Tag Archives: balance disorder

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 http://www.flickr.com/photos/ezu/59974538/


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-http://www.flickr.com/photos/irinaslutsky/4444402930/ (http://creativecommons.org/licenses/by/2.0/deed.en )

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.

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.