Patricia Bender
Sun, 30 Mar 2003 10:03:37 PST
Vertigo: Its Causes and Treatment
Huai Y. Cheng, M.D.
Dr. Cheng is Geriatric Fellow, Division of Geriatric Medicine, Saint 
Louis University, Health Sciences Center, St. Louis, MO. Dr. Cheng 
reports no commercial conflict of interest.
A 76-year-old man went to the hospital complaining that he had 
experienced vertigo for three years and that it had gotten worse in the 
last two to three months. What he meant by vertigo, he explained, was a 
sensation of "things in the house spinning," along with nausea lasting 
less than a minute. He felt fine if he stayed in bed and did not move. 
He did not have slurred speech, weakness of extremities or any other 
symptoms that might point to a neurological or brain problem.
He was first diagnosed with Meniere's syndrome, a mysterious disorder 
that causes severe vertigo, hearing loss and a ringing or other 
sensation in the ears. He was treated with the drug DiazideĀ®. After 
that, everything had been fine until the past few months, when he had 
several new attacks of the same symptoms, but with more severe nausea 
and vomiting. He was now afraid that he was about to have another 
A series of tests revealed that instead of Meniere's Disease, the man 
was actually suffering from another illness called Benign Paroxysmal 
Positional Vertigo, or BPPV. Meniere's Disease and BPPV are the two 
most common causes of vertigo. While one can be mistaken for the other, 
as in this example, they are different diseases with different symptoms 
and different treatments.
What Is Vertigo?
Vertigo is not a disease in itself, but rather a symptom that can have 
any number of causes. The famous Alfred Hitchcock film notwithstanding, 
a fear of heights is not normally one of them. Vertigo is defined in 
Webster's dictionary as a feeling "in which the external world seems to 
revolve around the individual or in which the individual seems to 
revolve in space."2 Occurring without warning, it comes and goes 
unpredictably and is often accompanied by nausea, vomiting and problems 
with equilibrium. Mild episodes may feel more like a rocking sensation 
or mere light-headedness.
Common Causes of Vertigo
Benign Paroxysmal Positional Vertigo
Benign paroxysmal positional vertigo (BPPV), the kind that was mistaken 
for Meniere's Disease in the above example, is one of the most common 
types of vertigo. It has many causes, not all of which are well 
understood. The most popular current theory is that it is usually 
caused by free-floating calcium carbonate crystals in an area of the 
inner ear called the posterior semicircular canal, which is part of the 
vestibular system.
The vestibular system, located in and around the ear, is responsible 
for integrating what we see, hear and feel with head and body movement. 
In short, it controls our body's sense of equilibrium. More 
specifically, the vestibular system works by monitoring head movement 
and then sending this information to organs inside the ear, which then 
relay the information to the brain.
Our ears play an essential part in this process. The inner ear contains 
an area called the labyrinth, in which are found three semicircular 
canals; these canals are surrounded by a special fluid. The canals' 
function is to transmit information about head movement to the 
vestibular nerve. This nerve passes the information along to the areas 
of the brain that control bodily coordination.
People with BPPV feel lightheaded. The lightheadedness is is often 
accompanied by nausea, vomiting, sweating and a skin pallor. It usually 
comes on suddenly and goes away in less than 30 seconds.
BPPV can be brought on by a sudden change in body position, such as 
turning over in bed or getting in and out of bed. Many people have only 
a single passing bout of BPPV but, for some, BPPV returns unexpectedly.
Meniere's Syndrome
Meniere's syndrome is another common cause of vertigo. Characterized by 
deafness, ringing in the ears and occasional vertigo,9,11 its cause is 
unknown. People with Meniere's get a feeling of fullness or pressure in 
the ear, followed by hearing loss in one ear, which is soon followed by 
vertigo. The vertigo builds in intensity over several hours and is 
sometimes accompanied by nausea and vomiting. The hearing loss 
gradually becomes total, at which point the vertigo begins to go away 
until it finally disappears.
Less Common Causes
There are many less common causes of vertigo. These include stroke, 
brain tumors, low blood pressure, heart arrhythmias, multiple sclerosis 
and migraine headache. Many prescription and non-prescription drugs can 
cause dizziness or vertigo. In some susceptible people, cold and flu 
medicines, painkillers, as well as treatments for high blood pressure, 
diabetes, thyroid disease, depression and anxiety can produce 
lightheadedness and dizziness.
Non-Surgical Treatments for BPPV
The most reliable treatment for BPPV is a fairly simple, non-surgical 
procedure called canalith repositioning..12 This is done by changing 
the patient's head and body position in a series of steps that are 
thought to dislodge the calcium crystals within the vestibular 
labyrinth that caused the problem.
Canalith repositioning is usually done under expert supervision, but it 
is easy enough that doctors often teach it to BPPV sufferers and their 
Many doctors also prescribe drugs called vestibular suppressants. 
Because of unwanted side effects, such as lethargy and impaired 
balance, they are given sparingly and only for more severe and 
long-lasting attacks. The elderly are particularly sensitive to these 
side effects.
Another concern about these drugs is that they may slow or prevent the 
central nervous system from adjusting to a problem in the vestibular 
system. While vetibular suppressants often help lessen symptoms, 
especially in the short term, surgery is the ultimate answer for the 
unlucky few with severe BPPV-related vertigo that does not respond to 
the canalith repositioning procedure.13
Treating Meniere's
The treatments for Meniere's disease are generally not as effective as 
those for BPPV. Severe attacks are treated with vestibular suppressant 
drugs; in between, Meniere's symptoms are often controlled by reducing 
salt intake and by taking diuretic drugs, which reduce the amount of 
fluids in the body.
For similar reasons, people with Meniere's should avoid alcohol, 
coffee, chocolate and other foods that are high in sugar or salt. As 
with BPPV, surgery is a last resort.
Vertigo is not a disease but a symptom that can have many causes. The 
most common are benign paroxysmal positional vertigo (BPPV) and 
Meniere's disease, which for most people can be treated and controlled 
without surgery. The best treatment for BPPV, a simple, non-surgical 
procedure called canalith repositioning, is easy to perform; both 
sufferers and their families can be trained to do it. Another option, 
vestibular suppressants drugs, has serious side effects and should be 
used very cautiously.
When should you seek medical help?
The answer is that anyone with recurring or severe dizziness or vertigo 
should see a doctor. Most of the time, the most serious cause will be 
BPPV or Meniere's, both of which can be treated and controlled with 
drugs and other non-surgical therapy. It is particularly urgent, 
however, to seek medical treatment if the dizziness or vertigo occurs 
together with one or more of the following symptoms, which can be a 
sign of a more serious underlying heath problem:

*	Severe or "different" headache
*	Blurred vision
*	Hearing loss
*	Speech problems
*	Weakness in a leg or arm
*	Fainting
*	Problems walking
*	Numbness or tingling
*	Chest pain or changes in heart rate

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