Vertigo: Causes, Symptoms and Treatment

Vertigo - the medical definition

In medical terms, vertigo is a specific kind of dizziness - a sense that you, or your environment, is moving or spinning, even though there is no movement.^1,2

Nor does vertigo, in the medical sense, mean a fear of heights. We all have a healthy respect for heights, but if this is to the extent of a phobia, it is termed acrophobia, not vertigo. (With acrophobia, people overestimate danger, become distressed, and avoid heights altogether.³)

Vertigo, then, is a specific symptom unrelated to heights that has various medical causes.

Specialist doctors in dizziness clinics have narrowed down the definition of vertigo, differentiating it from other types of dizziness and classifying it by its causes and its particular type of moving sensation - that you or your environment is moving or spinning.⁴

Vertigo is thereby set apart from presyncope, which is a sense of almost fainting (typically a result of temporarily lowered blood pressure). Disequilibrium is also something separate, seen in older people - an unsteadiness due to poor balance and strength.^4,5

Light-headedness, often associated with anxiety, is different too, sometimes called psychogenic vertigo.^4,5

Fast facts on vertigo

Here are some key points about vertigo. More detail and supporting information is in the main article.

• Vertigo is a sensation of spinning - a specific kind of dizziness.^1,2
• The dizziness that defines vertigo is caused by one of two causes - disturbance in either the balance organs of the inner ear, or parts of the brain or sensory nerve pathways.
• Peripheral vertigo is a term that collects together the inner ear causes.
• Central vertigo is a term that collects together the central nervous system.
• Vertigo is itself a symptom.
• Other symptoms can accompany vertigo: hearing loss, tinnitus, nausea, vomiting or a feeling of fullness in the ear.¹
• Physical examination might include looking into the ear, using a maneuver test or undergoing a MRI or CT scan.
• Doctors will also explore medication use, family history of migraines or Meniere's disease and recent ear infection or head injuries.
• Some types of vertigo can disappear without treatment.
• Other treatment options may include the Epley maneuver or symptomatic drug treatment.

What causes vertigo?

Vertigo is the spinning form of feeling dizzy.

The rotational dizziness that defines vertigo is brought on by one of two causes - disturbance in either:^2,4

• The balance organs of the inner ear, or
• Parts of the brain or sensory nerve pathways.

Inner ear disturbance

Peripheral vertigo is a term that collects together the inner ear causes.

The labyrinth of the inner ear has tiny organs that enable messages to be sent to the brain in response to gravity. By telling our brains when there is movement from the vertical position, we are able to keep our balance, maintain equilibrium.⁶

Disturbance to this system therefore produces vertigo and can be created by inflammation among other causes. Viral infection is behind the inflammation seen in the following two conditions:²

• Labyrinthitis - this is inflammation of the inner ear labyrinth and vestibular nerve (the nerve responsible for encoding the body's motion and position⁷)
• Vestibular neuronitis - this is thought to be due to inflammation of the vestibular nerve.

Ménière's disease can also be caused by inflammation, but this can be due to bacterial as well as viral infection.^2,8

This form of vertigo is thought to be caused by high pressure of a fluid in a compartment of the inner ear (a swelling that is also known as endolymphatic hydrops).

As well as infection, Meniere's disease can result from metabolic and immune disorders.

Most vertigo is a disturbance of the inner ear's role in balance perception.

Benign paroxysmal positional vertigo (BPPV) is thought to be caused by a disturbance in the otolith particles.²

These are the crystals of calcium carbonate within inner ear fluid that pull on sensory hair cells during movement and so stimulate the vestibular nerve to send positional information to the brain.⁶

With the BPPV disturbance, normal movement of the endolymph fluid continues after head movement has stopped.⁹

Benign paroxysmal positional vertigo is twice as common in women than men, usually affects older people and most often arises without a known cause (idiopathic). While most cases are spontaneous, BPPV vertigo can also follow:^2,9

• A head injury
• Reduced blood flow in a certain area of the brain (vertebrobasilar ischemia)
• An episode of labyrinthitis
• Ear surgery
• Prolonged bed rest.

Beyond peripheral vertigo brought on by benign paroxysmal positional vertigo, labyrinthitis, vestibular neuronitis or Meniere's disease, inner ear disturbance can also be caused by drug toxicity and syphilis.²

Rare causes are:¹⁰ perilymphatic fistula (tear in one or both of the membranes separating the middle and inner ear¹¹), cholesteatoma erosion (skin growth behind the eardrum¹²), Herpes zoster oticus (a viral infection of the ear, also known as Ramsay Hunt syndrome¹³), otosclerosis (a genetic ear bone problem that causes deafness¹⁴).

Brain or sensory nerve disturbance

Central vertigo is a term that collects together the central nervous system causes - involving a disturbance to one of the following two areas:²

• The parts of the brain (brainstem and cerebellum) that deal with interaction between the senses of vision and balance, or
• Sensory messages to and from the thalamus part of the brain.

Migraine headache is the most common cause of central vertigo.

Uncommon causes are stroke and transient ischemic attack, cerebellar brain tumor, acoustic neuroma (a non-cancerous growth on the acoustic nerve in the brain) and multiple sclerosis.

Signs and symptoms of vertigo

Rather than being a medical condition that shows signs and symptoms, vertigo is itself a single symptom.

Vertigo is simply a specific kind of dizziness, producing the sense that you, or your environment, is moving or spinning.^1,2

Depending on the cause, however, other symptoms can accompany vertigo, including hearing loss, tinnitus, nausea, vomiting or a feeling of fullness in the ear.¹

A classic eye movement sign of vertigo, nystagmus, is tested by doctors (see the next page for test and diagnosis inform

Tests and diagnosis

Dizziness specialists have found from research that the following question helps to distinguish vertigo from other types of dizziness:⁴

"Did you just feel lightheaded or did you see the world spin around as though you had just got off a playground roundabout?"

Doctors will also ask about other possible symptoms, including hearing loss, tinnitus, nausea, vomiting or a feeling of fullness in the ear - these are separate symptoms from vertigo but can be helpful to narrowing down its cause.¹

Doctors will also explore:¹

• Medication use
• Family history of migraines or Meniere's disease
• Recent ear infection or head injury.

History-taking also seeks to specify how and when the vertigo happens:¹

A feeling similar to that after getting off a merry-go-round is diagnostic of vertigo.

• How and when it first happened
• How often and for how long it typically lasts
• Its severity and whether it affects activities (e.g. whether it is possible to walk during an episode)
• If there is a trigger for the vertigo or anything that makes it worse (e.g. head movement to a particular side)
• If anything improves the symptoms.

Physical examination might include looking into the ear, or one of the maneuver tests below. Scans may also be arranged to explore what might be causing the vertigo, usually magnetic resonance imaging (MRI) or computerised tomography (CT).¹

Maneuvers to recreate vertigo and test for nystagmus

Nystagmus is uncontrolled eye movement and it happens because vertigo makes the brain think there is a rotational movement when there is not.

Similar eye movement happens when you try to fix your eyes on one position while looking at something that is passing quickly by - for example, when looking out from a train window, or trying to keep your eyes in one position as you stand on the platform and a train whizzes by.

Doctors can provoke nystagmus to test for vertigo by performing a positional physical maneuver such as the following examples.