Uncovering the Cause of Vertigo

Pohla Smith

Posted June 25, 2012

Vertigo, the sensation of you or your surroundings spinning around, is common -- primary care physician Marc Itskowitz estimates it's in the top 10 of his patients' complaints -- but it isn't a disease. It's a symptom of disease.

Many of them.

"There are multiple disorders that can cause vertigo," said Joseph Furman, an otoneurologist and neurologist who directs the UPMC Center for Balance Disorders. "Some are common and some are uncommon."

Which of those disorders is most common depends upon the doctor you talk to.

Dr. Furman named vestibular migraine, related to the inner ear balance system and the part of the brain that controls the inner ear, as the biggest offender. It is the most common cause of vertigo among women of child-bearing age, he said.

Douglas Chen, a neurotologist and director of the Hearing and Balance Center at Allegheny General Hospital, cited inner ear infection, or vestibular neuritis, as the most common source of vertigo.

Dr. Itskowitz, also of AGH, said he most often sees a disorder called benign paroxysmal positional vertigo. Called BPPV for short, it's caused when crystals in your inner ear (related to your sensations of movement and gravity) come loose and make you dizzy when you change your head position.

"About half the time they just come loose on their own for no obvious reason, and about half the time there is a reason," Dr. Furman said. The two most common reasons are head trauma and viral infections of the inner ear. It is more often seen in people over 30 or 40 because it's a degenerative process of the inner ear, Dr. Chen said.

Also common, said Drs. Furman and Chen, is Meniere's disease, which is caused by a buildup of fluid in the inner ear.

"There are about a half-dozen conditions that take care of most [of the vertigo] and then many others occur infrequently," Dr. Furman said.

Among the other causes of vertigo are brain tumors, strokes, surgery, general anesthesia, some medications, brain injury and inter-cranial hemorrhage.

Each disease or condition has its own symptoms and its own treatments, the doctors said.

To diagnose which one the patient has, Dr. Chen said, "the [patient's] history is key, vital. It distinguishes the type. ... There are balance tests, but the history is vital in sorting out the problems."

With vestibular migraine, for example, the patient often has had a headache, though not necessarily at the same time as the vertigo. It is treated the same way as the migraine headache, by lifestyle changes that call for avoiding chocolate, red wine, cheese and caffeine and by giving medications for a while, Dr. Furman said.

Patients with benign paroxysmal positional vertigo usually just have vertigo, though they also may experience nausea, vomiting, hearing loss, and balance and vision problems.

The most common treatment is a physical procedure that can be done by a doctor, physical therapist or other trained health care professional called the Epley maneuver. It is intended to move the loose crystals from the sensitive part of the inner ear to a less sensitive location. "That works 80 to 90 percent of the time," Dr. Chen said.

Meniere's disease is accompanied by hearing loss and ringing in the ear, usually in just one side. "We usually reduce the amount of sodium people are consuming and put them on a diuretic to reduce fluid pressure in the inner ear," Dr. Furman said. Patients who get nauseated and vomit sometimes are given anti-nausea drugs to take as needed.

Vestibular neuritis, often preceded by flu-like illness, is an inflammation of the nerve that controls balance and often goes away by itself. But Dr. Furman said he usually puts his patients on oral steroids for about 10 days to reduce the inflammation.

According to medical literature, Dr. Chen said, 80 percent of Meniere's patients will have their symptoms of vertigo controlled, and 80 to 90 percent of patients with benign paroxysmal positional vertigo will have resolved symptoms. More than 90 percent of patients with vestibular neuritis will recover spontaneously, the literature says. Based on his own experience, Dr. Chen estimated that vestibular migraine is controlled 80 to 90 percent of the time.

For the few patients with Meniere's disease or positional vertigo who don't respond to treatment, various surgeries are available, but surgery for the latter is only rarely performed.

Pohla Smith: psmith@post-gazette.com or 412-263-1228.

©2012 the Pittsburgh Post-Gazette

 
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