Vertigo

Prevalence of Vertigo and Dizziness in Canada

Vertigo and dizziness are common issues that affect many Canadians. In fact, according to studies, about 30% of people in Canada will experience dizziness at some point in their lives, and vertigo is one of the most frequent complaints in emergency departments. These balance disorders can significantly impact daily life, making it hard to walk, work, or even stand still. Vertigo specifically involves a sensation of spinning or moving when you're not actually moving. In this blog, we’ll explore the different types of vertigo, common causes, and what to do if you or someone you know is affected by it.

Types of Vertigo and Dizziness

There are several different sensations related to balance issues, and not all of them are classified as "true vertigo." Here are the main types:

• "True" Vertigo: This is the classic spinning sensation, as if the world is moving around you. It's often caused by problems in the inner ear or vestibular system. The analogy I use with my patients would be feeling like you are in a very rapid merry-go-round, or the sensation you have after spinning around a stick with your head down (you know, that game as a child) for a minute then trying to stand still - you'll feel your head is still spinning.
  
  

• Dizziness: A general term that describes various sensations, from feeling like you're swaying, unsteady or weak. Usually is not associated with a spinning sensation, and typically not caused by an inner ear issue. The analogy here would be feeling like you're on a boat, or on a wave. Some patients may describe their sensation as "brain fog" too. The feeling could be temporary (like a spell), more prolonged or even constant. 
  
  

• Loss of Balance: Also called disequilibrium, this is when you feel unsteady on your feet or wobbly. Often experienced as a feeling of unsteadiness or difficulty walking straight. It’s can happen with aging but can also be a sign of a vestibular or neurological issue. Patients frequently mention that they need to steady themselves by placing a hand on walls or furniture to feel safe while moving around.
  
  

• Light-Headedness: A feeling that you are about to faint or pass out, often caused by a drop in blood pressure or dehydration, rather than a problem with the ear. Typically associated with rapid change of position. Patients can report associated visual changes (black dots) or sweating.
  
  

• Gait or Coordination Issues: Problems mainly with walking, where you may feel unsteady or stagger (as opposed to loss of balance which can occur in various circumstances). Patient can report feeling weak on their feet, afraid to fall. They may mention "feeling dizzy", but with clarification, it often becomes apparent that it's more related to their gait than actual dizziness. This can occur in conditions affecting the brain, muscles, or vestibular system.

Symptoms Commonly Associated with Vertigo

During an initial consultation for vertigo, taking a detailed medical history is crucial in determining the cause of the symptoms. The following questions help describe and clarify the vertigo symptoms and must be answered to help tailor the diagnosis. I strongly believe it is important to allow patients to describe their symptoms in their own words for an accurate assessment.

1. Type of dizziness : spinning, swaying, light headedness, etc
2. Duration of dizziness: seconds, minutes, hours, days, weeks, constant
3. Frequency of spells: once a day, multiple times a day, etc.
4. Last dizzy spell
5. Triggering event: certain movements, positions (like turning the head or lying down), walking, running, certain postures, head trauma, medications
6. Associated symptoms: headaches, hearing loss, tinnitus, ear fullness, nausea, vomiting, etc. See below.

As mentioned, vertigo isn’t just about the sensation of spinning or dizziness. Other symptoms often come along with it, such as:

• Nausea or vomiting: The spinning sensation can disrupt your stomach, causing nausea.
  
  
• Hearing changes: Hearing loss can accompany vertigo, particularly in cases related to inner ear issues. Is it important to distinguish hearing loss that occurs specifically with the vertigo spell (which would be relevant to the vertigo diagnosis) from hearing loss that is chronic or progressive.
  
  
• Ear fullness: Also points to an inner ear issue.
  
  
• Tinnitus: Also points to an inner ear issue, usually accompanies the hearing loss.
  
  
• Sweating and palpitations: Some people feel flushed, sweaty, or like their heart is racing during a vertigo episode.
  
  
• Nystagmus: This is when your eyes move involuntarily, often in a jerking motion, which can occur with certain types of vertigo. I will usually ask my patients to try to record their nystagmus with their phone if possible (usually the partner will record). The type and direction of the nystagmus is an essential part of the diagnosis. 
  
  
• Headaches: Some forms of vertigo, especially central causes, are associated with migraines or headaches. This symptom is quite common.
  
  
• Cognitive symptoms: Experiencing dizziness can place a significant mental burden on your brain. Many patients report symptoms such as "brain fog," challenges with concentration, and memory issues. Although these symptoms are not directly caused by dizziness, they can result from it. Generally, they are not associated with inner ear problems.
  
  
• Sensitivity to visual stimulation: Patients may report having trouble in large open spaces (grocery stores), in outdoor environments or in situations where there is intense visual stimulation. Typical examples include being on a subway, in a vehicle, or when using screens and mobile devices. Associated with central disorders such as migraines, post-concussive syndromes and PPPD (see below).
  
  
• Sensitivity to sound: Condition where sounds, such as talking, traffic, or household noises, seem unbearably loud or uncomfortable. This can be caused by inner ear disorders (superior canal dehiscence for example) or central disorders, typically migraines or post-concussive syndrome. When caused by superior canal dehiscence, it is more likely to be a sensitivity to loud sounds (instead of everyday sounds), and the sound will trigger an immediate vertigo spell.
  
  
• Neurological symptoms: Examples would include trouble swallowing, trouble speaking, vision changes, limb weakness, facial or limb numbness. These would all indicate a neurological (central) disorder. 

Preparing for Your Appointment with an ENT Specialist 

Before your appointment with an ENT specialist, it would be very important to think about how you'll describe your vertigo symptoms. In my experience, many patients find it challenging to articulate their symptom clearly when facing the doctor, which complicates our diagnosis since vertigo is highly subjective. To assist with this, maintain a "vertigo calendar" for at least three months if possible. It is important not to overwhelm that calendar. Mark down the days you experience vertigo and complete it with the clinical details listed earlier (items 1-6). This will help your doctor gain a clearer understanding of your condition. Have your list of medications ready as well. If you experience a dizzy spell where your eyes move involuntarily (nystagmus), try to record it on your phone (you or anyone else with you if you are too dizzy); this visual record of the nystagmus can be invaluable for your doctor in diagnosing the issue.

Physiologic Vertigo 

Before we discuss "pathological" causes of vertigo, I wanted to address the topic of "physiologic vertigo". This term refers to dizziness or imbalance that occurs in response to normal sensory inputs, often in situations where the brain receives conflicting signals from the eyes, inner ears, and body. This leads to a sensory mismatch. Common examples include :

• Fear of heights. When a person is at a significant height, their eyes perceive distance differently, causing a mismatch between visual and balance signals, leading to dizziness or vertigo.
  
  
• Motion sickness. Happens when the inner ear senses movement (such as in a car or boat) but the eyes don't see it, or vice versa, creating confusion in the brain.

Both conditions are natural responses, and while uncomfortable, they typically resolve once the conflicting stimuli are removed. Prevention strategies, such as focusing on a fixed point during motion or gradually exposing oneself to heights, can help reduce symptoms. There is no medical treatment needed. Sometimes physiotherapy can help you become more resilient to these situations if they become really problematic.

Central vs. Peripheral Causes of Vertigo

When diagnosing vertigo, doctors usually classify it as either central or peripheral, depending on where the issue originates.

• Peripheral vertigo involves problems with the inner ear or the vestibular (balance) nerve. This typically causes "true" spinning vertigo.
  
  

• Central vertigo refers to issues within the brain, particularly in the brainstem or cerebellum, which are involved in controlling balance. This may cause non-spinning dizziness, unsteadiness and gait issues.

Here’s a breakdown of some common causes for each (some of these causes are explored in more detail in separate articles):

Peripheral (or vestibular) Causes

1. Benign Paroxysmal Positional Vertigo (BPPV): Small crystals in the inner ear move into the wrong position, causing brief episodes of vertigo. The most common cause of peripheral vertigo.
   
   
2. Vestibular Neuritis: Inflammation of the vestibular nerve, often due to a viral infection.
   
   
3. Meniere's Disease: A buildup of fluid in the inner ear, causing vertigo, hearing loss, and tinnitus.
   
   
4. Labyrinthitis: Inflammation of the inner ear, often from an infection, causing vertigo and hearing loss.
   
   
5. Perilymph Fistula: A small tear in the membrane between the middle and inner ear, causing dizziness when pressure changes.
   
   
6. Acoustic Neuroma: A non-cancerous tumor on the vestibular nerve, causing vertigo and hearing loss.
   
   
7. Superior Canal Dehiscence Syndrome: A small opening in the bone of the inner ear, causing vertigo and hearing problems.
   
   
8. Ototoxicity (vestibulotoxicity): Damage to the inner ear caused by certain medications or radiotherapy.
   
   
9. Otitis: A infection or fluid build up in the middle ear can cause pressure on the openings of the adjacent inner ear (called "windows") and cause vertigo. Usually temporary once the infection or fluid is cured.
   
   
10. Cholesteatoma: A non-cancerous growth in the middle ear that can affect balance if it destroys the inner ear structures, most commonly the horizontal semi-circular canal. Unlike the other causes listed above, a cholestestoma would easily be apparent on an ear physical exam (micro-otoscopy).

Central Causes

1. Vestibular migraines (or migraine-associated vertigo): One of the most common causes of vertigo, especially in females. Vertigo usually associated with migraine headaches, but can also occur without the headache itself. Typically associated with light and sound sensitivity. Can cause spinning or non-spinning dizziness.
   
   
2. Concussion (traumatic brain injury, TBI): Injury to the brain can affect balance and lead to vertigo. Can happen even in the mildest form of TBI. Usually associated with non-spinning dizziness. Symptoms are often chronic and do not arise in spells.
   
   
3. PPPD (Persistent postural perceptual dizziness): Type of functional neurologic disorder. Patients report chronic dizziness characterized by a constant sensation of imbalance or unsteadiness, often triggered by motion or visually complex environments. It typically develops after an episode of acute vertigo or vestibular dysfunction and is worsened by stress or anxiety.
   
   
4. Stroke: A disruption of blood flow to the brain can cause sudden vertigo and balance issues. Would rarely present with only vertigo as a symptom, usually accompanied by other neurological symptoms. This is a life-threatening emergency that requires immediate care.
   
   
5. Multiple Sclerosis (MS): A disease that affects the nervous system, sometimes causing vertigo as one of its symptoms. MS rarely presents with vertigo as the first symptom (visual changes would be much more common).
   
   
6. Tumors: Brain tumors, particularly those affecting the cerebellum or brainstem, can cause vertigo. Typically, these would be benign.
   
   
7. Cerebellar Ataxia: A condition that affects the part of the brain responsible for coordination, leading to balance issues and vertigo. Leads to trouble with coordination and gait.
   
   
8. Vertebrobasilar Insufficiency: Reduced blood flow to the back of the brain, causing dizziness and vertigo. Usually causes brief spells of vertigo with certain neck positions that are associated with other neurological symptoms such as blurry vision or trouble swallowing or speaking.  
   
   
9. Chiari Malformation: A structural defect in the brain that can cause pressure and affect balance (not so much spinning vertigo).
   
   
10. Parkinson’s Disease: A progressive nervous system disorder that can include balance issues as a symptom.

Other causes :

Cervicogenic dizziness is a characterized by a combination of 1) dizziness and associated neck pain, 2) imbalance or unsteadiness and 3) limited cervical range of motion. I listed it under "other" because it is neither a peripheral disorder (as the inner ear functions well) or a central disorder (although some would consider it a form of central disorder). It is believed to stem from dysfunction in the cervical spine, particularly in the neck muscles, joints, or nerves. The exact pathophysiology isn’t fully understood, but it’s thought that abnormal signals from neck proprioceptors (sensory receptors that detect movement and position) may interfere with the brain’s balance control, leading to dizziness and unsteadiness. Cervicogenic dizziness is commonly associated with degenerative neck diseases (arthritis), neck injuries such as whiplash from car accidents, or conditions like cervical spondylosis (wear and tear of the neck vertebrae) and muscle tension. Diagnosing cervicogenic dizziness can be challenging, as symptoms often overlap with other dizziness causes, but physical therapy and neck exercises are typically effective treatments. 

Diagnostic work-up

A detailed history is the most critical part of the diagnosis. It is very important to let the patient describe their vertigo. Unfortunately, this is where many healthcare providers fall short. A properly done medical history can avoid a lot of unnecessary testing. With the history, I can usually narrow down the diagnosis to a few potential causes, and the physical exam then allows me to pinpoint that even more. Only then would I obtain additional testing. The physical exam must include a complete neuro-vestibular exam, including a positional testing (such as Dix-Hallpike and supine roll).

When ordering diagnostic tests, I adopt a step-by-step approach rather than requesting all tests simultaneously. This approach allows me to confirm or dismiss my preliminary clinical hypotheses, initiate treatment more rapidly (avoiding delays associated with waiting for numerous test results, which can be time-consuming in public health systems like Canada's), and minimize unnecessary costs or discomfort for the patient. Here are some of the most common tests.

For Peripheral Causes:

• Audiometry (hearing tests): Usually the first test I order. It is non-invasive, inexpensive and quick to get. It assesses for hearing loss that frequently would accompany certain inner ear vertigo disorders (such as Menière's).
  
  
• Videonystagmography (VNG): This consists of a series of tests that provides information on the health of the vestibular system and of the oculomotor (eyes) system. Read more about it here.
  
  
• vHIT, VEMP, ECoG (other vestibular tests). Similar to the VNG, these tests assess different aspects of the vestibular system. It helps us determine if and what part of the vestibular system is damaged or not functioning properly.
  
  
• Imaging (CT temporal bone or MRI of the internal auditory canal): Not used routinely. Recommended to assess certain specific conditions such as, but not limited to, superior canal dehiscence, inner ear malformations and acoustic neuromas.

For Central Causes:

Diagnosis usually involves imaging tests like MRI or CT scans, neurological exams, and sometimes blood tests. These help identify issues within the brain or central nervous system. A neurology consultation would be indicated. 

Dizziness Handicap Inventory (DHI)

The Dizziness Handicap Inventory (DHI) is a questionnaire used to assess the impact of dizziness on a person's daily life, particularly focusing on physical, emotional, and functional aspects. It consists of 25 questions, with each question answered as "Yes," "Sometimes," or "No." Each "Yes" response scores 4 points, "Sometimes" scores 2 points, and "No" scores 0 points. The total score ranges from 0 to 100, with higher scores meaning a more significant impact of dizziness on the individual’s quality of life. A score between 0-30 suggests mild handicap, 31-60 indicates moderate handicap, and 61-100 signifies a severe handicap. Clinically, the DHI is used by healthcare providers to evaluate how dizziness affects a patient's daily activities, social interactions, and emotional well-being. It helps guide treatment decisions by identifying specific areas of difficulty and monitoring progress over time, especially in vestibular rehabilitation or medical management.

Treatment Options for Vertigo

This section will focus on the peripheral causes of vertigo, as central causes would lie outside of my area of expertise. It also presents the general concepts of vertigo treatment, for more details please refer to the articles discussing individual disorders.

Effective treatment starts with diagnosing the right condition. Once that is established, there are usually three approaches to treating vestibular disorders. Some conditions require one form of treatment, but more commonly they need a combination of one of these three:

Medical Treatment:

Focuses on both symptomatic relief (reducing the sensation of vertigo during a spell) and treating underlying causes.

• Vestibular suppressants (reducing the sensation of vertigo): antihistamines (e.g., meclizine) and benzodiazepines (e. g., Valium) can reduce acute symptoms such as vertigo and nausea, but are generally used short-term to avoid dependency and other side effects.
  
  
• For underlying causes, diuretics (water pills) are often prescribed in cases like Ménière’s disease to reduce fluid buildup in the inner ear. Corticosteroids, taken orally or injected directly into the middle ear (intratympanic steroids), may help reduce inflammation in the inner ear, often used in Ménière's disease, autoimmune inner ear disease or sudden sensorineural hearing loss.

Surgical management

Is considered when other treatments fail or for specific issues that can only be fixed with surgeries. For superior canal dehiscence, a surgical "canal plugging" procedure can help eliminate abnormal fluid movement in the affected canal, reducing vertigo. In Ménière's disease, endolymphatic sac decompression or clipping, or vestibular nerve sectioning may be options for severe, unresponsive cases. For benign paroxysmal positional vertigo (BPPV) that persists despite aggressive conservative treatment, a posterior canal occlusion surgery, though rare, might be considered. Other surgeries include repairing a perilymph fistula and removing an acoustic neuroma.

Vestibular physiotherapy

Is a key part of managing vestibular disorders, focusing on exercises that retrain the brain to compensate for inner ear dysfunction. This includes balance training, gaze stabilization, and habituation exercises designed to help patients adapt to motion sensitivity and reduce dizziness. Vestibular rehabilitation therapy is especially effective for conditions like BPPV, unilateral vestibular hypofunction and PPPD, significantly improving function and quality of life.

Conclusion

Vertigo can be a challenging condition to live with, but with the right diagnosis and treatment plan, many people can manage their symptoms effectively. If you’re experiencing persistent dizziness or balance issues, it’s important to consult a healthcare professional to determine the cause and find the best treatment options for you.