side vestibular labyrinth is damaged this system does not work. So person will not be able to keep the image of the moving object in the visual focus (on retina) and this retinal slips cause vertigo.

Eye movements are controlled by extra ocular muscle activity, under the control of an image stabilization. Adaptation exercises are basically retraining of the extra ocular muscles to stabilize the gaze while focusing on a stationary object and follow a moving object by moving head.

Ia. Gaze stability and ocular control exercise

1.  Focusing with Head Turns  (Head Eye Coordination exercise))

This exercise helps in stabilizing the gaze with quick, short head movements.

  • Sit in a comfortable chair and hold a card with a 1 inch letter written on it at arms length in front of you.
  • While keeping eyes focused on the letter move your head from side to side approx. 30 degrees.   .
  • Increase speed of head movement with each progression.
  • As function improves, move the card opposite to the head movement while keeping the eyes focused on the letters.
  • Move the head to the left and the card to the right keeping the eyes focused on the letters.
  • Begins slowly and increase the speed as the test progresses. Progress from sitting to standing to a sharpened stance.
  • Post the card on the wall with a plain background and progress to posting on a wall with a busy patterned background.

2.   Horizontal and Diagonal Head Movements)-This exercise helps to keep the vision stable with head movements.

  • Sit in a comfortable chair with feet flat on the floor and hands on thighs.
  • Have a target situated to your right and to your left as well as in the center.
  • Quickly turn only your head and eyes to the right target pause for 2-3 seconds and then return to the middle target and pause for 2-3 seconds.
  • Repeat 15-20 times
  • Repeat the sequence to the left and center.

II. Compensation exercises Ocular motor exercises

In a normal person fullest utilization of all the 3 inputs for balance (Eyes, Inner Ear, Proprioception) is usually not required. But when one of these input systems is defective the brain uses remaining senses more effectively to compensate for the partial loss of function.

When the patient’s vestibular labyrinth is damaged, and to compensate for it we try to train the patient to use inputs from other component of balance system more effectively (eyes and the proprioceptors)

See components of Balance system

IIa Sensory substitution exercises—

To sensitize and enhance sensory proprioceptive inputs patient is advised to exercise and walk on uneven surfaces.
IIb Visual inputs pursuit gain-

  • While seated on a chair holds a card with lettering at arm’s length
  • Move the card left and right across the visual field, tracking with eye movement and keeping the head still.
  • Repeat the full cycle 20-30 times.
  • Perform the procedure in the vertical and diagonal directions with increasing speed but being certain to keep the letters in focus.
  • Progress from sitting to standing

IIc Saccade latency, velocity, and accuracy B. Visual-ocular control exercise

  • Hold a card with lettering in each hand approximately 15 inches apart at arm’s length.
  • Keep the head still and move the eyes back and forth from card to card with 1 second per card.
  • Repeat 20-30 times for the complete cycle
  • This test also can be performed in the vertical and diagonal planes. Progress from sitting to standing

III. Habituation exercises

Repeated head Movements to stimulate balancing system and exposing the patient to small periods of tolerable vertigo causes body to get accustomed and thus threshold of vertigo increases.

IIIa Balance exercises

1 Touching front wall

  • Stand with the feet together and Maintain balance by touching the wall in front
  • Take the hands off the wall for progressively longer periods. First begin by taking 1 hand off the wall and alternate hands.
  • Stand with the feet shoulder-width apart looking at a target on the wall.
  • Perform   first with arms outstretched, then close to the body, and then folded across the chest.

Reach up as though for an object over the head and then bends over as though picking up an object from the floor.

The patient can then progress from sitting to standing to a sharpened stance. Exercises are performed in dim lighting and then with eyes closed. The difficulty level is raised by standing on foam or a pillow and then standing to one leg.

2.Ankle sways

Stand approx. 4 inches in front of the kitchen counter.

  • Stand approx 4 inches in front of the wall or kitchen counter with your feet shoulder width apart with equal weight on both feet and your arms relaxed at your side. Look straight ahead at a focal point.
  • Slowly shift your weight forwards attempting to touch the counter with the front of your thighs as well as your shoulders coming forward.  Return to midline position and repeat. All movement should be at ankles without bending at hips.
  • Repeat 10 times, then perform with eyes closed.

3. Circle with a ball

Focus eyes on the ball and move it in a circular fashion in both directions with increasing speed. The head and body moves with the ball. Raise the difficulty level from sitting to standing to a narrowed stance.

4. Ball Diagonals

  • Stand with your feet positioned shoulder width apart.   Grip the ground with your toes.  Hold a large ball or pillow with both hands and arms straight.
  • Keeping your arms straight, move the ball in a diagonal pattern starting by your left knee and moving toward the right upper diagonal.  Continue to keep eyes and head following the object as you return to the left lower diagonal.   Hold the position until motion sensitivity is eliminated.
  • Perform the activity 10 times and then repeat on the other diagonal pattern.

IIIb Gait exercises

1. Walking exercise —

a. Start walking next to a wall with the hand out for support. Then gradually increase the number of steps without support.

Difficulty is raised by narrowing the stance and by walking heel to toe.

b. Waling with head in motion-

Walk with the head in motion going left and right with increasing speed. The stance is narrowed and the patient can also move the head in the vertical plane.

c. Walking with Head turns

  • Begin walking at regular speed, with eyes focused on a target straight ahead,
  • After 3 steps turn head and eyes to the right 45 degrees, keeping eyes on a new target, (at eye level) while still walking straight ahead.  Do this for 3 steps, then turn eyes and head back to the center finding a target.
  • After three steps, turn your head and eyes to the left while walking straight ahead finding another target.
  • After three more steps, turn your head back to the center while walking straight ahead.
  • To increase the difficulty of this task, go from a solid floor to a carpeted floor, or walk outdoors on an uneven surface. Thick lawns usually are the most difficult surface.

2.  Sit to stand

  • The patient walks from one chair to another chair positioned 10 feet away.
  • Upon reaching the first chair, the patient sits without using the hands, waits for 5 seconds, and rises without using the hands.
  • The patient goes to the second chair, touches it, and, with support, practices standing on 1 leg for 5 seconds.
  • The entire cycle is repeated 10 times.
  • The patient can add head movements as the exercise progresses, increase walking speeds, and decrease the width of gait.

3.  Gait with a Focal Point–

  • Have a focal point approximately 20 feet in front of you at eye level.
  • As you begin walking keep eyes focused on target in front of you.
  • Periodically briefly look down toward the floor (approx. 5 ft. in front of you) to check for obstacles and then return eyes to the target.

Combined category exercises(At a grocery store or mall)

Crowd can play a factor in the rehabilitation. Initially  patient can go at a time of day when few people are shopping and then progress to a crowded time of the day. The patient should make an effort to look at items that are on the top and bottom shelves.

The patient can also walk at the mall by beginning with slow walks close to the wall and by going with the flow of the crowd. Then the patient can increase speed, move away from the walls, and go against traffic. Window shopping with purposeful head movements is helpful.

Patient can bend over, picking up objects, throwing and catching objects, bouncing them off walls, and walking on differing compliance surfaces.

Patient can also practice at the grocery store by pushing a cart. First the patient pushes with minimal support and then no support from the cart.  Patient can begin with slow, small head movements, increasing speed and degrees of motion.


Vestibular compensation takes place from repeated exposure to sensory conflicts produced by movements of eyes, head and trunk and active Central Nervous System.

One thing should be extremely clear that no medicine and no surgery can regenerate the damaged sensory epithelium in the vestibular labyrinths. Nature’s mechanism to compensate the balance system should be enhanced by Vestibular Rehabilitation Therapy and anything which will jeopardize should be avoided like prescribing CNS sedatives to give symptomatic relief to the patient.

Home Care for Benign Paroxysmal Positional Vertigo

You can read my older post about Benign Paroxysmal Positional Vertigo (B.P.P.V.)

Important–If diagnosis of BPPV is established Epley maneuver is first line of treatment.


Benign Paroxysmal Positional Vertigo and other non specific peripheral vestibular disorders where etiology is unknown can be managed by following protocol

  • Reassurance (Wait and watch) with home care
  • Vestibular Rehabilitation Exercises (physical therapy)
  • Medicines (pharmacotherapy)
  • Surgery

Reassurance and Home care Benign Paroxysmal Positional Vertigo

Peron with acute vertigo is anxious and afraid of stroke or tumor.  Most of the patients develop emotional reaction to vertigo which may result in aggravation of the symptoms. These patients need strong reassurance.

As BPPV is not intrinsically life threatening and symptoms usually reduce in a week’s time and disappear in about 4-6 weeks thus patient should be explained about the benign and self limiting nature of the disorder.

Nature has marvelous capacity for compensation of imbalance which can be accelerated by certain exercises.

Self Home care while waiting for nature’s compensation of imbalance

  • Take proper bed rest
  • Avoid sudden jerky head movements and body position changes.
  • Avoid sleeping on the “bad” side.
  • Get up slowly and sit on the bed for a minute before getting out of the bed.
  • Avoid bending down and extending the head
  • Avoid driving, working at heights or with machinery during acute attack of vertigo.
  • Cawthorne Cooksey exercises (see details below)
  • Positional exercises of Brandt and Daroff (see details below)
  • Home Epley Maneuver (See detail below)

Cawthorne Cooksey exercises

Positional exercises of Brandt and Daroff

    1. Sit on the edge of the bed near the middle, with legs hanging down. (position 1)
    2. Turn head 45° to right side.
    3. Quickly lie down on left side, with head still turned (angled upwards), and touch the bed with portion of the head behind the ear. (Position 2)
    4. Maintain this position and every subsequent position for about 30 seconds or till the dizziness disappears.
    5. Sit up again. (Position 3) stay for 30 seconds
    6. Quickly lie down to right side after turning head 45° toward the left side. (Position 4)
    7. Sit up again.
    8. Do 6-10 repetitions, 3 times per day for 2 weeks

The Brandt-Daroff Exercises are a home method of treating BPPV, usually used when the side of BPPV is unclear. They succeed in 95% of cases but may take longer than the other maneuvers. In approximately 30 percent of patients, BPPV will recur within one year.

Caution–When performing the Brandt-Daroff maneuver, person should immediately visit his physician if he feels weakness, numbness or visual changes.


The Epley and/or Semont maneuvers as described in my previous post can be done at home every night for a week.

The method (for the left side) is performed as shown on the figure. One stays in each of the lying down positions for 30 seconds, and in the sitting upright position (top) for 1 minute. Thus, once cycle takes 2 1/2 minutes. Typically 3 cycles are performed.

Caution Before doing home Epley maneuver diagnosis of BPPV should be confirmed, and one should know the affected or “bad” side. It is safer to have the first Epley performed in a doctor’s clinic which can be followed at home.

Spinning world: Benign Paroxysmal Positional Vertigo

Dizziness, a common cause of referral to otolaryngology clinic, includes a broad range of sensations from severe vertigo to momentary light-headedness , and Vertigo most common of dizziness  is an illusion of movement of the body or environment.

Vertigo may be because of otologic, neurologic, or systemic reasons.

Causes of Otologic dizziness

  • Benign paroxysmal positional vertigo) – about 50% of otologic, 20% all
  • Meniere’s disease – about 20%
  • Vestibular neuritis and related conditions (15%)
  • Bilateral vestibular loss (about 1%)
  • SCD and Fistula (rare)

What is Benign Paroxysmal Positional Vertigo?

Benign paroxysmal positional vertigo (BPPV) is the most common underlying cause of vertigo accounting for about 20% of all dizziness and 50% of otologic dizziness.

Benign paroxysmal positional vertigo is defined as a disorder of the inner ear characterized by repeated episodes of positional vertigo.

Positional vertigo means a spinning sensation produced by changes in head position relative to gravity.
Benign means not due to any serious brain or CNS (Central Nervous System)disorder  and the overall prognosis for recovery is favorable. (However, undiagnosed and untreated BPPV may have health, and quality-of-life impacts).
Paroxysmal—  means Rapid and sudden onset of the vertigo

Symptoms of BPPV-

Dizziness, Imbalance, Nausea, light-headedness

That is

  • Brief and strong
  • Provoked by change of head position
  • Definitively diagnosed by Hallpike test
  • Many patients wake up with the condition, noticing the vertigo while trying to sit up suddenly.
  • People do not usually feel dizzy all the time. Dizziness attacks triggered by head movements (classically with lying down or rolling over in bed) and between episodes patients usually have few or no symptoms.
  • Classic BPPV is usually triggered by the sudden action of moving from the erect position to the supine position while angling the head 45° toward the side of the affected ear.

The pathophysiology of BPPV –

Normal Ear Anatomy

The labyrinth of the inner ear is composed of the vestibule (utricle and saccule) and the 3 semicircular canals. These are filled with fluid called endolymph and have receptors to inform the brain about the head’s position in space.

Inner Ear

Utricle contains small calcium oxalate crystals called otoliths or otoconia for gravity and position receptors for linear acceleration.

Similarly, angular acceleration receptors are located in the cupula of the semicircular canals. When head turns, these receptors inform the brain via vestibular nerve that the head is turning. Once the head stops turning, the endolymph stops moving, the receptors stop firing, and the brain now knows that the head has stopped turning.

Inner ear semicircular canals-BPPV

In BPPV, the otoliths become dislodged from normal position and accumulate in wrong place in one of the semicircular canals (most commonly in the posterior semicircular canal since it is at the most dependent position)

When the patient turns his head, otoliths move, and trigger faulty signals even after head stops moving. The eyes, however, inform the brain that the head has stopped moving. Brain Receives conflicting information causing brief but intense sense of spinning.

Diagnosis of BPPV—

Comprehensive History is most important aspect. Patient describes his complaints in his own words and a specific set of leading questions specially onset of symptoms, duration, associated eye,  ear and neurologic systems, history of any ear/head trauma, medical disease or medication  are asked by health care provider. While talking to patient usually a diagnosis is established.

Basic ENT and Ear examination is done for concomitant ear problem.

Neurological examination to rule out any CNS lesion is carried out.

Neurotologic examination Evaluation of static disturbances (with head still) and dynamic disturbances (with head motion)

Dix-Hallpike maneuver– Standard clinical test for BPPV

This test is performed by rapidly moving the patient from a sitting position to the supine position with the head turned 45° to the right. After waiting approximately 20-30 seconds, the patient is returned to the sitting position. If no nystagmus is observed, the procedure is then repeated on the left side.

The finding of classic rotatory nystagmus with latency and limited duration is considered pathognomonic. A negative test result is meaningless.

Classic BPPV is the most common variety of BPPV. It involves the posterior Semi Circular Canals.

Diagnostic criteria for posterior canal BPPV
  • History – Patient reports repeated episodes of vertigo with changes in head position.
  • Physical examination each of the following criteria are fulfilled:–
  • Vertigo associated with nystagmus is provoked by the Dix-Hallpike test. There is a latency period between the completion of the Dix-Hallpike test and the onset of vertigo and Nystagmus, Geotropic (means towards earth-refer to upper half of the eyes nystagmus with the problem ear down
  • The provoked vertigo and nystagmus increase and then resolve within a time period of 60 seconds from onset of nystagmus.
  • Reversal upon return to upright position
  • Response decline upon repetitive provocation
Nystagmus is involuntary eye movements (usually triggered by inner ear stimulation) named by the direction of the fast phase. Thus, nystagmus may be horizontal (right beating, left beating, up-beating), vertical (down-beating), or rotational (geotropic-towards earth and ageotropic).

Workup for BPPV

Laboratory Studies

  • Laboratory tests are not needed to make the diagnosis of benign paroxysmal positional vertigo (BPPV).
  • Tests may be advised for other associated inner ear pathology.
  • Blood sugar and routine complete blood count may be done to rule out hypoglycemia and anemia.
  • Electrolyte level may be done if patient had severe episodes of vomiting

Imaging Studies

Imaging studies (CT scan and MRI) are not routinely required for patient with BPPV. In cases of doubt it may be advised.

Other tests

  • Audiogram – simple test which may be done for concomitant ear pathology
  • Caloric test
  • Electronystagmography (ENG)
  • Posturography

Differential diagnoses for benign paroxysmal positional vertigo (BPPV)

  • Ménière disease
  • Inner ear concussion
  • Alcohol intoxication
  • Vestibular labyrinthitis
  • Vascular loop syndrome
  • Lesion of the nodulus from stroke, multiple sclerosis, Arnold-Chiari malformation, ischemia, cerebellar degeneration, and intoxication.
  • Posterior fossa lesion such as acoustic neuroma or meningioma.
  • Vertebral artery insufficiency
  • Cervical vertigo, or head extension vertigo,
  • Orthostatic hypotension,
  • Medication side effects
  • Anxiety or panic disorder
  • Migraine related vertigo
  • Management of BPPV

    Epley Maneuver— Initial and most important management strategy is Canalith repositioning maneuver or CRP or Epley maneuver. ( for details read previous post Canalith repositioning maneuver for BPPV)

    Vestibular Rehabilitation Exercises Vestibular rehabilitation is an exercise program to help compensate for a loss or imbalance within the vestibular system either self-administered or with a clinician.

    Cawthrone cooksey exercises and Brand  Daroff exercises for BPPV are beneficial for hastening of restoration of normal balance.

    Observation – wait and watch with reassurance and follow-up visits as symptoms resolve in 1-2 month time.

    Medical TherapyVestibular suppressant medications can be used but many times not effective and masks the problem.. Adverse effects of grogginess and sleepiness ca occur.

    Health Education – Patients are counseled regarding the impact of BPPV on their safety, the potential for disease recurrence, and the importance of follow-up.

    Surgical Care

    Surgery is reserved for those in whom CRP fails. There is possibility of complications such as hearing loss and facial nerve damage.

    The most viable surgical option is posterior canal occlusion. The aim is to stop the benign positional vertigo by collapsing the posterior canal, immobilizing the movement of particles through the canal.

    Benign Paroxysmal positional vertigo usually is not due to any serious neurological disorder and the overall prognosis for recovery is favorable; however, undiagnosed and untreated BPPV may have safety concerns and quality-of-life impacts.

    Proper Diagnosis and treatment of patients with BPPV may lead to significant health care quality improvements thus it is very important to implement a well-constructed clinical practice guidelines.

    Canalith Repositioning Procedure for Vertigo: Active treatment of BPPV

    Update — in my other posts read more about Benign Paroxysmal Positional Vertigo

    and Home care of vertigo

    Benign paroxysmal positional vertigo (BPPV) is one of the most common causes of dizziness, most often experienced when patients lies down.

    Because BPPV is not intrinsically life threatening and symptoms are usually self limiting patient is usually kept under watchful wait but as BPPV can last for much longer than 2 months, it is better to treat it actively by Epley maneuvers or Semont Maneuver. The Semont and Epley maneuvers may improve or cure benign paroxysmal positional vertigo (BPPV) with only one procedure however some people may need multiple sittings.

    CRP / Epley maneuver/  Canalith repositioning procedure

    The Canalith Repositioning Procedure (CRP) or epley’s maneuver is a rehabilitation treatment for Benign positional vertigo.  CRP is very effective, with an approximate cure rate of 80%. The recurrence rate for BPPV after these maneuvers is low. However, in some instances additional treatment may be necessary.

    Canalith/otolith/or otoconia are small crystals of calcium carbonate attached to the otolithic membrane in the utricle of the inner ear. Because of trauma, infection, or aging, canaliths can detach from the utricle and collect within the semicircular canals. Here these canaliths shift with the head movement  and stimulate sensitive nerve endings to cause dizziness.

    Epley’s maneuvers involve a series of specifically patterned head and trunk movements performed by a trained professional. This head position change, moves the canaliths from the problematic location in one of the semicircular canal to the utricle.

    Procedure: The procedure takes approximately 20-30 minutes.

    You will be placed on a table and then laid back with your head hanging over the end of the table.
    If you have a “positive” response in this position you will then be moved through the procedure.

    A. Patient is placed in sitting position on the edge of the examination table (Position A).

    B. Head is rotated 45° towards the affected ear, and the patient is swiftly placed in lying position with the head hanging 30° below the horizontal over the table edge (Position B). Positive response (primary stage nystagmus) is observed position is maintained for 1-2 minutes.

    C. The head is rotated 90° towards the opposite ear while maintaining the head hanging position. (Position C)

    D. Patient is turned further 90° towards the unaffected side to face the floor. (Position D)

    The patient’s eyes are observed for secondary-stage nystagmus, it should be in the same direction as the primary-stage nystagmus.

    E. Position is maintained for 30 to 60 seconds, and then again laced in sitting position (Position E). Upon sitting, there should be no vertigo or nystagmus in a successful maneuver.

    Instructions Following the Canalith Repositioning Procedure

    Wait for 10 minutes after the maneuver is performed before going home. Don’t drive yourself home.

    For first 48 hours

    1. Do not tip your head up or down or bend at the waist. Use of the cervical collar will help prevent you from tipping your chin down.
    2. Do not visit the places that require you to lie down or tilt your head (hairdresser, dentist, chiropractor or barber).
    3. Avoid tipping your head up or down when brushing teeth, shaving or washing your hair.
    4. Sit down and get up from chairs while keeping your back straight, without bending forward and avoid tilting your head forward.
    5. Housework such as cooking or cleaning should be avoided for the next 48 hours.
    • Do Not Lie Flat in Bed:

    Sleep semi-recumbent for the next night. This means sleep with your head halfway between being flat and upright (a 45 degree angle) by using a recliner chair or by using pillows arranged on a couch

    The Following Week:

    • Do Not Sleep on your treated side
    • Use two pillows when you sleep.
    • Avoid sleeping on the “bad” side.
    • Don’t turn your head far up or far down

    (Like head extended positions at the beauty parlor, dentist’s office, and while undergoing minor surgery).

    • No “sit-ups” for at least one week and no “crawl” swimming.

    After 1 week you can resume your daily activities without any restrictions. Move around as you wish.


    Contraindications to perform Epley Maneuver

    • Unstable heart disease
    • High grade carotid stenosis,
    • CNS disease (stroke or Transient Ischemic Attack),
    • Physical limitation– neck disease (rheumatoid arthritis, cervical radiculopathies, ankylosing spondylitis, cervical spine fracture or surgery)
    • Pregnant women beyond the 24th week of pregnancy

    Semont Maneuver

    The Semont maneuver (liberatory” maneuver) involves a procedure whereby the patient is quickly moved from lying on one side to lying on the other side.

    © Liberatory manoeuvre of Semont (right ear)Parnes LS, Agrawal SK, Atlas J. Diagnosis and management of benign paroxysmal positional vertigo (BPPV). CMAJ. 2003:169:681-693.

    Position 1. Patient is made to sit on the examination table with legs hanging over the edge and head turned 45 degrees horizontally towards the unaffected ear.

    Position 2. While maintaining head rotation patient’s upper body is swiftly moved to side lying position on the affected side with head resting on examination table and nose pointed upwards. Position is maintained for 3 minutes or till vertigo and nystagmus subsides. This step moves the debris to the apex.

    Position 3. Patient is rapidly moved through the sitting position (Position 1) to lying on the opposite or unaffected side (maintaining same head rotation) with nose pointed to the ground. Position is again maintained for 3 minutes or till the vertigo and nystagmus subsides. This maneuver moves the debris towards exit of the canal.

    Idea is to move the debris into the utricle where it will no longer cause vertigo.

    Semont maneuver is 90% effective after 4 treatment sessions

    Update — Next post–Read more about BPPV (Spinning world–Benign Paroxysmal Positional Vertigo)

    and Home care of Vertigo