How long does vertigo typically last. What are the common causes of vertigo episodes. Can vertigo go away completely on its own. What are effective treatments for managing vertigo symptoms.

What is Vertigo and How Does it Differ from Dizziness?

Vertigo is often confused with general dizziness, but there are key differences between these two sensations. Vertigo specifically refers to the false sensation that you or your surroundings are spinning or moving, even when you’re stationary. This can create a very disorienting experience.

In contrast, dizziness typically causes a feeling of lightheadedness or wooziness without the spinning sensation. While both can be unsettling, vertigo tends to be more intense and disruptive to daily activities.

Common Symptoms Associated with Vertigo

In addition to the characteristic spinning sensation, vertigo often comes with other symptoms, including:

• Nausea and vomiting
• Loss of balance
• Sweating
• Abnormal eye movements (nystagmus)
• Ringing in the ears (tinnitus)
• Temporary hearing loss

The severity and combination of these symptoms can vary depending on the underlying cause and individual factors.

How Long Do Typical Vertigo Episodes Last?

The duration of vertigo episodes can vary widely, ranging from just a few seconds to several days in severe cases. However, most episodes tend to be relatively brief, lasting only seconds to minutes. The specific length often depends on the underlying cause of the vertigo.

Factors Affecting Vertigo Duration

Several factors can influence how long a vertigo episode lasts:

1. Underlying condition causing the vertigo
2. Severity of the episode
3. Individual physiology and health status
4. Presence of triggers or exacerbating factors
5. Effectiveness of any treatment measures

Understanding these factors can help in managing and potentially shortening the duration of vertigo episodes.

Common Causes of Vertigo and Their Typical Durations

Different underlying conditions can lead to vertigo, each with its own characteristic pattern and duration of symptoms. Here are some of the most common causes:

Benign Paroxysmal Positional Vertigo (BPPV)

BPPV is one of the most frequent causes of vertigo. It occurs when small calcium crystals in the inner ear become dislodged, leading to false signals about head position and movement. BPPV episodes are typically very short, lasting less than one minute. However, they can recur frequently if left untreated.

Meniere’s Disease

This inner ear disorder can cause severe vertigo episodes lasting hours or even days. Meniere’s disease is often accompanied by fluctuating hearing loss, tinnitus, and a feeling of fullness in the affected ear. The unpredictable nature of these episodes can be particularly challenging for those affected.

Vestibular Neuritis or Labyrinthitis

These conditions involve inflammation of the inner ear or vestibular nerve, often due to viral infections. Vertigo from these causes can persist for days or even weeks as the inflammation subsides. Proper medical treatment can help manage symptoms and potentially shorten the duration.

Can Vertigo Resolve on Its Own?

In some cases, vertigo can indeed resolve on its own without specific treatment. This is particularly true for milder cases or those caused by temporary factors like certain medications or dehydration. However, it’s important to note that recurring or severe vertigo often requires medical intervention for proper management and relief.

When to Seek Medical Attention

While some vertigo episodes may resolve spontaneously, there are situations where prompt medical attention is crucial:

• Vertigo accompanied by severe headache, vision changes, or difficulty speaking
• Persistent vertigo lasting more than a few hours
• Vertigo that significantly interferes with daily activities
• Any new or unexplained vertigo, especially in older adults

Early diagnosis and treatment can often lead to better outcomes and prevent complications.

Effective Treatment Options for Managing Vertigo

The treatment approach for vertigo depends largely on its underlying cause. However, several strategies can help manage symptoms and potentially shorten episode duration:

Vestibular Rehabilitation Therapy

This specialized form of physical therapy helps train the brain to compensate for inner ear problems. It can be particularly effective for chronic vertigo conditions and may help reduce the frequency and severity of episodes.

Canalith Repositioning Procedures

For BPPV, specific head movements can help reposition the displaced calcium crystals in the inner ear. The Epley maneuver is a common example that can often provide immediate relief when performed correctly.

Medications

Various medications can help manage vertigo symptoms:

• Antihistamines to reduce inner ear inflammation
• Antiemetics to control nausea and vomiting
• Diuretics for conditions like Meniere’s disease
• Vestibular suppressants for acute, severe episodes

It’s important to use these medications under medical supervision, as some can have side effects or interact with other conditions.

Lifestyle Modifications to Reduce Vertigo Frequency

In addition to medical treatments, certain lifestyle changes can help minimize vertigo episodes and their impact:

Dietary Adjustments

For some individuals, particularly those with Meniere’s disease, reducing salt intake and avoiding trigger foods like caffeine and alcohol can help manage symptoms. Staying well-hydrated is also important for overall vestibular health.

Stress Management

Stress can exacerbate vertigo in some people. Incorporating stress-reduction techniques like meditation, yoga, or deep breathing exercises may help reduce the frequency and severity of episodes.

Sleep Hygiene

Maintaining a consistent sleep schedule and ensuring adequate rest can support overall vestibular function and potentially reduce vertigo occurrences.

Long-Term Outlook for Individuals with Vertigo

The prognosis for vertigo varies depending on its underlying cause. Many cases, especially those related to BPPV or vestibular neuritis, can be effectively managed or may resolve completely with proper treatment. However, some conditions like Meniere’s disease may require ongoing management.

With appropriate medical care and lifestyle adjustments, most individuals with vertigo can experience significant improvement in their symptoms and quality of life. Regular follow-ups with healthcare providers can help monitor progress and adjust treatment plans as needed.

Preventive Measures and Safety Considerations

While not all cases of vertigo can be prevented, certain measures can help reduce the risk of episodes or complications:

Fall Prevention

Individuals prone to vertigo should take precautions to prevent falls, especially during episodes. This may include:

• Removing tripping hazards from the home
• Using assistive devices like handrails or walking aids when necessary
• Avoiding sudden head movements or position changes

Driving Safety

It’s crucial to avoid driving during active vertigo episodes. Those with frequent or unpredictable vertigo may need to discuss driving restrictions with their healthcare provider to ensure safety on the road.

Regular Check-ups

Routine medical evaluations can help identify and address potential vertigo triggers or underlying conditions before they lead to severe episodes. This is particularly important for individuals with a history of vertigo or associated conditions.

By understanding the nature of vertigo, its potential causes, and available management strategies, individuals can work towards minimizing its impact on their daily lives. While the experience of vertigo can be unsettling, with proper care and attention, many people find effective ways to manage their symptoms and maintain a good quality of life.

How Long Does Vertigo Last? Mild-to-Severe Symptom Duration

How Long Does Vertigo Last? Mild-to-Severe Symptom Duration

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Medically reviewed by Elaine K. Luo, M.D. — By Kimberly Holland — Updated on March 30, 2019

Vertigo isn’t a disease or a condition on its own but a symptom of an underlying condition. Identifying the cause of your vertigo can help find a treatment that works to prevent episodes from occuring.

Overview

Episodes of vertigo can last a few seconds, a few minutes, a few hours, or even a few days. In general, however, an episode of vertigo typically lasts just seconds to minutes.

Vertigo isn’t a disease or condition. Instead, it’s a symptom of a condition. Identifying the underlying cause of your vertigo can help you and your doctor find a treatment that works to prevent the episodes.

Vertigo is different from dizziness. This is because the sensations from vertigo make you feel like your surroundings are moving, or that you’re moving when you’re actually standing still. Dizziness typically causes you to feel woozy or lightheaded.

Vertigo episodes may come and go and cause sudden, severe episodes of disorientation. They can also be incredibly mild, or be chronic and last for longer periods of time.

Other symptoms of vertigo include:

• feeling nauseated
• sweating
• vomiting
• abnormal or unusual eye movements, such as jerking
• loss of balance
• ringing in the ears
• hearing loss

The cause of your vertigo plays a big role in how long your symptoms will last.

Benign paroxysmal positional vertigo (BPPV)

BPPV is one of the most common causes of vertigo. The average episode reoccurs but usually lasts for one minute or less.

Meniere’s disease

A severe episode of vertigo caused by Meniere’s disease can last for several hours or even days. This condition causes vertigo that can often cause vomiting, nausea, and hearing loss, as well as ringing in the ear.

Inner ear problems

Vertigo caused by inflammation or an infection in the inner ear may remain until the inflammation subsides. If you have any signs of inner ear problems, it’s important to talk to your doctor about treatment so they can get the vertigo under control. They’ll determine if there are any medications that may be right for the condition.

Stroke or head injury

Vertigo may be a permanent or semi-permanent state for some individuals. People who’ve had a stroke, head injury, or neck injury may experience long-term or chronic vertigo.

Other factors

There are other conditions and injuries that may cause episodes of vertigo. The length of your vertigo episode will depend on what that underlying cause is.

When you experience an episode of vertigo, it’s wise to practice these do’s and don’ts so you can stay safe and also reduce your chances of greater side effects or complications.

Get a diagnosis

If you haven’t already been diagnosed, see a doctor after you experience vertigo symptoms for the first time. Together, you and your doctor can review your symptoms and decide on a treatment plan that fits what you’re experiencing and what’s causing the symptoms.

Check out this list of vertigo-associated disorders for more information.

Sit somewhere safe

Take precautions to prevent injury as soon as you begin experiencing signs and symptoms of vertigo. The sensations you experience from an episode can be disorienting and may make you more likely to stumble or fall. This can lead to injury.

Get off the road

If you’re driving when a vertigo episode starts, pull over as soon as you’re able. Wait out the episode before you continue driving so you don’t put yourself and others at risk.

Begin home remedies

When vertigo symptoms start, your doctor may instruct you to perform self-care home remedies or physical therapy maneuvers to ease the symptoms. Do them as soon as you safely can.

Seek treatment

If vertigo is the result of a health complication you’re not treating, vertigo symptoms may become worse. You can begin to experience long-term health complications as a result of not treating the underlying cause for your vertigo.

Vertigo is bothersome, but it’s rarely a sign of a serious health problem. Treatment for vertigo aims to treat the underlying cause that’s producing the disorienting sensations in order to eliminate the symptoms. If a cause isn’t known, your doctor may also treat the symptoms of vertigo alone.

The most common treatments for vertigo include:

Home remedies

The majority of home remedies are designed to prevent or reduce the risk for a vertigo episode, but some can be used when the disorientation begins. These include:

• trying acupuncture
• avoiding caffeine, tobacco, and alcohol
• staying hydrated
• taking herbal supplements

Medications

Some medications may help stop severe vertigo episodes. The most commonly prescribed medications for vertigo are:

• anti-nausea medicines, such as promethazine (Phenergan)
• sedative medicines, such as diazepam (Valium)
• antihistamines, such as diphenhydramine (Benadryl)

These medicines may be administered by mouth, patch, suppository, or IV. Both over-the-counter (OTC) and prescription options are available.

Physical therapy maneuvers

Two main physical therapy maneuvers are used to treat symptoms of vertigo. Your doctor will work with you to learn the proper technique so you can perform them correctly. These maneuvers include:

• Modified Epley maneuvers. The Epley maneuver is a type of treatment that uses head and body movements to encourage the inner ear to reabsorb any matter that’s floating in the inner ear and causing vertigo. The relief can be immediate, or it may take several days.
• Vestibular rehabilitation exercises. Moving your head and body when you’re experiencing a vertigo episode may feel too difficult. Your doctor can teach you rehabilitation exercises that can help your brain adjust to the changes in the inner ear. These balancing techniques will help your eyes and other senses learn to cope with the disorientation.

Time

Waiting out the symptoms of vertigo may be the best option for some people. After all, vertigo can ease in a matter of hours, minutes, or even seconds. In those cases, you’re better off waiting for the body to correct itself than trying another treatment option.

If you experience episodes of vertigo, make an appointment to see your doctor. If you don’t already have a primary care provider, you can browse doctors in your area through the Healthline FindCare tool. Describe what you’re experiencing, how long the episodes last, and what makes them end, if you’ve used any type of treatment. Your doctor will perform a physical exam. They may also conduct several tests to check your eyes, hearing, and balance.

If those results aren’t enough for a conclusive diagnosis, your doctor may request some imaging tests to look at your brain. An MRI can give your doctor a detailed image of your brain.

You should seek emergency medical help if you experience vertigo with any of the following:

• a severe headache
• a high fever
• weakness in your arms or legs
• inability or trouble walking, speaking, hearing, or seeing
• passing out
• chest pain

It’s important to talk with your doctor any time you experience vertigo. They can work with you to understand the underlying cause and find treatments that can both prevent vertigo attacks and ease them if and when they occur.

Fortunately, most of the underlying causes of vertigo aren’t serious. They can be treated easily, which will eliminate vertigo episodes. If the underlying cause can’t be treated, your doctor can work with you to reduce disorientation and hopefully prevent future complications.

Last medically reviewed on March 7, 2018

How we reviewed this article:

Healthline has strict sourcing guidelines and relies on peer-reviewed studies, academic research institutions, and medical associations. We avoid using tertiary references. You can learn more about how we ensure our content is accurate and current by reading our editorial policy.

• Barton JJS. (2016). Benign paroxysmal positional vertigo.
  uptodate.com/contents/benign-paroxysmal-positional-vertigo
• Dizziness and vertigo. (2018).
  medlineplus.gov/dizzinessandvertigo.html
• Furman JM, et al. (2017). Patient education: Dizziness and vertigo (beyond the basics).
  uptodate.com/contents/dizziness-and-vertigo-beyond-the-basics
• Mayo Clinic Staff. (2015). Dizziness.
  mayoclinic.org/diseases-conditions/dizziness/symptoms-causes/syc-20371787
• Rubinstein J. (n.d.). Vertigo: Frequently asked questions.
  uihc.org/health-library/vertigo-frequently-asked-questions
• Vertigo. (2015).
  nhsdirect.wales.nhs.uk/encyclopaedia/v/article/vertigo/

Our experts continually monitor the health and wellness space, and we update our articles when new information becomes available.

Current Version

Mar 30, 2019

Written By

Kimberly Holland

Edited By

Nizam Khan (TechSpace)

Mar 7, 2018

Medically Reviewed By

Elaine K. Luo, MD

Share this article

Medically reviewed by Elaine K. Luo, M.D. — By Kimberly Holland — Updated on March 30, 2019

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How Long Does Vertigo Last? Mild-to-Severe Symptom Duration

How Long Does Vertigo Last? Mild-to-Severe Symptom Duration

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Medically reviewed by Elaine K. Luo, M.D. — By Kimberly Holland — Updated on March 30, 2019

Vertigo isn’t a disease or a condition on its own but a symptom of an underlying condition. Identifying the cause of your vertigo can help find a treatment that works to prevent episodes from occuring.

Overview

Episodes of vertigo can last a few seconds, a few minutes, a few hours, or even a few days. In general, however, an episode of vertigo typically lasts just seconds to minutes.

Vertigo isn’t a disease or condition. Instead, it’s a symptom of a condition. Identifying the underlying cause of your vertigo can help you and your doctor find a treatment that works to prevent the episodes.

Vertigo is different from dizziness. This is because the sensations from vertigo make you feel like your surroundings are moving, or that you’re moving when you’re actually standing still. Dizziness typically causes you to feel woozy or lightheaded.

Vertigo episodes may come and go and cause sudden, severe episodes of disorientation. They can also be incredibly mild, or be chronic and last for longer periods of time.

Other symptoms of vertigo include:

• feeling nauseated
• sweating
• vomiting
• abnormal or unusual eye movements, such as jerking
• loss of balance
• ringing in the ears
• hearing loss

The cause of your vertigo plays a big role in how long your symptoms will last.

Benign paroxysmal positional vertigo (BPPV)

BPPV is one of the most common causes of vertigo. The average episode reoccurs but usually lasts for one minute or less.

Meniere’s disease

A severe episode of vertigo caused by Meniere’s disease can last for several hours or even days. This condition causes vertigo that can often cause vomiting, nausea, and hearing loss, as well as ringing in the ear.

Inner ear problems

Vertigo caused by inflammation or an infection in the inner ear may remain until the inflammation subsides. If you have any signs of inner ear problems, it’s important to talk to your doctor about treatment so they can get the vertigo under control. They’ll determine if there are any medications that may be right for the condition.

Stroke or head injury

Vertigo may be a permanent or semi-permanent state for some individuals. People who’ve had a stroke, head injury, or neck injury may experience long-term or chronic vertigo.

Other factors

There are other conditions and injuries that may cause episodes of vertigo. The length of your vertigo episode will depend on what that underlying cause is.

When you experience an episode of vertigo, it’s wise to practice these do’s and don’ts so you can stay safe and also reduce your chances of greater side effects or complications.

Get a diagnosis

If you haven’t already been diagnosed, see a doctor after you experience vertigo symptoms for the first time. Together, you and your doctor can review your symptoms and decide on a treatment plan that fits what you’re experiencing and what’s causing the symptoms.

Check out this list of vertigo-associated disorders for more information.

Sit somewhere safe

Take precautions to prevent injury as soon as you begin experiencing signs and symptoms of vertigo. The sensations you experience from an episode can be disorienting and may make you more likely to stumble or fall. This can lead to injury.

Get off the road

If you’re driving when a vertigo episode starts, pull over as soon as you’re able. Wait out the episode before you continue driving so you don’t put yourself and others at risk.

Begin home remedies

When vertigo symptoms start, your doctor may instruct you to perform self-care home remedies or physical therapy maneuvers to ease the symptoms. Do them as soon as you safely can.

Seek treatment

If vertigo is the result of a health complication you’re not treating, vertigo symptoms may become worse. You can begin to experience long-term health complications as a result of not treating the underlying cause for your vertigo.

Vertigo is bothersome, but it’s rarely a sign of a serious health problem. Treatment for vertigo aims to treat the underlying cause that’s producing the disorienting sensations in order to eliminate the symptoms. If a cause isn’t known, your doctor may also treat the symptoms of vertigo alone.

The most common treatments for vertigo include:

Home remedies

The majority of home remedies are designed to prevent or reduce the risk for a vertigo episode, but some can be used when the disorientation begins. These include:

• trying acupuncture
• avoiding caffeine, tobacco, and alcohol
• staying hydrated
• taking herbal supplements

Medications

Some medications may help stop severe vertigo episodes. The most commonly prescribed medications for vertigo are:

• anti-nausea medicines, such as promethazine (Phenergan)
• sedative medicines, such as diazepam (Valium)
• antihistamines, such as diphenhydramine (Benadryl)

These medicines may be administered by mouth, patch, suppository, or IV. Both over-the-counter (OTC) and prescription options are available.

Physical therapy maneuvers

Two main physical therapy maneuvers are used to treat symptoms of vertigo. Your doctor will work with you to learn the proper technique so you can perform them correctly. These maneuvers include:

• Modified Epley maneuvers. The Epley maneuver is a type of treatment that uses head and body movements to encourage the inner ear to reabsorb any matter that’s floating in the inner ear and causing vertigo. The relief can be immediate, or it may take several days.
• Vestibular rehabilitation exercises. Moving your head and body when you’re experiencing a vertigo episode may feel too difficult. Your doctor can teach you rehabilitation exercises that can help your brain adjust to the changes in the inner ear. These balancing techniques will help your eyes and other senses learn to cope with the disorientation.

Time

Waiting out the symptoms of vertigo may be the best option for some people. After all, vertigo can ease in a matter of hours, minutes, or even seconds. In those cases, you’re better off waiting for the body to correct itself than trying another treatment option.

If you experience episodes of vertigo, make an appointment to see your doctor. If you don’t already have a primary care provider, you can browse doctors in your area through the Healthline FindCare tool. Describe what you’re experiencing, how long the episodes last, and what makes them end, if you’ve used any type of treatment. Your doctor will perform a physical exam. They may also conduct several tests to check your eyes, hearing, and balance.

If those results aren’t enough for a conclusive diagnosis, your doctor may request some imaging tests to look at your brain. An MRI can give your doctor a detailed image of your brain.

You should seek emergency medical help if you experience vertigo with any of the following:

• a severe headache
• a high fever
• weakness in your arms or legs
• inability or trouble walking, speaking, hearing, or seeing
• passing out
• chest pain

It’s important to talk with your doctor any time you experience vertigo. They can work with you to understand the underlying cause and find treatments that can both prevent vertigo attacks and ease them if and when they occur.

Fortunately, most of the underlying causes of vertigo aren’t serious. They can be treated easily, which will eliminate vertigo episodes. If the underlying cause can’t be treated, your doctor can work with you to reduce disorientation and hopefully prevent future complications.

Last medically reviewed on March 7, 2018

How we reviewed this article:

Healthline has strict sourcing guidelines and relies on peer-reviewed studies, academic research institutions, and medical associations. We avoid using tertiary references. You can learn more about how we ensure our content is accurate and current by reading our editorial policy.

• Barton JJS. (2016). Benign paroxysmal positional vertigo.
  uptodate.com/contents/benign-paroxysmal-positional-vertigo
• Dizziness and vertigo. (2018).
  medlineplus.gov/dizzinessandvertigo.html
• Furman JM, et al. (2017). Patient education: Dizziness and vertigo (beyond the basics).
  uptodate.com/contents/dizziness-and-vertigo-beyond-the-basics
• Mayo Clinic Staff. (2015). Dizziness.
  mayoclinic.org/diseases-conditions/dizziness/symptoms-causes/syc-20371787
• Rubinstein J. (n.d.). Vertigo: Frequently asked questions.
  uihc.org/health-library/vertigo-frequently-asked-questions
• Vertigo. (2015).
  nhsdirect.wales.nhs.uk/encyclopaedia/v/article/vertigo/

Our experts continually monitor the health and wellness space, and we update our articles when new information becomes available.

Current Version

Mar 30, 2019

Written By

Kimberly Holland

Edited By

Nizam Khan (TechSpace)

Mar 7, 2018

Medically Reviewed By

Elaine K. Luo, MD

Share this article

Medically reviewed by Elaine K. Luo, M.D. — By Kimberly Holland — Updated on March 30, 2019

Read this next

• How to Tell the Difference Between Dizziness and Vertigo

  Medically reviewed by Meredith Goodwin, MD, FAAFP

  Dizziness and vertigo are two similar feelings. Dizziness is a feeling of being off-balance. Vertigo is the feeling that you or your surroundings are…

  READ MORE

• I Feel Dizzy: Peripheral Vertigo

  Medically reviewed by Graham Rogers, M.D.

  Vertigo is dizziness that is often described as a spinning sensation. It may also feel like motion sickness or as if you’re leaning to one side.

  READ MORE

• Benign Positional Vertigo (BPV)

  Medically reviewed by Seunggu Han, M.D.

  Benign positional vertigo (BPV) is the most common cause of vertigo, the sensation of spinning or swaying. Learn about causes, symptoms, risk factors…

  READ MORE

• Why Do I Feel Dizzy When I Lie Down?

  Medically reviewed by Seunggu Han, M.D.

  One of the most frequent sources of vertigo, or the unexpected feeling that you or the room around you is spinning, is benign paroxysmal positional…

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Persistent postural perceptual vertigo in the elderly

The elderly often have a fear of a possible fall. Sometimes it appears on its own, in other cases it occurs after an accidental fall, often it accompanies one or another gait disturbance. Often this fear can be even more incapacitating than the underlying disease itself, because it forces the patient to limit their movements and interfere with their usual daily activities. In such cases, one speaks of astazobazophobia. On the other hand, a disease has been described relatively recently, which is based on a functional dysfunction of complex systems for maintaining balance and stability, combined with affective disorders. This disease outwardly resembles astazobasophobia, but has several other, more complex mechanisms of development.

Persistent postural-perceptual vertigo (PPPV) is a chronic functional disorder of the nervous system characterized by non-rotational vertigo or subjective unsteadiness. Usually patients turn to neurologists, otoneurologists and general practitioners with complaints of constant or frequent dizziness (or unsteadiness), which usually occurs for no apparent reason, but can often be triggered by movement or visual stimuli. This dizziness usually disappears if the patient lies down or sits down, however, sometimes patients continue to feel some vibrations, reminiscent of the rolling of the sea, even in bed.

Anxiety and depression often accompany PPPV, but are not a mandatory diagnostic criterion. In some cases, the most thorough neuropsychological examination reveals no affective disturbances in patients with PPPG, suggesting complex disease mechanisms.

Historical background to the development of ideas about RPP

The relationship between anxiety and dizziness has been the subject of study since the mid-19th century. In 1872, the German physician K. Westphal proposed to call conditions in which patients experienced a feeling of instability and dizziness while in open spaces, agoraphobia. He especially emphasized that the subjective balance disorders in such patients are due to anxiety, and not to organic damage to the nervous system.

In 1986, the German neurologists T. Brandt and M. Dieterich proposed the term “postural phobic instability” to describe the sensation of subjective instability provoked by environmental influences or social factors [1]. In this disorder, the sensation of non-vestibular vertigo appears only when standing or walking, and neurological examination, including the Romberg test, tandem walking, balancing on one leg, does not reveal any disorders. For the diagnosis of postural phobic instability, diagnostic criteria have been proposed [2–6]:

1. Vertigo of a non-vestibular nature on standing or walking. At the same time, a neurological examination, including the Romberg test, tandem walking, standing on one leg, does not reveal abnormalities.

2. Constant (sometimes increasing, sometimes decreasing) feeling of unsteadiness or short-term (several seconds or minutes) feelings of incoordination.

3. Attacks of vertigo may occur spontaneously, but more often develop in a certain situation (on a bridge, on stairs, in an empty room or on the street, in a store, in a crowd, in a restaurant or at a concert). Characterized by a tendency to quickly consolidate negative associations and the desire to avoid provoking circumstances.

4. Anxiety and autonomic disorders develop during and after dizziness, and attacks with anxiety and without it may alternate.

5. Tendency to obsessive states, mild depression.

6. The onset of the disease usually coincides with stress, severe illness or organic disease of the vestibular system.

In 2004, J. Staab et al. [7] proposed the term “chronic subjective vertigo”, the symptoms of which include: sensation of non-rotational vertigo, unsteadiness lasting more than 3 months, aggravated by multiple visual stimuli (for example, in large shopping centers) or when performing work that requires visual accuracy (for example, working on a computer monitor). Patients describe their condition as a feeling of lightness in the head; feeling of heaviness in the head; a feeling of unsteadiness (swaying), which is not noticeable to others; a sensation of rotation inside the head in the absence of a sensation of movement of surrounding objects; sensation of the floor swaying underfoot; feeling of derealization.

The term “persistent postural perceptual vertigo” as used in this article was proposed in subsequent years, and the World Health Organization included PPPV in the new version of the ICD (ICD-11).

Diagnostic criteria for PPPV

Currently used diagnostic criteria for PPPV proposed by the Barani Society [8]:

1. Persistent feeling of swaying or unsteadiness and/or non-rotational vertigo lasting at least 3 months (at least 15 days per month), sometimes daily:

– symptoms persist for hours, but may fluctuate in severity;

– symptoms are not necessarily always present.

2. The sensation of dizziness is aggravated by the transition to a vertical position, movement, and also under the influence of visual stimulation (flashing of objects around, moving objects).

3. The disease is provoked by a neurological, somatic or mental disorder, manifested by vestibular vertigo, balance disorders or a feeling of unsteadiness. Disorders that provoke PPPG can occur acutely, recur or persist:

– if the disease is provoked by an acute or recurrent disorder, then at the onset, the manifestations of PPPG may also be episodic, becoming constant only with time;

– if the disease is initially provoked by a chronic disorder, then the manifestations of PPPG are immediately perceived as chronic; over time, they progress and get worse.

4. Symptoms of the disease significantly reduce the patient’s quality of life and become the cause of chronic stress.

5. Symptoms cannot be explained by other diseases.

Thus, the manifestations of postural phobic instability, chronic subjective vertigo and PPPV are similar. In fact, they are one and the same functional disease, the view of the mechanisms of development of which is only slightly improved or corrected over time.

Epidemiology

PPPG accounts for 15-20% of all causes of dizziness. On average, this diagnosis is the second most common cause of vertigo, second only to benign paroxysmal positional vertigo. Moreover, at the age of less than 45 years, PPPG becomes the most common cause of complaints of dizziness. In the elderly, as mentioned above, such dizziness is also common, although in this case it is usually a complication of an organic neurological disease or vestibular neuronitis [9].

PPPG is more common in women. The median age at diagnosis is 40 years. On average, about 4.5 years pass from the onset of dizziness and the establishment of this diagnosis, which significantly aggravates the well-being of patients due to the development of anxiety states due to the disease [10].

Pathogenesis

The pathogenesis of PPPV remains incompletely understood. Several hypotheses have been proposed to explain the clinical manifestations of this disease. Thus, it is believed that PPPG is based on the tendency of patients to extend the stressful strategy of maintaining balance to ordinary conditions. Normally, the stress strategy is used only in difficult situations, such as when driving on ice, in the dark, or at altitude. It consists in shortening the step, constrained and tense posture, simultaneous contraction of the muscles of agonists and antagonists. As soon as difficult conditions are resolved, the stress strategy is replaced by the usual, everyday one. This does not happen in PPPG, when the stress strategy is included in the period of the provoking disease at the onset of PPPG and persists for a long time, often only getting worse.

The reason for this chronification of the stress strategy may presumably be an increase in sensitivity to physiological fluctuations in the center of gravity inherent in the normal process of maintaining stability. Normally, the body makes many small corrective movements to maintain an upright posture and balance while walking. These movements have a small amplitude and remain out of conscious control. Due to mechanisms that are not fully understood, they can become noticeable to patients with PPPG, which leads to a constant feeling of instability.

Another concept of the development of PPPG implies a violation of the processes of comparison between real and expected afferent information. Normally, to ensure movement and maintain balance, the brain uses the mechanisms of “anticipation” based on previous experience [2]. A momentary failure of these mechanisms is normal and familiar, for example, from the feeling of unsteadiness that occurs when standing on an unexpectedly stationary escalator or when looking from a platform at a train that has suddenly started moving in the neighborhood. It is assumed that in PPPV the processes of comparison between real and expected afferent information are permanently disturbed. However, the specific mechanisms of such a violation have not yet been studied.

Another concept of the pathogenesis of PPPG is based on disruption of the processes of vestibular adaptation and readaptation [6]. This concept describes those cases of PPPV that develop after a vestibular disease, such as vestibular neuronitis or benign paroxysmal positional vertigo (BPPV). Due to vestibular dysfunction, processes of central vestibular compensation are triggered, which, after the disappearance of vestibular dysfunction during recovery (for example, with the disappearance of otolith particles in BPPV or normalization of the labyrinth function in vestibular neuronitis), are replaced by vestibular readaptation. The causes and subtle mechanisms of disruption of the processes of vestibular readaptation have not yet been studied, but it is believed that anxiety plays a key role, since the systems for maintaining balance and the system that controls emotions have close connections all the way from the brainstem to the cerebral cortex [11, 12].

Another important factor in the pathogenesis of PPPG seems to be the occurrence of visual dependence. Visual addiction is the over-reliance on visual stimuli in the process of maintaining balance and stability. At the same time, vestibular and proprioceptive signals are partly ignored. Such a strategy may go unnoticed under normal conditions with a stable visual environment. However, in the absence of visual cues (eg, in the dark) or in complex, moving visual environments, visually addicted patients become vulnerable. Lost ability to rely on vestibular and proprioceptive stimuli contributes to instability and loss of balance control. This concept explains the increased symptoms of PPPV in open spaces, supermarkets, or other visually challenging environments. The theory of visual dependence is partly supported by the results of functional neuroimaging, which, specifically in patients with PPPG, reveals increased activity in the visual cortex of the brain. Moreover, the degree of increased activity of the visual cortex correlates with the severity of the disease. Recent studies have shown that visually induced vertigo and visual dependence in PPPV may be based on an altered connection between the primary visual cortex, the secondary visual cortex, and other areas of the brain that process and regulate responses to multimodal three-dimensional movement information [13] .

An equally important factor contributing to the onset of functional vestibular disorders is anxiety, which can contribute to central sensitization, leading to inadequate assessment of physiological proprioceptive, visual, and labyrinthine stimuli, followed by hyperresponsiveness to subthreshold stimuli [14].

Clinical Diagnostics

The diagnosis of PPPV is made if the patient has disorders that meet all 5 criteria of the Barany Society. Since there are no instrumental or laboratory research methods that confirm the assumption of the functional nature of the balance disorder, the diagnosis is made only on the basis of the clinical picture.

The diagnosis is especially difficult in elderly patients, when numerous comorbid conditions can play the role of the leading cause of subjective dizziness. It is in this category of patients that strict compliance with diagnostic criteria and the exclusion of other significant causes of dizziness are especially important.

Even more complicating the diagnosis are various diseases that occur at the onset of PPPG, provoking it and at the same time often making it difficult to interpret the symptoms as functional. BPPV or vestibular neuronitis often act as triggers for PPPG. Both of these diseases are more common in the elderly, and vestibular migraine is slightly less common [8]. Even more rarely, PPPV is initially triggered by a panic attack or generalized anxiety disorder. Mild traumatic brain injury, trauma to the cervical spine, and orthostatic hypotension are also common PPPV precipitating disorders [15].

In some cases, analysis of the patient’s gait can help diagnose the problem. Patients with PPPG are characterized by excessive compensatory movements of the hands when performing the Romberg test (while the legs remain motionless and the patient does not stumble), walking in small steps (“like on slippery ice”). In contrast to the stiff gait in parkinsonism, “pacing” is not characteristic of PPPG [16]. However, with distraction, gait and balance in stato-coordinating tests can improve significantly [16]

Another characteristic is that patients with PPPG can more easily perform more complex tests. For example, instability in the complicated Romberg test or during tandem walking is significantly less pronounced than in the simple Romberg test and during normal walking [17, 18]. More accurate performance of complex tests for postural stability than simple tests can sometimes be registered with stabilometry or posturography, which makes these studies useful when trying to objectify the functional nature of the disease. On the other hand, PPPV patients are less stable in those posturographic tests when the visual environment ceases to be immobile [19, 20].

Treatment

The treatment of PPPV is a difficult task requiring close collaboration between a neurologist, a psychotherapist and a rehabilitation specialist. It consists of psychotherapy, drug treatment and vestibular rehabilitation. Rational psychotherapy is very important and consists in explaining to the patient the mechanism and nature of the disease [21, 22]. Since patients suffering from PPPG are confident in the organic nature of their disease, the leading role in the implementation of psychotherapeutic correction belongs to the neurologist, and not to the psychotherapist. It is the neurologist who, having the results of instrumental and laboratory studies in his hands, can argue the functional nature of the disease [23].

An important component of the treatment of PPPG is vestibular rehabilitation. Patients should be instructed to start the exercises slowly, only gradually increasing the speed and pace of movements from day to day. Exercise must be done daily. An exercise program that is too intense can exacerbate symptoms, causing patients to stop much sooner than they can achieve any results. Among the areas of vestibular rehabilitation, preference is given to exercises to stabilize the gaze and reduce visual dependence. In the latter case, an important role is played by rehabilitation in virtual reality (for example, while performing stability exercises, the patient sees flashing visual stimuli in front of him in the form of rapidly changing pictures, rapidly moving horizontal and vertical stripes, etc.). In addition, exercises are used to train walking with eyes closed on hard and soft surfaces [24].

Antidepressants from the SSRI and SNRI groups are emerging as the drugs of choice for the treatment of PPPG. Drugs are prescribed in ultra-low doses, gradually increasing them. Improvement in well-being is usually observed after 8-12 weeks. The duration of taking the drugs should last at least a year [23].

Since the rehabilitation of PPPG is largely based on the stimulation of the readaptation of the vestibular system, and these processes are slowed down by sedatives, the use of vestibular suppressants, antipsychotics and benzodiazepines is undesirable.

Transcranial magnetic stimulation can be attributed to new directions in the treatment of PPPG. In particular, good results were noted with transcranial stimulation of the left supplementary prefrontal cortex in 8 patients with PPPG (5 daily stimulation sessions for 30 minutes). However, the effect did not last long, and symptoms recurred after treatment was stopped [23]. Nevertheless, the available results make it reasonable to conduct further studies on the effectiveness of transcranial magnetic stimulation in the treatment of PPPG.

Thus, PPPG is a common cause of vertigo complaints in patients of all ages. Especially often this disease develops in young and middle age. In geriatric practice, the diagnosis and treatment of this condition is particularly difficult due to the large number of comorbid disorders and conditions that often claim to be a factor that causes a feeling of dizziness. Diagnosis in this case consists of a thorough analysis of clinical data, the results of instrumental examination methods and (sometimes) response to trial treatment.

Authors claim
about
no conflict of interest.

The authors declare no conflicts of interest.

Credits

Shapovalova M.V. — https://orcid.org/0000-0001-5888-2323; e-mail: [email protected]

Zamergrad M.V. — https://orcid.org/0000-0002-0193-2243; e-mail: [email protected]

How to quote:

Shapovalova M.V., Zamergrad M.V. Persistent postural perceptual vertigo in the elderly. Journal of Neurology and Psychiatry. S.S. Korsakov. 2019;119(9 vol. 2):5-9. https://doi.org/10.17116/jnevro20191190925

Corresponding author: Shapovalova Maria Vasilievna — e-mail: [email protected]

causes, symptoms of which diseases can be

Symptoms of dizziness

Scientists dealing with the problems of quality of life after a heart attack say that in general, after stabilization of the condition and the resumption of an active life, having sex does not pose a direct threat to health ^1-5 . They also warn that you should neither force things nor give up sex completely. The most correct option is to ask the doctor about everything. Many patients are hesitant to ask the doctor “uncomfortable questions” about sexual relations, experiencing unnecessary embarrassment, called “feeling of false shame.” But it is the doctor who can suggest the optimal time for the resumption of sexual life, the permissible loads with it ^4.5

Dizziness, or vertigo, is not a disease, but a subjective symptom of various diseases and conditions that can be described in different ways. Most often it is perceived as:

• weakness;
• “feeling of lightheadedness”, “lightness in the head”;
• false “sense of rotation”, a change in the position of the body in space;
• unsteadiness, staggering when walking;
• “loss of balance”.

Typical symptoms may be aggravated by walking or moving the head. Sometimes the main problem is supplemented by a number of other symptoms, in particular, nausea, vomiting, sweating, palpitations ³ .

An episode of dizziness can have a different duration. Sometimes it can last a few seconds, but persistent dizziness is also possible for several hours, days, etc. ³ .

Dizziness in women:

reasons

Most often, dizziness is benign and does not pose a threat to health ⁴ . It can occur in healthy women at various times in their lives. Consider the most common reasons.

What should you check with your doctor?

1. 1
   Premenstrual period.
   Dizziness may be due to the approaching menstruation.
   Some women experience dizziness 4-10 days before the onset of critical days. The reason is fluctuations in the levels of progesterone, estrogen and other hormones. With the onset of menstruation, the balance is restored and the problem disappears ⁵ .
2. 2
   Pregnancy.
   Expectant mothers may experience mild dizziness due to the increasing levels of hormones that contribute to the expansion and relaxation of blood vessels.
   This is necessary for the baby to get enough oxygen.
   and nutrients, but the woman herself may experience a slowdown in blood flow. As a result, blood flow to the brain may be reduced and dizziness may occur ⁶ .

   Dizziness in the second trimester of pregnancy (from 12 weeks) may be due to the increasing pressure of the enlarging uterus on the blood vessels that carry blood from the lower extremities to the heart. Besides,
   During pregnancy, blood sugar levels may rise. This condition is called gestational diabetes. It may also be accompanied by dizziness ⁶ .

3. 3
   Menopause.
   Menopause can cause dizziness in menopausal women. The exact mechanism underlying this condition is unknown. Scientists suggest that vertigo in middle-aged women develops
   due to deficiency of the sex hormone estrogen ⁷ .
4. 4
   Decreased blood glucose levels.
   Glucose is the source of energy for all cells. With a low content of glucose in the blood, hypoglycemia, all organs and systems, including the brain, experience a lack of energy. This can lead to weakness and dizziness. Hypoglycemia can develop in diabetic patients taking too high a dose of antidiabetic drugs. Occasionally, glucose levels may decrease in people with normal carbohydrate metabolism during fasting, poor diet ⁸ .
5. 5
   Migraine.
   Headaches and dizziness can occur with migraine, a common disease that is two to three times more common in women than in men [9]. It is known that in 30-50% of cases, vertigo occurs at the height of an attack. This form of the disease is called vestibular migraine. According to statistics, it occurs in 1% of the population ¹⁰ .
6. 6
   Dehydration.
   If there is a loss of fluid in the body, for example, when overheating,
   against the background of digestive disorders, respiratory infections, the water-salt balance may change and dehydration may develop. It leads to a decrease in blood volume, a drop in blood pressure. Under such conditions, the brain does not receive enough oxygen, which leads to
   to dizziness, lethargy ⁸ .

Arterial hypertension and dizziness

Frequent dizziness in women can become a sign of various pathologies. So, it is experienced in about half of the cases of one of the most common diseases in the world, arterial hypertension. The main cause of dizziness in hypertension is the narrowing of blood vessels that feed the brain and inner ear.
This leads to a lack of oxygen and disruption of the vestibular apparatus ¹¹ .

Scientists dealing with the problems of quality of life after a heart attack say that in general, after stabilization of the state and the resumption of an active life, having sex does not pose a direct threat to health ^1-5 . They also warn that you should neither force things nor give up sex completely. The most correct option is to ask the doctor about everything. Many patients are hesitant to ask the doctor “uncomfortable questions” about sexual relations, experiencing unnecessary embarrassment, called “feeling of false shame.” But it is the doctor who can suggest the optimal time for the resumption of sexual life, the permissible loads with it ^4.5

Emotional experiences and unfavorable meteorological factors can also contribute to the development of dizziness ^2.11 . With arterial hypertension, there may be complaints about ¹¹ :

• dizziness, headache;
• feeling of “bursting in the head”;
• deterioration of memory, attention;
• sleep disorder;
• irritability;
• imbalance, unsteadiness when walking;
• flashing “flies” before the eyes.

Dizziness in arterial hypertension may occur when the pressure drops too sharply after taking antihypertensive drugs (for example, with an overdose of the drug). Feeling of dizziness and “shakyness”, may also occur with hypertension with concomitant heart rhythm disturbances ^2.12 .

Why you feel dizzy:

pathological causes

Frequent dizziness may also occur in some other diseases:

1. 1
   Anemia – a number of clinical conditions associated with a decrease in hemoglobin levels. Often occurs during pregnancy due to iron deficiency. May be accompanied by fatigue, blanching of the skin, taste perversion, loss of appetite, palpitations and other symptoms. A typical complaint of women with anemia is dizziness and weakness ¹³ .
2. 2
   Osteochondrosis – disease in which irreversible degenerative changes occur in the joints. It is assumed that due to the deterioration of the supply of oxygen to the brain in cervical osteochondrosis, one may periodically or even constantly feel dizzy ¹⁴ .
3. 3
   Psychogenic diseases – neurotic disorders associated with stress, schizophrenia, depression, panic attacks ¹⁴ .

How to deal with the problem?

Severe, sudden dizziness may require medical attention.
Alarm signs are considered ¹⁵ :

• 
  
  increased dizziness compared to previous attacks;
• 
  
  chest pain, difficulty breathing;
• 
  
  loss of consciousness;
• 
  
  impaired vision, speech, hearing;
• 
  
  limb numbness.