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Vertigo

Vertigo is a symptom of several different conditions.

Vertigo is a symptom of several different conditions.

It's most often caused by a problem with the balance mechanisms of the inner ear, although it can also be because of a problem within the brain or the nerves.

Some of the more common causes of vertigo are explained in more detail below.

Labyrinthitis

Labyrinthitis is an inner ear infection that causes a delicate structure deep inside your ear (the labyrinth) to become inflamed. The labyrinth is a maze of fluid-filled channels that control hearing and balance.

If the labyrinth becomes inflamed, the information it sends to your brain will be different from the information sent from your unaffected ear and your eyes. These conflicting signals can cause vertigo and dizziness.

Labyrinthitis is usually caused by a viral infection, such as the common cold or flu, which spreads to the labyrinth. Less commonly, it's caused by a bacterial infection.

Vertigo caused by labyrinthitis may be accompanied by nausea, vomiting, hearing loss, tinnitus and sometimes a high temperature and ear pain.

Vestibular neuronitis

Vestibular neuronitis, also known as vestibular neuritis, is an inner ear condition that causes inflammation of the nerve connecting the labyrinth to the brain. In some cases, the labyrinth itself can also be inflamed.

The condition is usually caused by a viral infection. It usually comes on suddenly and can cause other symptoms such as unsteadiness, nausea (feeling sick) and vomiting (being sick). You won't normally have any hearing problems.

It usually lasts a few hours or days, but it may take three to six weeks to settle completely.

Benign paroxysmal positional vertigo (BPPV)

This is one of the most common causes of vertigo. It is usually brought about and made worse by positional changes and head movements. BPPV involves short, intense, recurrent attacks of vertigo (usually lasting a seconds to a few minutes).

BPPV can occur when you make a sudden movement, such as turning your head, standing up or bending over, crossing the road, or turning in bed.

BPPV is often accompanied by nausea, although vomiting is rare. During the attack, you may also experience brief nystagmus (where your eyes move uncontrollably and you are unable to focus). Lightheadedness and a loss of balance can last for several minutes or hours after the attack.

You won't experience tinnitus (hearing noise that comes from inside the body) or hearing loss.

BPPV is thought to be caused by small fragments of debris (calcium carbonate crystals), which break off from the lining of the channels in your inner ear. The fragments don't usually cause a problem unless they get into one of the ear's fluid-filled canals.

When your head is still, the fragments sit at the bottom of the canal. However, certain head movements cause them to be swept along the fluid-filled canal, setting off abnormal fluid movements. This sends confusing messages to your brain, causing vertigo.

BPPV usually affects older people, with most cases occurring in people older than 50 years of age. However, it can sometimes affect younger people.

BPPV may occur for no apparent reason, or it may develop after:

  • an ear infection
  • ear surgery
  • a head injury
  • prolonged bed rest – for example, while recovering from an illness

Attacks of BPPV can clear up within a few days, but persistent BPPV may need a simple corrective manoeuvre that your GP or specialist can do.

Ménière's disease

Severe vertigo is sometimes caused by a rare condition that affects the inner ear called Ménière's disease. This can cause vertigo as well as hearing loss, tinnitus and aural fullness (a feeling of pressure in your ear).

If you have Ménière's disease, you may experience sudden attacks of vertigo that last for hours or days. The attacks often cause nausea and vomiting.

The cause is unknown, but symptoms can be controlled by diet and medication. Rarely, you may need further treatment in the form of surgery. 

Migraines

A migraine is a severe headache that's usually felt as a throbbing pain at the front or on one side of your head. Some people also experience other symptoms, such as nausea and sensitivity to light (photophobia).

It's thought that migraines may be one of the most common causes of vertigo and are especially common in younger people. Avoiding migraine triggers and controlling the migraine usually relieves the vertigo.

Head injury

Vertigo can sometimes develop after a head injury. If you have symptoms following a head injury, such as dizziness or vertigo, you should visit your GP as soon as possible. Alternatively, go to your nearest hospital's accident and emergency (A&E) department.

Read more about severe head injury and minor head injury.

Other causes

Other less common causes of vertigo include:

  • medication – vertigo may also occur as a side effect of some types of medication: check the patient information leaflet that comes with your medicine to see if vertigo is listed as a possible side effect
  • multiple sclerosis – a condition that affects the central nervous system (the brain and spinal cord)
  • acoustic neuroma – a rare, non-cancerous (benign) brain tumour that grows on the acoustic nerve, which is the nerve that helps control hearing and balance
  • a brain tumour in the cerebellum, located at the bottom of the brain
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Vertigo

Your GP will ask you about your symptoms and carry out some simple tests to help differentiate between vertigo and general dizziness.

Your GP will ask you about your symptoms and carry out some simple tests to help differentiate between vertigo and general dizziness.

In some cases, you may be referred for some further tests.

Important questions

To make an accurate diagnosis of vertigo, your GP will want to know:

  • details of the first episode of your symptoms
  • what symptoms you had – for example, whether you felt lightheaded or if you or your surroundings were spinning
  • how often your symptoms occur
  • how long your symptoms usually last for
  • if your symptoms are associated with hearing loss, tinnitus, nausea, vomiting or fullness in the ear
  • if your symptoms are affecting your daily activities – for example, whether you're unable to walk during an episode of vertigo
  • whether anything triggers your symptoms or makes them worse, such as moving your head in a particular direction
  • what makes your symptoms better 

You may be asked a number of further questions to help determine the cause of your vertigo, such as:

Physical examination

Your GP may also carry out a physical examination to check for signs of conditions that may be causing your vertigo. This could include looking inside your ears and checking your eyes for signs of uncontrollable movement (nystagmus).

Your GP may check your balance or try to recreate your symptoms using a test such as Dix-Hallpike's manoeuvre.

Dix-Hallpike's manoeuvre

Dix-Hallpike's manoeuvre is a test that can bring on the symptoms of vertigo. It's often used to confirm cases of benign paroxysmal positional vertigo (BPPV).

The test involves moving quickly from a sitting to a lying position, with your head below the horizontal line of the surface that you're lying on. As you lie back, you'll be asked to rotate your head towards the person testing you, keeping your eyes open.

In cases of BPPV, the symptoms of vertigo may appear for several seconds before disappearing. This may be corrected immediately by a corrective manoeuvre called Epley's manoeuvre (see treating vertigo for more information about this).

Further tests

Depending on your symptoms, your GP may refer you to a hospital or specialist for further tests.

Hearing tests

If you have tinnitus (ringing in your ears) or hearing loss, your GP may refer you to an ear, nose and throat (ENT) specialist who can carry out some hearing tests. 

Some possible hearing tests that you might have are:

  • an audiometry test – a machine called an audiometer produces sounds of different volume and pitch. You listen to the sounds through headphones and signal when you hear a sound, either by raising your hand or pressing a button.
  • tuning fork test – a tuning fork produces sound waves at a fixed pitch when it's gently tapped. The tester will tap the tuning fork before holding it at each side of your head.

Read more about how hearing tests are carried out.

Electronystagmography 

Electronystagmography (ENG) is sometimes used to check for signs of nystagmus in more detail. Nystagmus can indicate a problem with the organs that help you balance.

During this test, special goggles are placed over your eyes and you will be asked to look at various still and moving targets.

In some cases, these goggles are fitted with a video camera to record the movements of your eyes. This is known as videonystagmography (VNG).

Caloric testing

A caloric test involves running warm or cool water into your ear for about 30 seconds. The change in temperature stimulates the balance organ in the ear, allowing the specialist to check how well it's working.

This test is not painful, although it is normal to feel dizzy for a couple of minutes afterwards.

Posturography

A machine to test your balance may be used to give valuable information about how you are using your vision, proprioception (sensations from your feet and joints) and the input from your ear to maintain balance. This may help to plan rehabilitation as well as monitor your treatment.

Scans

In some cases, a scan of your head may be used to look for the cause of your vertigo, such as an acoustic neuroma (a non-cancerous brain tumour).

Usually, either a magnetic resonance imaging (MRI) scan or a computerised tomography (CT) scan is used. An MRI scan uses a strong magnetic field and radio waves to produce a detailed image of the inside of your head, whereas a CT scan uses a series of detailed X-rays to create an image.

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Vertigo

Treatment for vertigo will depend on the cause and severity of your symptoms.

Treatment for vertigo will depend on the cause and severity of your symptoms.

During a vertigo attack, lying still in a quiet, darkened room may help to ease any symptoms of nausea that you have and reduce the sensation of spinning. You may be advised to take medication during this time.

You should also try to avoid stressful situations, as anxiety can make the symptoms of vertigo worse.

Labyrinthitis

Labyrinthitis is an inner ear infection that causes the labyrinth (a delicate structure deep inside your ear) to become inflamed. It's usually caused by a viral infection and clears up on its own without treatment. In rare cases where labyrinthitis is caused by a bacterial infection, antibiotics may be prescribed.

If you have experienced any hearing loss, your GP may refer you to an ear, nose and throat (ENT) specialist or an audiovestibular physician. This is a doctor who specialises in hearing and balance disorders. You may need emergency treatment to restore your hearing.

Labyrinthitis may also be treated with vestibular rehabilitation, also called vestibular rehabilitation training or VRT.

See treating labyrinthitis for more information.

Vestibular neuronitis

Vestibular neuronitis, also known as vestibular neuritis, is inflammation of the vestibular nerve (one of the nerves in your ear that's used for balance). It's usually caused by a viral infection.

The symptoms of vestibular neuronitis often get better without treatment over several weeks. However, you may need to rest in bed if your symptoms are severe. See your GP if your symptoms get worse or don't start to improve after a week.

You may find that your balance is particularly affected if you:

  • drink alcohol
  • are tired
  • have another illness as well

Avoiding these can help improve your condition.

Vestibular neuronitis can also be treated with vestibular rehabilitation and medication.

Benign paroxysmal positional vertigo (BPPV)

Like vestibular neuronitis, benign paroxysmal positional vertigo (BPPV) often clears up without treatment after several weeks or months. It's thought the small fragments of debris in the ear canal that cause vertigo either dissolve or become lodged in a place where they no longer cause symptoms. BPPV can sometimes recur.

Until the symptoms disappear or the condition is treated, you should:

  • get out of bed slowly
  • avoid activities that involve looking upwards, such as painting and decorating or looking for something on a high shelf

BPPV can be treated using a procedure called the Epley manoeuvre.

The Epley manoeuvre

The Epley manoeuvre is a type of procedure called a canalith repositioning procedure. It is often effective in resolving the symptoms of vertigo.

The Epley manoeuvre involves performing four separate head movements to move the fragments that cause vertigo to a place where they will no longer cause symptoms. Each head position is held for at least 30 seconds. You may experience some vertigo during the movements.

In the past, patients were given instructions to follow after performing the Epley manoeuvre, such as not lying flat for 48 hours. However, this is now considered unnecessary.

Your symptoms should improve shortly after the Epley manoeuvre is performed, although it may take up to two weeks for a complete recovery. Return to your GP if your symptoms haven't improved after four weeks. The Epley manoeuvre isn't usually a long-term cure and may need to be repeated.

Brandt-Daroff exercises

If the Epley manoeuvre doesn't work or if it's not suitable – for example, because you have neck or back problems – you can also try Brandt-Daroff exercises. These are a series of movements you can do unsupervised at home to treat BPPV.

Your GP will need to teach you how to do the exercises. You repeat them three or four times a day for two days in a row. Your symptoms may improve for up to two weeks.

Referral for BPPV

Your GP may refer you to a specialist, such as an ear, nose and throat (ENT) specialist if:

  • the Epley manoeuvre doesn't work or can't be performed
  • you still have symptoms after four weeks
  • you have unusual signs or symptoms

In rare cases, where the symptoms of vertigo last for months or years, surgery may be recommended. This may involve blocking one of the fluid-filled canals in your ear. Your ENT specialist will be able to advise you further about this.

Ménière's disease

If your vertigo is caused by Ménière's disease (a rare condition that affects the inner ear), there are a number of treatment options for both the vertigo and other symptoms caused by the condition.

Possible treatments for Ménière's disease include:

  • dietary advice, particularly a low salt diet
  • medication to treat attacks of Ménière's disease
  • medication to prevent attacks of Ménière's disease
  • treatment for tinnitus (ringing in your ears), such as sound therapy, a therapy that works by reducing the difference between tinnitus sounds and background sounds to make the tinnitus sounds less intrusive
  • treatment for hearing loss, such as using hearing aids
  • physiotherapy to deal with balance problems
  • treatment for the secondary symptoms of Ménière's disease, such as stress, anxiety and depression

See treating Ménière's disease for more information.

Central vertigo

Central vertigo is caused by problems in part of your brain, such as the cerebellum (which is located at the bottom of the brain) or the brainstem (the lower part of the brain that's connected to the spinal cord).

Causes of central vertigo include migraine headaches and, less commonly, brain tumours.

If your GP suspects you have central vertigo, they may organise a scan or refer you to a hospital specialist, such as a neurologist or an ENT (ear, nose and throat specialist) or audiovestibular physician.

Migraines

You can be treated at home if you've already been diagnosed with vertigo caused by migraines. The condition may be treatable with the same medications used to control migraines, such as triptans.

See treating migraines for more information.

Vertigo with an unknown cause

If the cause of your vertigo is unknown, you may be admitted to hospital if:

  • you have severe nausea and vomiting and can't keep fluids down
  • your vertigo comes on suddenly and was not caused by you changing position
  • you possibly have central vertigo
  • you have sudden hearing loss but it's not thought to be Ménière's disease

Alternatively, you may be referred to a specialist such as:

  • a neurologist – a specialist in treating conditions that affect the nervous system
  • an ENT specialist – a specialist in conditions that affect the ear, nose or throat
  • an audiovestibular physician – a specialist in hearing and balance disorders

While waiting to see a specialist, you may be treated with medication. 

Vestibular rehabilitation

Vestibular rehabilitation, also called vestibular rehabilitation training or VRT, is a form of "brain retraining". It involves carrying out a special programme of exercises that encourage your brain to adapt to the abnormal messages sent from your ears.

During VRT you keep moving despite feelings of dizziness and vertigo. Your brain should eventually learn to rely on the signals coming from the rest of your body, such as your eyes and legs, rather than the confusing signals coming from your inner ear. By relying on other signals, your brain minimises any dizziness and helps you maintain your balance.

An audiologist (hearing specialist) or a physiotherapist may provide VRT. Your GP may be able to refer you for VRT, although it will depend on availability in your area.

In some cases, it may be possible to use VRT without specialist help. Research has shown people with some types of vertigo can improve their symptoms using a self-help VRT booklet. However, you should discuss this with your doctor first. If it is likely to be useful, you can download a copy of this booklet from the Ménière's society.

Medicines

Medication can be used to treat episodes of vertigo caused by vestibular neuronitis or Ménière's disease. It may also be used for central vertigo or vertigo with an unknown cause.

The medicines are usually prescribed for 3 to 14 days, depending on which condition they're for. The two medicines that are usually prescribed are:

  • prochlorperazine
  • antihistamines

If these medicines are successful in treating your symptoms, you may be given a supply to keep at home so you can take them the next time you have an episode of vertigo.

In some cases you may be advised to take long-term medication, such as betahistine, for conditions like Ménière's disease.

Prochlorperazine

Prochlorperazine can help relieve severe nausea and vomiting associated with vertigo. It works by blocking the effect of a chemical in the brain called dopamine.

Prochlorperazine can cause side effects, including tremors (shaking) and abnormal or involuntary body and facial movements.

It can also make some people feel sleepy. For the full list of possible side effects, check the patient information leaflet that comes with your medicine or see prochlorperazine medicines information.

If you're vomiting, there are some types of prochlorperazine that dissolve on your tongue so you don't have to swallow any tablets. It can also be administered as a suppository (a medication inserted into the rectum).

Antihistamines

Antihistamines can be used to help relieve less severe nausea, vomiting and vertigo symptoms. They work by blocking the effects of a chemical called histamine.

Possible antihistamines that may be prescribed include:

Like prochlorperazine, antihistamines can also make you feel sleepy. Headaches and an upset stomach are also possible side effects. Check the patient information leaflet that comes with your medicine for the full list of possible side effects.

A medication called betahistine works in a similar way to antihistamines. It has been used to treat Ménière's disease and may also be used for other balance problems. It may have to be taken for a long period of time. The beneficial effects vary from person to person.

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