Vertigo is more than than simple dizziness and it can be scary—but it can be treated
By Wendy Haaf
Joyce Pinsker was cleaning her refrigerator when she suddenly felt a spinning sensation that forced her to drop to the floor. Within a minute or so, however, the feeling had passed, so the Vancouver resident, then in her early 50s, wasn’t too concerned. But as she was about to get into bed one night soon after, she was hit with the sensation of falling off a precipice, the room seemingly spinning around her. Pinsker was certain then that something was terribly wrong.
The sensation of movement Pinsker, now 68, describes is called “vertigo.” While vertigo is sometimes confused with dizziness, unsteadiness, imbalance, lightheadedness, and giddiness, in fact, “the term usually refers to a hallucination of movement, either of oneself or one’s environment,” explains Dr. John Rutka, a professor in the Department of Otolaryngology–Head & Neck Surgery at the University of Toronto (U of T), a staff neuro-otologist with the Toronto University Health Network, and co-director of the University Health Network’s Hertz Multidisciplinary Neurotology Clinic in Toronto.
Spinning isn’t the only possible manifestation of vertigo. “It can occur in other forms,” Rutka says, such as a rocking or swaying sen sation similar to feeling that you’re standing on a pier or being pushed or pulled, the impression of plunging or falling through a trap door, or even a sense that your feet are floating above the floor, as if walking on clouds.
Such powerful and unpleasant bodily sensations that conflict with what’s happening in the world around us can be extremely distressing, even terrifying. In fact, vertigo can lead to anxiety. But such severe symptoms are often wildly out of proportion to the seriousness of the cause (unless they’re accompanied by strokelike symptoms, such as drooping on one side of the face—in that case, you should seek immediate medical attention). Recurrent bouts of dizziness or imbalance definitely merit a discussion with your physician to review your medications, prescription and otherwise, and rule out conditions such as high blood pressure and heart problems, but vertigo typically originates from a disturbance in the vestibular system, which provides the brain with information we need to detect movement, sense our position relative to other objects in our threedimensional world, and maintain balance.
While vertigo can be disabling, “a lot of the most common vestibular conditions are benign, so they’re not worrisome from a medical standpoint,” explains Ronald Fletcher, a certified vestibular therapist and an assistant professor at the University of British Columbia’s Department of Physical Therapy who also serves on the BC Balance and Dizziness Disorders Society board of directors. What’s more, appropriate treatment can often either eliminate symptoms or greatly reduce their effect on quality of life.
Of course, treatment hinges on a proper diagnosis, which, in most cases, begins with a family doctor’s referral to a specialist. The specialist normally begins the initial evaluation by recording a patient’s medical history, including such details as what the illusory movements feel like; the activities and movements that trigger, worsen, or improve symptoms; the duration of each episode; any associated symptoms (such as fluctuating hearing and a ringing, pressure, or feeling of fullness in the ears); and whether there’ve been any recent falls or vehicle collisions.
The next step in the assessment often involves tests to determine if certain body positions bring on symptoms; these positional tests may be carried out while you’re wearing a pair of infrared video goggles that capture and record eye movement. “We get patients to move their eyes around, and then we’ll get them moving their head around; then we lie them down on a bed, roll the bed around, and drop it down with a bit of velocity,” Fletcher explains. “These tests are designed to stimulate the vestibular system.”
Audiologists and otolaryngologists (ear, nose, and throat specialists) can do more advanced testing. Since the sensors for balance and hearing are nextdoor neighbours that share nerves and blood vessels, “vestibular audiologists can trouble shoot” both, says Erica Zaia, a registered audiologist certified in vestibular assessment and management, and the founder and director of AudioVestibular Clinic in Vancouver. Eye movement patterns and an idea of what a patient experiences during these tests can help form a diagnosis.
Benign Paroxysmal Positional Vertigo (BPPV)
“In the over 65 age group, by far the most common cause of vertigo is benign positional vertigo,” says Shaleen Sulway, a vestibular rehabilitation physiotherapist and co-director of Vestibular Health in Toronto, and a consultant with the U of T’s Hertz Multidisciplinary Neurotology Program. Younger people can develop the condition, she adds, but it becomes much more common with age.
As the condition’s name implies, position relative to gravity plays a role in the vertigo. “Some of the tiny calcium crystals that are normally found in the inner ear are dislodged,” Fletcher explains. “Once these particles, called ‘otoliths’ or ‘canaliths,’ become unstuck, they can drift into one of three fluidfilled tubes called the semicircular canals.” Since these structures work together as a sort of gyroscope, an imbalance in the position of the otoliths in one ear compared with the other causes dysfunction.
Common triggers include lying down, rolling over in bed, tilting the head upwards (such as when reaching to grab an item off a high shelf), lying with your neck bent (as you might in a dentist’s chair or during a wash at a hair salon), and bending down.
There are two other hallmark features of BPPV. “Typically people will say they have a spinning or vertical sensation and that it usually lasts less than 60 seconds”—although it may subjectively feel much longer—Sulway says.
After Joyce Pinsker’s initial bouts of vertigo, her doctor diagnosed her with BPPV because certain head movements provoked a recurrence of her symptoms.
Fortunately, relatively simple treatments are effective for the over whelming majority of people with BPPV. Doctors instruct patients to follow a series of specific movements that work the calcium particles back into their proper position. (The precise manoeuvres vary depending on the semicircular canal to which the particles have migrated.) “Recall those handheld games we had when we were little, with a ball in a maze,” Zaia says. “There’s a certain way that you tilt the maze that makes the ball roll back into place.”
According to Fletcher, BPPV is “a very rewarding thing to treat, because it can be quite disabling and concerning for patients. Luckily we have a slightly greater than 90 per cent success rate with a repositioning manoeuvre. The sad thing is that some people live with this for years before it’s recognized and treated.”
Pinsker’s doctor sent her to a vestibular physiotherapist for repositioning treatment. “It’s amazing that someone can put your head through these series of movements, and suddenly the problem is gone,” she says.
The manoeuvres may cause brief bouts of severe nausea and an off feeling that lasts a few days. While BPPV can recur periodically—as it has for Pinsker—knowing the cause can go a long way towards easing any anxiety. “The first time I experienced these symptoms was very scary,” she says. “I wish I had known that it could happen.”
Vertigo can also occur during a particular type of migraine—in which case, it’s often accompanied by other migrainerelated symptoms, such as temporary sensitivity to light (interestingly, headache isn’t always among these symptoms).
“Vestibular migraine can particularly affect women in the 50 to 55 age range, because it can be exacerbated during menopause,” Zaia says. Because vertigo is common to vestibular migraine (for which it can be spontaneous) and BPPV (for which it can result from particular movements), the conditions can sometimes be confused and “people can be misdiagnosed,” Fletcher says. Vestibular migraine also seems to predispose people to other balance disorders, including BPPV, he adds.
Treatment of vestibular migraine, which ideally should be done in consultation with a neurologist or otolaryngologist with an interest in the area, is multipronged and includes identifying and avoiding triggers, taking medication, and practising relaxation exercises. “The point is to calm the migraine activity in the brain,” Zaia explains.
Labyrinthitis and Vestibular Neuritis
“There are infections that can occur in the ear, often on one side,” Zaia says; these can then cause a nerve in the ear to become inflamed, thereby disrupting the balance system.
“Labyrinthitis, which is often thought to be bacterial, affects hearing and balance at the same time,” she says, while “vestibular neuritis, which is thought to be the viral counterpart, often affects only balance.” The result of either of the two is what Zaia describes as attacks of “prolonged spinning, dizziness, uncontrollable vomiting, and an inability to stand up—usually for days and improving over the course of weeks.” As the infection and inflammation resolve, symptoms dissipate. (Nerve inflammation caused by the balance organs bouncing against surrounding bone—for example, during a fall—can cause similar symptoms, a condition called vestibular concussion.)
However, some people still find that certain movements bring on a bit of dizziness and disorientation, “and then often people stop moving because they don’t like that feeling,” Fletcher says. If someone is otherwise healthy, exercises that help the brain adjust or compensate can often banish symptoms.
People with impaired vision or compromised nerve function affecting a sense known as “proprioception” may have more difficulty adapting. (Proprioception allows you to sense your body’s position and movement, in part from feedback from sensors in muscles and joints.) In such cases, “we focus on training the other two senses that help with balance,” Sulway says, “by doing exercises on different surfaces, and with the eyes closed.” And if some one has good hearing, “we can train them to use sound as a means of orienting their bodies for better balance,” she adds.
Persistent Postural-Perceptual Dizziness (PPPD, pronounced three PD)
Rather than featuring vertigo as a symptom, this condition, known historically as chronic subjective dizziness, can develop in the wake of a vestibular disorder. Indeed, having had a bout of vertigo increases one’s risk for PPPD. “It’s more persistent dizziness or unsteadiness—people just don’t feel quite right; they’re disoriented,” Fletcher explains.
Joyce Pinsker is one vertigo patient who later developed PPPD, but oddly, without dizziness. Two stops into a trip on rapid transit, she says, “I suddenly felt like I was floating three inches off the ground. It was terrifying. I thought I was going insane.”
Attacks of PPPD, Fletcher says, “last for a good chunk of the day, and it’s often worse when people are up and moving around.” Frequently, those with the condition “struggle with visual or motion triggers,” he adds. Examples include travelling through busy, complex environments (as when walking along a grocery-store aisle), sitting in a car when there’s passing traffic, and cycling alongside a fence.
Since such stimuli might set off flares lasting days, people with PPPD commonly develop anxiety about doing anything they think might ignite symptoms; as a result, they start avoiding activity and begin moving in an overly careful, unnatural manner. However, these responses make matters worse. “You’ve changed your body mechanics and you change the way your brain processes moving from A to B,” Zaia explains. “This can send you on a downward spiral.”
However, it’s possible to retrain your balance system and brain, as well as to relearn how to move more naturally, with the help of a vestibular physiotherapist. Therapy can include exercises that briefly bring on symptoms and gradually build up one’s ability to tolerate movement, often in conjunction with measures for damping down the associated anxiety—such as cognitive behavioural therapy and meditation, and even medication.
Fortunately for Pinsker, her doctor fast-tracked her for a vestibular assessment. When the vestibular neurophysiologist confirmed that one of the gravity-sensing organs in Pinsker’s ears wasn’t working normally, he recommended a therapist specializing in vestibular rehabilitation.
Pinsker’s road to recovery took the better part of a year and a great deal of persistence on her part. At first, even the thought of an exercise such as standing on a very soft surface nearly brought on a panic attack. “Things had to be very solid, because I couldn’t connect my brain with my eyes, my inner ear, and my sense of touch,” she explains.
However, with a combination of graduated exercises, medication, and advice from a counsellor on how to concentrate on a single task and break it down into bite-sized steps, Pinsker eventually got her life back. And while the process was exhausting (for months, simply staying up right consumed most of her mental and physical energy), she feels very fortunate. “It was a bit of good luck that I got treatment fairly early, so my symptoms didn’t become entrenched; I also had people who explained what was wrong in ways that I could understand,” she says.
But none of that could have happened had Pinsker’s doctor not taken her symptoms seriously to begin with. Older people in particular, she says, may be told that their dizziness is due to aging or that they simply have to get used to it.
“People have to be persistent and proactive,” Pinsker says. “It’s not necessarily that they’ll be cured, but they can at least learn ways of man aging their symptoms, improving their lives, and staying positive.”