Vertigo Treatment

What is Vertigo?

Vertigo is a medical condition characterized by dizziness and the feeling that the room is spinning around you.  Symptoms are usually associated with instability and nausea or vomiting.  Other conditions can produce symptoms of vertigo, such as dehydration, infections, and certain medications.

Most cases of vertigo are caused by benign conditions that are self-limited.  Occasionally, vertigo can be a manifestation of a serious condition such as stroke.  Due to the importance of this condition, it is critical that patients understand its causes, symptoms, and treatment.  By the end of this article, you will have the answers to these essential questions:

What causes Vertigo?

Vertigo is caused by disruption of the semicircular canals in the middle ear.  Our ear is anatomically broken down into the outer ear, middle ear, and inner ear.  The outer ear is the ear canal with transmits sound to the ear drum (tympanic membrane).  This sound is then transmitted to the middle ear, which contains bones (ossicles) that further transmit the sound waves in to the inner ear.  The middle ear is connected to the nose and mouth via a structure called the eustachian tube.

The inner ear contains labyrinthine structures called semicircular canals.  The canals play an important role in balance and stability.  Sometimes these canals can become inflamed due to viral infection (labyrinthitis).  This can cause symptoms of dizziness and vertigo, but is also usually associated with cold-like symptoms such as low grade fever, runny nose, nasal congestion, sneezing, sore throat, and cough.

Another common cause of vertigo is called benign paroxysmal positional vertigo (BPPV).  This is called the movement of crystals in the semicircular canals in the inner ear.  Patients usually experience dizziness after rotating their head to the side, often first thing in the morning.  Symptoms tend to last for seconds.

Other causes of dizziness that can be confused with vertigo include:

  • Stroke
  • Orthostatic hypotension
  • Hypoglycemia
  • Cardia arrhythmia
  • Heart attack
  • Aortic stenosis – narrowed aortic valve
  • Vasovagal syncope
  • Seizure

How common is Vertigo?

Vertigo is a common condition that is frequently evaluated in the primary care clinic.  Advanced cases that are not responsive to first-line measures or therapy often require neuroimaging and referral to either a neurologist or otolaryngologist.

Studies show that the 1-year prevalence of vertigo is approximately 4.9%.  The prevalence of benign paroxysmal positional vertigo is specifically 1.6%.  Other sources report a 5%-10% overall incidence of dizziness, vertigo, and imbalance.  In patients age >40, this incidence increases to about 40%.

What are the symptoms and signs of Vertigo?

The most common symptoms of vertigo include:

  • Dizziness – like the room is spinning
  • Instability
  • Trouble balancing
  • Nausea or vomiting

 Symptoms of benign paroxysmal position vertigo often last for weeks - they also tend to recur.

Your doctor will often evaluate for certain findings on your physical examination such as:

  • Blood pressure & heart rate laying down, sitting, then standing (orthostatic vital signs)
  • Heart sounds, heart rhythm & rate
  • Carotid bruits – narrowed arterial plaques in the neck (carotid artery)
  • Detailed neurologic assessment – pupillary reflexes, facial expression, muscle strength, sensation, balance, cerebellar function
  • Nystagmus – repetitive eye movements

They may perform the Dix-Hallpike test in which they instruct you to go from sitting to lying down as you simultaneously turn the head – they are evaluating for eye nystagmus and symptoms of vertigo.  If this test is positive, it suggests benign paroxysmal positional vertigo.

How is Vertigo diagnosed?

Vertigo is diagnosed based on symptoms and physical examination.  Certain laboratory tests may be ordered to rule out other conditions.

Your doctor will likely order blood tests such as a CMP (comprehensive metabolic panel), CBC (complete blood cell count), thyroid function (TSH, free T4), and coagulation studies (PT/INR, PTT).  They will also check your cholesterol levels and screen for diabetes.

Another important test is an EKG (electrocardiogram)

If they are concerned that your symptoms may be caused by cardiovascular disease, they will often obtain an ultrasound of the neck, and ultrasound of the heart (echocardiogram).

An MRI and MRA of the head and neck is also frequently obtained in patients with cardiovascular risk factors.

How is Vertigo treated?

The treatment of vertigo is based on the underlying cause.  Once dangerous causes of dizziness have been excluded – stroke, heart attack, seizure - and benign vertigo has been determined to be the origin of symptoms, patients may be trained on the Epley maneuver.  This maneuver helps reposition crystals in the inner ear that are responsible for causing symptoms of dizziness.  Patients may be sent home with Epley maneuver instructions.  Other parameters that are generally recommended for dizziness include:

  • Staying well hydrated – most people require 1.5-2L of fluids daily
  • Going from sitting to standing slowly
  • Driving carefully – you driver’s license may be suspended if you have seizure or are a danger to yourself or others on the road
  • Avoiding triggers – such as sudden head movement
  • Patients with vasovagal syncope may be trained to perform counterpressure maneuvers to prevent loss of consciousness

If you have orthostatic hypotension, your doctor may recommend decreasing the dose of you blood pressure medication or discontinuing it temporarily.

Medications are often prescribed to reduce the severity and duration of your vertigo and nausea.  This frequently includes:

  • Antivert (meclizine)
  • Serc (betahistine)
  • Scopolamine
  • Benadryl (diphenhydramine)

These medications work by blocking histamine receptors in the brain – these receptors play a role in dizziness and nausea.

Vertigo Patient Summary:

  • Vertigo is a very common condition characterized by dizziness and the room spinning around.
  • It is typically caused by stones in the inner ear, which cause disequilibrium and instability.
  • It may also be caused by viral infection (labrynthitis).
  • The most common symptoms include dizziness – like the room is spinning, instability, trouble balancing, nausea or vomiting.
  • Symptoms typically last for seconds and tend to reoccur – patients can have recurrent symptoms for several weeks.
  • Diagnosis usually requires a detailed history, physical examination, and special maneuvers.
  • Your doctor will likely obtain orthostatic vital signs and perform a detailed neurologic examination.
  • If they suspect heart disease they may order an EKG and echocardiogram – ultrasound of the heart.
  • The Dix-Hallpike maneuver is used to diagnose benign paroxysmal positional vertigo (BPPV).
  • Your doctor may recommend getting an MRI and MRA of the head and neck to rule out stroke or brain tumor.
  • Treatment typically consists of reversing known causes of dizziness - staying well hydrated if you have orthostatic hypotension, going slowly from sitting to standing positions, driving safely, and avoiding triggers.
  • Counter pressure techniques may be useful in patients with vasovagal syncope.
  • Your doctor may perform the Epley maneuver and provide you with instructions on how to perform the maneuver at home.
  • Medications are often prescribed to reduce the severity and duration of your vertigo and nausea.  This frequently includes: Antivert (meclizine), Serc (betahistine) Scopolamine, and Benadryl (diphenhydramine).
  • These medications work by blocking histamine receptors in the brain.

 

References:

  1. Muncie HL, Sirmans SM, James E. Dizziness: Approach to Evaluation and Management. Am Fam Physician. 2017 Feb 1;95(3):154-162.
  2. Bhattacharyya N, Baugh RF, Orvidas L. Clinical practice guideline: benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. 2008 Nov;139(5 Suppl 4):S47-81.

 

 

 

 

 

 

 

 

 

Popular Vertigo Medications

The above information is an educational aid only. It is not intended as medical advice for individual conditions or treatments. Talk to your doctor, nurse or pharmacist before following any medical regimen to see if it is safe and effective for you.