Common and Rare Causes of Vertigo

Finding the Culprit Behind Your Dizzy Spells Requires a Doctor's Evaluation

Vertigo
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People mean many different things when they say they are dizzy. Vertigo is the dizzy sensation associated with spinning around in a circle too fast, or as if the world is spinning around you.

Vertigo can be very uncomfortable and may sometimes lead to nausea or vomiting. It can be hard to get out of bed, much less walk around and perform the tasks that we need to accomplish every day.

While most causes of vertigo aren't life-threatening, some are very serious, like a stroke in the back of the brain near the cerebellum.

On the other hand, many kinds of vertigo can be easily treated with simple maneuvers like head positioning.

Common Causes 

Most often, people who are experiencing vertigo or dizziness will have one of the more common causes.

Benign Paroxysmal Positional Vertigo (BPPV)

Is vertigo provoked by a change in head position? If so, the cause may be benign paroxysmal positional vertigo (BPPV), one of the most common causes of vertigo. This disorder is caused by a small crystal called an otolith which normally sits out of harm's way in the center of the middle ear (the utricle and saccule). In BPPV, an otolith breaks free and enters one of the three canals that usually signal that our body is turning in space. The crystal causes pressure changes in the canal that trick the body into believing it is turning, even when it's standing still. The resulting confusion causes vertigo.

The vertigo of BPPV tends to occur in brief episodes and is brought on by head turning, because shifting the head can cause the otolith to move in the canal, triggering faulty signals to the brain.

The good news is that a series of particular head maneuvers (called the Epley maneuver) can be used to reposition the otolith out of the canals where it can't cause any more discomfort.

Spells that last less than a minute or so are frequently due to BPPV. Longer spells of acute vertigo may be due to a problem in the inner ear, such as a peripheral vestibulopathy or Meniere's syndrome, or to central vertigo, meaning a problem with the brainstem such as can be found in stroke or vestibular migraines.

Meniere's Disease

The inner ear contains a membranous sac that floats within a thin layer of fluid. Inside that sac is more fluid but of a different kind. Meniere's disease is thought to be caused by an imbalance between the fluid space inside the sac and the fluid outside the sac, with too much fluid building up inside. This is known as endolymphatic hydrops.

The disease usually comes on between the age of 30 and 50 years and causes attacks of vertigo, hearing loss, and a ringing in the ears. In contrast to BPPV, attacks can last 20 minutes to several hours at a time. As with other forms of vertigo, nystagmus will likely be present. The attacks can vary from anywhere between several times a week to less than once a year. After 5 to 15 years, the dizziness becomes less severe but more constant, and hearing loss can become permanent, though complete deafness in the affected ear is rare.

Meniere disease can be diagnosed by a physician without any additional tests, but audiometry is sometimes useful. No treatment has been found to stop the progressive changes in the inner ear, but medications can help with symptoms when they occur.

Vestibular Neuritis

This disorder goes by many other names, including vestibular neuronitis, labyrinthitis, neuro labyrinthitis, and acute peripheral vestibulopathy.

The disorder usually resolves completely on its own but causes very uncomfortable vertigo in the meantime. The disorder is thought to be due to inflammation of the vestibular nerve provoked by a virus -- although, there's actually only minimal evidence to support this theory.

The diagnosis of vestibular neuritis is usually done by a doctor examining you and asking you questions, though testing may be done to exclude other causes, such as a stroke. Vertigo from vestibular neuritis usually resolves within a few days, but sometimes there is a mild residual imbalance that lasts for months. It is not clear that any particular treatment is useful, though many doctors will prescribe a short course of the steroid prednisone based on sparse data supporting the practice.

Vestibular Paroxysmia

Sometimes vertigo attacks only last a few seconds at a time but may occur many times a day. Some physicians believe that this may be due to a blood vessel pressing on the eighth cranial nerve, which leads to feelings of vertigo.

Other physicians have criticized the lack of good data for supporting this theory. For example, up to 30 percent of healthy people also have blood vessels that contact the vestibulocochlear nerve, according to an article in the Journal of Vestibular Research.

Some have suggested that surgery can be used to remove the pressure placed on the nerve by blood vessels, but others have found that a low dose of carbamazepine (an anti-seizure medication) may also help. Given the uncertain evidence for the blood vessel as a culprit, use of medication is the best initial treatment.

Vestibular Migraine

While the preceding causes of vertigo lead to what is called peripheral vertigo, meaning that the vertigo is caused by something outside the brain and brainstem, it is also possible to get vertigo from problems within the brain itself, which is called "central" vertigo. One of the least serious causes of this central vertigo is a vestibular migraine.

Migraines are usually thought to instigate headaches, but atypical migraines can actually cause almost any transient neurological symptom, including weakness, tingling, numbness, and dizziness. A headache, however, is technically required to make the diagnosis of a vestibular migraine. Other symptoms of a migraine, or onset of vertigo with typical migraine triggers, can be helpful in making the diagnosis.

Vertebrobasilar Transient Ischemic Attack (TIA)

The brainstem receives most of its blood supply via what is called the posterior circulation. Two vertebral arteries come together to form the basilar artery, which sends branches that send nourishing blood to the brain stem and back of the brain.

If arteries in the brain are temporarily blocked by a blood clot, the brain cells can begin to starve. If the blood clot dissolves, symptoms improve, and the event is called a transient ischemic attack. If the blood clot remains, then it leads to a stroke with permanent deficits.

Because the brainstem contains our body's centers for balance, including the relays for all information sent to the brain from the inner ear, vertigo is a common symptom of posterior circulation. More concerning, though, are other important functions of the brainstem, such as breathing, movement, and more. For this reason, symptoms of concern for vertebrobasilar TIA are considered a warning of potentially bigger problems to come.

Fortunately, it's rare that a vertebrobasilar TIA will only cause vertigo and nothing more. The brainstem is a small area about as big as your thumb and is packed with important nerves. If the damage is done to one part of the brainstem, others will likely also be affected, leading to additional neurological symptoms. For this reason, doctors are keen to find signs of "central" vertigo, meaning vertigo that stems from the brainstem rather than then vestibular nerve or inner ear.

Risk factors for vertebrobasilar TIA are almost identical to those for other forms of the ischemic vascular disease, such as stroke. For more information about determining if your vertigo is serious, read about when dizziness is serious.

Rare Causes

Sometimes the cause of your vertigo is actually something rare. Even though these uncommon causes of vertigo occur less often, it's important to be aware of these other diagnoses so that your symptoms are not mistaken for something more commonplace.

Let's take a look at these unusual causes of vertigo.

Autoimmune Inner Ear Disease

Sometimes, the immune system mistakes part of our own body for an invading infection. When this occurs -- when the body attack itself -- it is referred to as an autoimmune disorder. If this happens in the inner ear, it can cause progressive hearing loss as well as vertigo.

About a quarter of such people will have other autoimmune diseases such as systemic lupus erythematosus, polyarteritis nodosa, or Wegener granulomatosis. About half of these people will respond to corticosteroids.

Labyrinthine Concussion

Concussions often cause headaches, nausea, vomiting, and dizziness. A sense of vertigo after a concussion can result from injury to the vestibular organs after the head is hit. Depending on the nature of the injury, there may be blood in the inner ear. While this is usually worst directly after the head injury, vertigo may come and go for a while afterward. Occasionally, post-traumatic changes in the pressure gradient between components of the inner ear (endolymphatic hydrops) can develop, leading to Meniere syndrome.

Perilymphatic Fistula

Head injury, heavy lifting, or injury due to changes in pressure (such as with scuba diving) can sometimes lead to an abnormal connection between parts of the ear which not meant to be connected. An abnormal connection between two regions of the body which are not ordinarily connected is called a fistula.

Symptoms of a perilymphatic fistula are often worsened by a change in external or internal pressure, such as sneezing, straining, coughing, or loud noises.

Changes in elevation may also exacerbate symptoms, such as flying in a plane or even riding an elevator.

The diagnosis of perilymphatic fistula can be difficult unless an inciting incident is described. The treatment usually involves resting with the head elevated and avoiding all forms of straining. In those who do not improve with such treatment, surgery may be necessary.

Canal Dehiscence

Another related phenomenon is dehiscence, in which the connection between two chambers is not complete, but bone may be thinner than it usually would be. An example is dehiscence of the superior canal of the inner ear which causes unique symptoms like sound induced vertigo.

About half also have autophony, meaning they hear internal sounds like their own voice, heartbeat, or sometimes even their own eye movements at a disturbingly loud volume.

Otosclerosis

Otosclerosis is a sometimes inherited disorder in which bones are reabsorbed, and new bone formation occurs in the middle and inner ear. This usually begins between the second and fourth decades of life. The result is a bilateral progressive hearing loss. About 20 percent of people with otosclerosis also have vertigo or imbalance, which results from destruction of the inner ear. Others may develop endolymphatic hydrops with Meniere syndrome. An audiogram can be helpful in making the diagnosis.

Epileptic Vertigo

Rarely, spells of vertigo can actually be due to seizures. Many people are familiar with typical tonic-clonic seizures (grand mal seizures) but there are actually many different types of very different symptoms. Abnormal electrical activity can occur in parts of the brain that process the vestibular system.

An electroencephalogram (EEG) can be used to determine whether spells are epileptic in nature. Some people may have an epileptic aura prior to the vestibular seizures, which can help point to the possible diagnosis.

Chiari Malformation

A Chiari I malformation is a congenital abnormality (something you are born with) in which the bottom of the cerebellum (the part of the brain which controls balance and coordination) extends lower than it normally would. Usually, this doesn't cause any symptoms, but can sometimes lead to a headache, gait imbalance, and vertigo. When the vertigo is present, it may be worsened by bending the neck backward (head motion induced vertigo.)

While nystagmus (uncontrolled eye movements) is often present in any form of vertigo, in Chiari malformations, the nystagmus may beat in the downward direction instead of the side, which is unusual. Surgery may be needed if symptoms are severe with a Chiari malformation. That said, most people with Chiari malformations do not require surgery.

Episodic Ataxia

Episodic ataxia, and episodic ataxia type 2, in particular, can cause severe episodes of vertigo with nausea and vomiting in childhood or early adult life. Nystagmus may be present both during and between attacks. The attacks often become progressively worse, and symptoms may begin to occur between attacks as well.

Medications

A wide number of medications can cause dizziness, and some cause vertigo specifically. Antibiotics known as aminoglycosides are particularly problematic, and can even lead to permanent damage. Lithium toxicity may also cause vertigo. In addition, Vertigo is a possible side effect with medications such as:

A Word From Verywell

In general, vertigo is not a symptom that should be ignored. While it is usually not due to something like a stroke or transient ischemic attack, it is important to know for sure so that worse problems do not arise. Furthermore, vertigo is extremely uncomfortable, and there are techniques and medications that can help if you seek the proper medical advice.

Sources

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