Vertigo

Vertigo can be of peripheral or central cause.

1. Peripheral vertigo

Its origin is located in the vestibular apparatus located in the inner ear or in the vestibular nerve.

1.1 Benign paroxysmal positional vertigo

The vertigo picture is triggered by a turn or head movement. It is very typical, for example, that it appears while lying in bed when we wake up and turn around. The inner ear contains the semicircular canals, which contain a liquid known as endolymph. Vertigo is triggered by the displacement of calcium particles known as otoconia within these semicircular canals, caused by head rotation.

Episodes of vertigo in these cases are usually intense and of very short duration, although they may recur recurrently with cephalic movements if not adequately treated.

1.2 Vestibular neuronitis

It consists of inflammation of the vestibular nerve. Vertigo appears intensely at the beginning and usually improves progressively in the following days. Its most common cause is a viral infection. Generally it is a respiratory virus that produces a catarrhal picture and inflammation of the vestibular nerve. Various autoimmune processes can also cause inflammation of the vestibular nerve.

1.3 Meniere’s disease

It is a condition that presents with vertigo, tinnitus or tinnitus (which are noises or whistling in the ears) and hearing loss. Its origin is a dysfunction of the inner ear, although the mechanisms by which it occurs are not clear. It tends to become chronic and can significantly affect quality of life.

1.4 Vestibular paroxysmia

It is a rare cause of vertigo. Episodes are of very short duration, usually a few seconds, and are not triggered by head turning movements. They typically respond to carbamazepine.

1.5 Other causes:

Acoustic neuroma

Acoustic nerve-dependent tumor lesion (VIII cranial nerve)

Post-traumatic

A craniocerebral trauma can cause the otoliths in the semicircular canals to detach and trigger a picture of benign paroxysmal positional vertigo. Of course, there will also be vertigo if there is injury or fracture of the skull base with involvement of the inner ear, in these cases usually associated with other symptoms and problems.

Ototoxicity

Drugs such as amnioglucosides, azithromycin or some chemotherapies can cause damage to both hearing and the vestibular system.

2. Central vertigo

Its origin is located in the central nervous system, affecting areas such as the cerebellum or the vetibular nuclei in the brainstem.

2.1 Vertebrobasilar ischemic stroke

Vertigo secondary to vertebrobasilar stroke usually appears together with other focal neurological symptoms such as double vision, inability to walk, limb coordination problems or facial asymmetry. Infarcts in the territory of the anteroinferior cerebellar artery (PICA) may present only with vertigo, without other focal symptoms. In these cases vertigo is characterized by being constant and not responding to the usual therapeutic measures in a vestibular syndrome.

2.2 Multiple Sclerosis and other demyelinating diseases

A demyelinating inflammatory flare with involvement of the vestibular nuclei or other structures located in the brainstem may cause vertigo. As in the case of stroke, the patient will also not respond to the usual treatments.

2.3 Tumors in posterior territory

Space-occupying lesions will cause vertigo if they compress or infiltrate the vestibular nuclei or the VIII cranial nerve.

2.4 Vestibular migraine

People with migraine may present a pre-pain phase with symptoms such as visual disturbances, slurred speech or tingling sensations. In some cases, these patients have, as a symptom prior to or accompanying the headache, a clinically typical picture of vertigo. It usually resolves in no more than 30 minutes, although sometimes it can be more prolonged.

DIAGNOSIS

The diagnosis is eminently clinical and semiological. When faced with a clinical picture, the physician explores the patient and identifies typical signs of vertigo, such as nystagmus. In the Dix-Hallpike maneuver, the physician performs maneuvers to mobilize the otoliths in the endolymphatic fluid of the semicircular canals. If the patient has benign paroxysmal positional vertigo, the Dix-Hallpike maneuver will trigger a picture of vertigo and will be diagnostic. It is advisable to have a complete evaluation by the otolaryngologist. Sometimes it is necessary to perform a brain imaging test of the skull base and internal auditory canal, in order to rule out compressive or inflammatory processes, among others. If there are clinical or exploratory data suggesting the possibility of central vertigo, such as double vision, gait disturbance or lack of response to symptomatic treatments, an imaging test is required, preferably a brain MRI, since cranial CT does not correctly evaluate the posterior fossa.

TREATMENT

In benign paroxysmal positional vertigo, we resort to repositioning maneuvers, such as the Epley maneuver, as the first treatment option. With this technique, the otoliths are directed from the semicircular ducts to adjacent cavities called utricle and saccule. Vestibular neuritis is usually treated with corticosteroids. Sometimes, regardless of the cause of vertigo, we associate vestibular sedative drugs such as betahistine or sulpiride. These drugs should always be taken with caution, with medical prescription and avoiding prolonged periods.

FREQUENT QUESTIONS

What measures should I take if I have vertigo and what should I not do?

In cases of benign paroxysmal positional vertigo and Meniere’s disease, during the acute phase and the following days, it is recommended not to sleep flat but with the head of the bed elevated; the first day it is advisable to sleep in an armchair. Likewise, during these first days, it is necessary to avoid intense physical activity and sudden head turns. Postural changes, such as getting out of bed, should be made slowly and with caution.

Is it advisable to do rehabilitation?

Yes, in all cases rehabilitation can be beneficial. In recurrent vertigo, as in the case of benign paroxysmal positional vertigo, an adequate program of exercises guided by the physiotherapist will help us in the recovery and prevention of new episodes, as well as in the incorporation to daily routines and activities.

Websites of interest

https://asmes.org/ (ASMES. Asociación Síndrome de Meniere España)

https://www.uptodate.com/contents/vertigo-beyond-the-basics

https://salud.nih.gov/recursos-de-salud/nih-noticias-de-salud/sobrellevar-los-mareos