First things first: Vertigo itself is not a disease. It is a symptom of a disturbance of the sense of balance. In most cases, these disturbances are harmless and pass quickly.

However, around 30% of all people develop a vertigo requiring treatment once in their lifetime. Despite this high relevance, dizziness and vertigo symptoms care oftentimes still met with lacking treatment and diagnosis. This can be explained, at least in part, by the many disorders underlying the dizziness, which not only unsettle patients.

Definition

Vertigo or dizziness is what we call the everyday feeling of turning or swaying, the feeling of not being able to move safely in the room, or the feeling of impending unconsciousness.

In the medical sense, vertigo is defined as a perceived apparent movement between oneself and one’s environment. There are different forms of vertigo:

  • vertigo (rotational, swaying, lifting)
  • Disequilibrium (unsteadiness, disorientation)
  • Spatial disorientation
  • Dizziness (lightheadedness, faintness)
Our sense of balance

Our sense of balance is the result of an extremely complex interplay of different senses. In addition to our inner ear with its vestibular system, our eyes are involved as an optical system as well as countless positional receptors in our muscles and joints, the so-called proprioceptive system.

The balance organ of the inner ear, the vestibular organ, is made up of various parts: mainly the atrial bags located in the so called vestibulum and the arcades.

 

Anatomy of the ear

Anatomy of the vestibular organ

 

Our sense of balance is the result of an extremely complex interplay of different senses. In addition to our inner ear with its vestibular system, our eyes are involved as an optical system as well as countless positional receptors in our muscles and joints, the so-called proprioceptive system.

The balance organ of the inner ear, the vestibular organ, is made up of various parts: mainly the atrial bags located in the so called vestibulum and the arcades.

The atrial bags, utriculus and sacculus, contain sensory hairs that protrude into a gelatinous membrane. These are arranged horizontally in the utricle, vertically in the saccule. In the surface of the gelatinous layers are small crystals of calcium carbonate, the so-called otoliths. Every change in position of the body sets the gelatinous layer in motion, and the sensory hairs are – like grass swaying in the wind – sheared off. In this way we perceive gravity and accelerations.

The semi-circular canals are three semi-circular, fluid-filled canals that are approximately perpendicular to each other and thus depict the three spatial planes. These also contain sensitive sensory hairs. With them we perceive rotational movements of the head.

The information taken by the vestibular organ is transmitted via the vestibular nerve to the brain and brain stem and processed there. These three elements

  • the vestibular organ in the inner ear,
  • the balance nerve and
  • the associated brain areas

together form our equilibrium or vestibular system.

The vestibular system is divided into the so-called central vestibular and peripheral vestibular sections. Central elements refer to structures centrally located in our brain. Correspondingly, central vestibular vertigo is rooted in the brain itself. “Peripheral” refers to those areas that are not located in the brain itself but are peripheral: the vestibular organ in the inner ear and the vestibular nerve. This is where peripheral vestibular vertigo, the vertigo that can usually be eliminated completely with targeted training, originates from.

Hence non-vestibular vertigo originates entirely outside the vestibular system. These causes can include mental causes (e.g. stress and anxiety), cardiovascular problems, side effects of medication or drug use, as well as illnesses affecting other sensory systems involved in the sense of balance.

Vestibular vertigo

If a cause for vertigo can be found, it is oftentimes the so-called vestibular vertigo. Its causes lie in the balance system and affect our vestibular organ in the inner ear or the balance nerves.

In peripheral vertigo, the unilateral or bilateral failure of the vestibular system, balance training is the best and fastest therapy measure. The brain is trained through targeted exercises to compensate for the failure with the remaining senses – without any medication and in a completely non-invasive manner.

Benign paroxysmal positional vertigo (BPPV)

Peripheral vertigo most commonly occurs as benign paroxysmal positional vertigo. This is triggered by free-moving small calcified otoliths. They are dislodged from their original position in the utricle and migrate to one of the semi-circular canals. Despite their small size, their weight causes a dysfunction which leads to rotational vertigo.

As a result, affected people respond hypersensitively to spin. Age is the major risk factor for BPPV. However, accidents with trauma to the head, inner ear infections (labyrinthitis) or episodes of long-term bed rest may predispose individuals to BPPV in the future.

Fortunately, BPPV can be treated with relative ease by those affected with the so-called Epley Maneuver.

Ménière’s disease

Ménière’s disease is a chronic, incurable vestibular disorder. It is defined as “the idiopathic syndrome of endolymphatic hydrops” (Committee on Hearing and Equilibrium of the American Academy of Otolaryngology-Head and Neck Surgery). More colloquially put this means that Ménière’s disease is a set of symptoms caused by an abnormally large amount of fluid, called endolymph, in the inner ear.

Even though Ménière’s disease can develop at any age it most frequently develops in adults between 40 and 60 years of age.

The exact cause prompting Ménière’s disease to start is not yet known. The many theories that have been proposed over the years include: circulation problems, viral infection, allergies, autoimmune reactions, migraine as well as a genetic predisposition.

Oncoming attacks are often preceded by a specific set of warning signals. Paying attention to these can allow an affected individual to move to adopt appropriate measures for their safety and comfort before an attack.

  • balance disturbance
  • dizziness, light-headedness
  • headache, increased ear pressure
  • hearing loss or tinnitus increase
  • sound sensitivity
  • vague feeling of uneasiness

The symptoms of an early-stage attack of Ménière’s disease include:

  • spontaneous, violent vertigo
  • fluctuating hearing loss
  • ear fullness (aural fullness) and/or tinnitus

 In addition, the following symptoms may occur during an attack:

  • anxiety, fear
  • diarrhoea
  • blurry vision or eye jerking
  • nausea and vomiting
  • cold sweat, palpitations or rapid pulse
  • trembling

Subsequent to an attack, a period of extreme fatigue or exhaustion often occurs, prompting the need for hours of sleep.

Existing treatments either aim at reducing the severity of an attack while it is occurring or they attempt to reduce the severity and number of attacks in the long term.

Medications can be used during an attack to reduce the vertigo or nausea/vomiting, or both.

 To help with the imbalance that can plague people between attacks balance training is the treatment of choice. It retrains the body’s and brains ability to process the remaining balance information.

For those affected who do not respond to medication or balance training, a physician may recommend a treatment that involves more physical risk. The options available today include the destruction of vestibular tissue with injections of an aminoglycoside antibiotic (gentamicin) into the ear and injections with an intratympanic steroid which seem to pose a lesser risk of hearing loss and persistent imbalance.

Furthermore, there are two treatment methods involving surgery. The goal of the first method is to relieve the pressure on the inner ear. In recent years this type of surgery has been used less due to questions about its long-term effectiveness.

The second type of surgery aims at blocking the transmission of information from the affected ear to the brain by either destroying the vestibular organ itself, or the vestibular nerve.

In either instance, balance training accompanied by physical therapy is useful to help the brain compensate for the loss of inner ear function.

Age-related vertigo and imbalance

In addition to illness-related causes most people develop age-related vertigo and imbalance later in life. This is caused by the age-related decrease in the sensory capacity and thus belongs to the normal side effects of a long life.

The typical age-related dizziness or age vertigo has a variety of further causes: The perfusion (blood flow) of the inner ear deteriorates. There is also a slower nerve transmission to and stimulus processing in the brain. This, combined with age-related changes in the eye (cataract, glaucoma and general defective vision), decreased muscle mass and strength, decreased responsiveness and coordination, can cause dizziness, vertigo, imbalance and unsteady gait. These different causes of course mean that age-related vertigo is not only vestibular in nature but has roots in non-vestibular vertigo as well.

Further information can be found in our comprehensive guide ” Age-related dizziness and imbalance”.

Fractures of the petrous bone

In everyday life a temporal bone fracture is usually referred to as a basal skull fracture. The petrous bone is the part of the skull that surrounds the inner ear. Although the petrous bone is the hardest bone of the human skull, it can be fractured by severe accidents in particular.

The inner ear, and thus our organ of balance (the vestibular organ), is especially affected by a so-called longitudinal fracture, which runs along the auditory canal. At 85% it is also the most common form of temporal bone fracture.

Acute inner ear hearing loss is treated with blood-thinning agents. Special medicines, known as antivertigo drugs, are used against acute dizziness and vertigo. With permanent damage to the vestibular organ, balance training can help to compensate for the functional impairment.

Central vertigo

Central vertigo is vertigo due to a disease originating from the central nervous system. That means that the causes for central vestibular vertigo do not lie within the inner ear. Central vertigo may be caused by haemorrhagic or ischemic insults to the cerebellum, the vestibular nuclei and their connections within the brain stem. Other causes include tumours, infection, trauma and multiple sclerosis.

Depending on the cause, balance training can be used for therapy. The brain is trained through targeted exercises to compensate for the failure with the remaining senses – without medication and in a completely non-invasive manner.

Dizziness attacks of a central origin often occur suddenly and their duration varies, depending on the cause, from a few seconds to several days. They are often accompanied by significant physical restrictions, such as impaired eyesight or swallowing and speech disorders. In addition, they can also lead to paralysis, coordination disorders or a false sense of touch. In addition, directional or vertical nystagmus (an uncontrollable and rhythmic eye movement) can be an indicator of central dizziness.

In the event of accompanying symptoms, a doctor should be consulted as soon as possible to rule out a stroke as a cause!

In addition to illnesses and injuries, some medications may be the cause of vestibular dizziness. These include antihypertensive agents, depression, epilepsy and migraines, tranquilisers (sedatives) and antibiotics (from the family of aminoglycosides).

Vestibular paroxysmia

Typical for vestibular paroxysmia are short, recurring vertigo attacks that only last a few seconds to a few minutes. The cause is a disturbance of or to damage to the balance nerve. Often pressure exerted by an artery is the cause. As a result, both rotational and swaying vertigo may occur, in few cases accompanied by hearing loss.

Often the vertigo can be triggered by a certain head posture or by rapid and deep breathing (hyperventilation). For the treatment of vestibular paroxysm, medicines are used which are also used in the treatment of epilepsy (so-called anticonvulsants).

If the drug treatment does not improve, there is still the possibility to prevent the contact between the balance nerve and the artery by a neurosurgical intervention.

Acoustic neuroma

Acoustic neuroma or vestibular schwannoma is a rare, benign tumour of the auditory and equilibrium nerves. Benign means that the tumour isolates itself from the surrounding tissue, does not form metastases (i.e. does not “scatter”) and only grows very slowly.

The symptoms include hearing loss and vertigo, but often it does not cause any discomfort.

The treatment typically depends on the size of the tumour and the age of the person affected. Smaller tumours are often only monitored at first, since it may no longer be growing or even be shrinking, especially among older people. If treatment is necessary, smaller tumours are irradiated, while larger ones are removed surgically.

Vestibular epilepsy

Vestibular epilepsy is one of the many different forms in which epileptic disorders occur. In addition to vertigo, the symptoms include involuntary twitching of the eye (nystagmus), which is typical of rotational vertigo.

Vertigo often precedes the actual epileptic seizure. Like other types of epilepsy, vestibular epilepsy is treated with antiepileptic drugs.

Non-vestibular vertigo

Non-vestibular vertigo is not caused by a disturbance of the sense of balance. It is caused by a number of different clinical conditions, including diseases of the cardiovascular system (e.g. blood pressure fluctuations), poisoning, impaired vision, cervical spine syndrome and trauma.

In addition, psychogenic dizziness/vertigo is one of the most common forms of non-vestibular dizziness/vertigo. It is triggered by stress or anxiety and is often situational. Also described as phobic dizziness, it is triggered when a person is subject to a situation that is perceived as stressful, e.g. height and claustrophobia as well as stage fright.

How to get the right diagnosis

Those who suffer from vertigo or dizziness should consult a doctor. To be able to make a reliable diagnosis, your doctor needs the most accurate information possible regarding the following questions:

  1. From what kind of dizziness or vertigo do you suffer? Rotational vertigo, swaying vertigo, lifting vertigo, unstableness or dizziness?
  2. How long do the episodes last? Short attacks or permanent vertigo/dizziness?
  3. Can the vertigo/dizziness be triggered or intensified deliberately?
  4. Do you experience any other symptoms, such as vomiting, hearing problems, headaches or blurred vision?

You can prepare your doctor’s appointment with our EQUIVert Vertigo Diary.

1. How to distinguish between different forms of vertigo and dizziness

Rotational vertigo feels “like you are in a carousel”

In the case of the rotational vertigo, those affected feel as if they themselves or the environment around them are spinning. Often, the vertigo is so severe that it leads to nausea to vomiting or near-vomiting.

Swaying vertigo feels “like being on a ship”

Those affected by swaying vertigo feel as if the ground is moving under their feet. Due to involuntary compensatory movements this form of vertigo is associated with a particularly high tendency to fall. However, nausea and vomiting are rare. For those affected swaying vertigo is often associated with the feeling of impending unconsciousness.

Lift vertigo feels “like an elevator ride”

Lift vertigo expresses itself in the feeling of moving quickly up and down, or even falling. Often the actual dizziness is followed by drowsiness and malaise.

Spatial disorientation (with a clear head)

Spatial disorientation is often described by those affected not as dizziness but as an uncertain sense of space. This only starts when walking and stops as soon as the person is sitting or lying down. Nausea and even vomiting do not occur during episodes of spatial disorientation.

Dizziness

Dizziness is characterised as a sensation of light-headedness, faintness or unsteadiness without a rotational component.

2. Vertigo attacks or permanent vertigo

In addition to the type of vertigo the duration of vertigo episodes is key in isolating the cause.

Vertigo attacks

The vertigo sets in quickly and disappears within a few seconds or minutes.

Permanent vertigo

If the symptoms persist for hours, days or even weeks, this is called permanent vertigo.

3. What triggers the vertigo? Can the symptoms be deliberately intensified?

The triggers of vertigo and dizziness are as diverse as those who suffer from them. Common triggers are:

  • certain head movements,
  • standing up quickly,
  • overhead work,
  • new glasses (especially varifocal glasses),
  • drugs and medications,
  • major life events or mental stress
4. Accompanying symptoms

Usually vertigo causes or is accompanied by more symptoms. These include:

  • imbalance and spatial disorientation
  • nausea, vomiting and tinnitus
  • hearing disorders
  • numbness in the legs
  • tachycardia or cardiac arrhythmias
  • involuntary eye movements, so-called nystagmus or eye tremors