How long does vertigo typically last. What are the main causes of vertigo. Which treatments are most effective for managing vertigo symptoms. How can you prevent vertigo attacks. When should you see a doctor for vertigo.

Understanding Vertigo: A Comprehensive Overview

Vertigo is a disorienting condition characterized by a sensation of spinning or dizziness. It can significantly impact a person’s quality of life, affecting balance, coordination, and daily activities. This article delves into the causes, symptoms, and various treatment options available for vertigo sufferers.

What Exactly is Vertigo?

Vertigo is not a condition itself but a symptom of various underlying disorders. It’s often described as a feeling that you or your surroundings are moving or spinning, even when everything is still. This sensation can be accompanied by nausea, vomiting, and difficulty maintaining balance.

How Common is Vertigo?

Vertigo is a relatively common complaint, affecting millions of people worldwide. It’s estimated that about 40% of adults experience vertigo at least once in their lifetime. The prevalence increases with age, with older adults being more susceptible to certain types of vertigo.

Common Causes of Vertigo: From Inner Ear Issues to Neurological Conditions

Vertigo can stem from various sources, primarily related to the inner ear or the central nervous system. Understanding these causes is crucial for proper diagnosis and treatment.

Inner Ear Disorders

• Benign Paroxysmal Positional Vertigo (BPPV)
• Labyrinthitis
• Vestibular Neuronitis
• Ménière’s Disease

Central Nervous System Issues

• Migraines
• Multiple Sclerosis
• Brain Tumors
• Stroke

Can medications cause vertigo? Yes, certain medications, particularly those that affect the inner ear or brain, can induce vertigo as a side effect. These may include antidepressants, anti-seizure drugs, and some blood pressure medications.

Recognizing Vertigo Symptoms: Beyond the Spinning Sensation

While the primary symptom of vertigo is a spinning sensation, other signs and symptoms often accompany this condition. Recognizing these can help in early diagnosis and treatment.

Common Symptoms Associated with Vertigo

• Dizziness or a sense of spinning
• Loss of balance
• Nausea and vomiting
• Headache
• Sweating
• Abnormal eye movements (nystagmus)
• Ringing in the ears (tinnitus)
• Hearing loss

Is vertigo always accompanied by nausea? Not necessarily. While nausea is a common symptom, not all individuals with vertigo experience it. The presence and severity of symptoms can vary depending on the underlying cause and individual factors.

Diagnosing Vertigo: The Path to Proper Treatment

Accurate diagnosis is crucial for effective vertigo treatment. Healthcare providers use a combination of methods to identify the underlying cause and determine the best course of action.

Diagnostic Approaches for Vertigo

1. Medical History: Detailed discussion of symptoms, onset, and duration
2. Physical Examination: Checking balance, coordination, and eye movements
3. Dix-Hallpike Test: Specific maneuver to diagnose BPPV
4. Imaging Tests: CT scans or MRI to rule out central nervous system issues
5. Audiometry: Hearing tests to assess inner ear function
6. Vestibular Function Tests: Evaluating balance and inner ear function

How long does it typically take to diagnose vertigo? The time frame for diagnosis can vary depending on the complexity of the case. Some causes, like BPPV, can be diagnosed in a single visit, while others may require multiple tests and consultations over several weeks.

Treating Vertigo: A Multi-Faceted Approach

Treatment for vertigo depends on its underlying cause and the severity of symptoms. A combination of medical interventions, physical maneuvers, and lifestyle changes often yields the best results.

Medical Treatments for Vertigo

• Vestibular Suppressants: Medications to reduce the sensation of spinning
• Antiemetics: Drugs to control nausea and vomiting
• Antibiotics: For bacterial infections causing labyrinthitis
• Diuretics: Sometimes used in Ménière’s disease to reduce fluid buildup

Physical Therapies and Maneuvers

• Epley Maneuver: Specific head movements to treat BPPV
• Vestibular Rehabilitation: Exercises to improve balance and reduce dizziness
• Brandt-Daroff Exercises: Home exercises for BPPV

How effective is the Epley maneuver in treating BPPV? The Epley maneuver has been shown to be highly effective, with success rates of up to 80% in resolving BPPV symptoms after one or two treatments.

Living with Vertigo: Coping Strategies and Lifestyle Adjustments

While medical treatments are important, managing vertigo also involves adapting daily routines and implementing strategies to minimize symptoms and prevent falls.

Practical Tips for Managing Vertigo

• Avoid sudden head movements
• Use good lighting and remove tripping hazards at home
• Practice relaxation techniques to reduce stress
• Maintain a healthy diet and stay hydrated
• Get adequate sleep
• Avoid triggers like certain foods or activities

Can dietary changes help manage vertigo? In some cases, yes. For instance, individuals with Ménière’s disease may benefit from a low-salt diet to reduce fluid retention. Additionally, staying hydrated and avoiding excessive caffeine and alcohol can help manage symptoms for many vertigo sufferers.

When to Seek Medical Attention: Recognizing Serious Symptoms

While many cases of vertigo are benign and self-limiting, certain symptoms warrant immediate medical attention. It’s crucial to recognize these signs to ensure prompt and appropriate care.

Red Flags: When to See a Doctor Immediately

• Sudden, severe headache
• Chest pain or heart palpitations
• Difficulty speaking or slurred speech
• Sudden vision changes
• Weakness or numbness in limbs
• Loss of consciousness
• Persistent vomiting

Should you go to the emergency room for severe vertigo? If vertigo is accompanied by any of the above symptoms, or if it’s so severe that you can’t perform daily activities, it’s advisable to seek immediate medical care. These symptoms could indicate a more serious underlying condition requiring urgent attention.

Preventing Vertigo: Proactive Measures for Long-Term Management

While not all cases of vertigo can be prevented, certain lifestyle choices and preventive measures can reduce the frequency and severity of episodes, particularly for those with recurrent vertigo.

Strategies for Vertigo Prevention

1. Regular Exercise: Improves balance and reduces fall risk
2. Stress Management: Reduces a common trigger for vertigo
3. Proper Hydration: Maintains fluid balance in the inner ear
4. Avoiding Triggers: Identifying and avoiding personal vertigo triggers
5. Regular Check-ups: Early detection of underlying conditions
6. Vestibular Rehabilitation: Ongoing therapy to improve balance

How effective is vestibular rehabilitation in preventing vertigo recurrence? Vestibular rehabilitation has shown significant success in reducing vertigo symptoms and improving overall balance. Studies indicate that up to 85% of patients report improvement in their symptoms after completing a vestibular rehabilitation program.

The Role of Technology in Vertigo Management

Advancements in technology have introduced new tools for managing and monitoring vertigo symptoms. From smartphone apps that help track triggers and symptoms to virtual reality-based balance training, these innovations offer additional support for vertigo sufferers.

• Balance Training Apps: Provide exercises and track progress
• Symptom Tracking Tools: Help identify patterns and triggers
• Virtual Reality Therapy: Simulates challenging environments safely
• Wearable Devices: Monitor balance and provide real-time feedback

Are technology-based interventions as effective as traditional therapies for vertigo? While technology offers promising supplementary tools, it’s generally most effective when used in conjunction with traditional medical treatments and under the guidance of healthcare professionals.

The Future of Vertigo Treatment: Emerging Research and Therapies

The field of vertigo treatment is continually evolving, with ongoing research exploring new therapeutic approaches and enhancing our understanding of the condition.

Promising Areas of Vertigo Research

• Gene Therapy: Targeting genetic causes of vertigo
• Stem Cell Research: Potential for inner ear repair and regeneration
• Neuromodulation Techniques: Non-invasive brain stimulation therapies
• Advanced Imaging: Improved diagnostic techniques for underlying causes
• Personalized Medicine: Tailoring treatments based on individual factors

What is the most exciting recent development in vertigo treatment? One notable advancement is the use of portable vestibular stimulation devices, which provide targeted electrical stimulation to help manage symptoms. Early studies show promising results in reducing vertigo severity and improving quality of life for patients with chronic vestibular disorders.

The Impact of Lifestyle Factors on Vertigo Management

Recent research has highlighted the significant role that lifestyle factors play in managing vertigo symptoms. Understanding and addressing these factors can greatly enhance the effectiveness of medical treatments.

Key Lifestyle Considerations for Vertigo Patients

• Sleep Quality: Ensuring adequate and restful sleep
• Dietary Choices: Identifying and avoiding trigger foods
• Physical Activity: Balancing exercise with rest
• Stress Management: Implementing effective coping strategies
• Environmental Modifications: Creating a vertigo-friendly living space

How much can lifestyle changes impact vertigo symptoms? Studies suggest that comprehensive lifestyle modifications can lead to a 30-50% reduction in vertigo frequency and severity for many patients, particularly when combined with appropriate medical treatments.

Understanding the Psychological Impact of Vertigo

The psychological effects of living with vertigo are often underestimated but can significantly impact a person’s overall well-being. Addressing these aspects is crucial for comprehensive vertigo management.

Common Psychological Challenges Associated with Vertigo

• Anxiety and Depression: Due to unpredictable symptoms and lifestyle limitations
• Fear of Falling: Leading to reduced activity and social isolation
• Loss of Confidence: Impacting work and personal relationships
• Frustration: From recurring symptoms and treatment challenges

What percentage of vertigo patients experience significant psychological distress? Research indicates that up to 60% of individuals with chronic vertigo report experiencing anxiety or depression related to their condition. This highlights the importance of addressing mental health as part of vertigo treatment.

Holistic Approaches to Vertigo Care

A holistic approach to vertigo management, considering both physical and psychological aspects, often yields the best outcomes for patients.

Elements of Holistic Vertigo Care

1. Medical Treatment: Addressing the underlying cause
2. Physical Therapy: Improving balance and reducing symptoms
3. Psychological Support: Counseling or therapy for mental health
4. Lifestyle Coaching: Guidance on diet, exercise, and stress management
5. Support Groups: Connecting with others for shared experiences
6. Education: Empowering patients with knowledge about their condition

How effective is a holistic approach in managing vertigo? Studies show that patients receiving comprehensive care addressing both physical and psychological aspects of vertigo report better overall outcomes, with improvements in symptom management, quality of life, and treatment adherence.

Navigating Daily Life with Vertigo: Practical Advice and Adaptations

Living with vertigo requires adapting various aspects of daily life to manage symptoms effectively and maintain independence. Here are some practical strategies for different life situations:

At Home

• Install handrails in bathrooms and along staircases
• Use night lights to navigate safely in the dark
• Keep frequently used items within easy reach
• Consider using a walking aid for added stability

At Work

• Communicate with employers about your condition and needs
• Request accommodations like an ergonomic workstation or flexible hours
• Take regular breaks to rest and reorient yourself
• Use anti-glare screens if computer work triggers symptoms

While Traveling

• Choose aisle seats on planes for easier movement
• Inform travel companions about your condition
• Carry medication and any necessary medical documentation
• Plan rest stops during long journeys

How can you maintain an active social life with vertigo? Maintaining social connections is crucial for mental well-being. Consider hosting gatherings at home where you feel more comfortable, choosing quieter venues for outings, and being open with friends about your limitations and needs.

The Role of Support Systems in Vertigo Management

A strong support system can significantly improve the quality of life for individuals with vertigo. Family, friends, and support groups play a crucial role in providing both emotional support and practical assistance.

Benefits of a Strong Support Network

• Emotional Support: Reducing feelings of isolation and frustration
• Practical Help: Assistance with daily tasks during severe episodes
• Motivation: Encouragement to adhere to treatment plans
• Information Sharing: Learning coping strategies from others with similar experiences

How can family members best support someone with vertigo? Education about the condition, patience during episodes, and offering help without compromising the individual’s independence are key ways family members can provide effective support.

Vertigo causes & treatment – Illnesses & conditions

Treatment for vertigo depends 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 and reduce the sensation of spinning. You may be advised to take medication.

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

Read more about what to do if you’re struggling with stress

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’ve 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 below).

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 your balance is particularly affected if you:

• drink alcohol
• are tired
• have another illness

Avoiding these can help to 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 that 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 return.

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

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.

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 to a specialist

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 can give more advice on this.

Ménière’s disease

If your vertigo is caused by Ménière’s disease, 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, which 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 migraines 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.

Treating your migraine should relieve your vertigo if it’s caused by a migraine.

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 wasn’t 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 to 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 depends on availability in your area.

In some cases, it may be possible to use VRT without specialist help. Research has shown that 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.

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.

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:

• cinnarizine
• cyclizine
• promethazine teoclate

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.

Safety

If you have vertigo, there are some safety issues to consider. For example:

• you should inform your employer if your job involves operating machinery or climbing ladders
• you may be at increased risk of falls – see preventing falls for advice on making your home safer and reducing your risk

Vertigo could also affect your ability to drive. You should avoid driving if you’ve recently had episodes of vertigo and there’s a chance you may have another episode while you’re driving.

It’s your legal obligation to inform the Driver and Vehicle Licensing Agency (DVLA) about a medical condition that could affect your driving ability. Visit the GOV.UK website for more information on driving with a disability.

Vertigo – NHS

Vertigo gets better in most cases without treatment. See a GP if it keeps coming back or is affecting your daily life.

Check if it’s vertigo

Vertigo feels like you or everything around you is spinning – enough to affect your balance. It’s more than just feeling dizzy.

A vertigo attack can last from a few seconds to hours. If you have severe vertigo, it can last for many days or months.

Help with vertigo

There are things you can do to ease vertigo symptoms when they’re happening, and to reduce the number of episodes you have.

Do

• lie still in a quiet, dark room to reduce the spinning feeling

• move your head carefully and slowly during daily activities

• sit down straight away when you feel dizzy

• turn on the lights if you get up at night

• use a walking stick if you’re at risk of falling

• sleep with your head slightly raised on 2 or more pillows

• get out of bed slowly and sit on the edge of the bed for a while before standing up

• try to relax – anxiety can make vertigo worse

Don’t

• do not bend over to pick things up – squat to lower yourself instead

• do not stretch your neck – for example, while reaching up to a high shelf

Non-urgent advice: See a GP if you:

• have vertigo that will not go away or keeps coming back

What happens at your appointment

The GP will ask about your symptoms to try to find out what type of vertigo you have.

A simple test that involves you moving quickly from a sitting to a lying position might be done to check your balance. This could bring on symptoms.

You might also be referred to a specialist for further tests.

Urgent advice: Get advice from 111 now if you have vertigo and:

• have a severe headache
• are being sick or feel very sick
• have a very high temperature or feel hot and shivery

111 will tell you what to do. They can arrange a phone call from a nurse or doctor if you need one.

Go to 111.nhs.uk or call 111.

Other ways to get help

Get an urgent GP appointment

A GP may be able to help you.

Ask your GP practice for an urgent appointment.

Immediate action required: Go to A&E if you have vertigo and:

• double vision or loss of vision
• hearing loss
• trouble speaking
• leg or arm weakness, numbness or tingling

Always take someone who cannot be woken up to A&E or call 999.

Treatment for vertigo

Most cases of vertigo get better without treatment.

Treatment will depend on the cause. The GP might prescribe antibiotics if it’s caused by an infection.

You could also be given special exercises to do to try to correct your balance.

Antihistamines can sometimes help with vertigo symptoms.

Important

If you drive, you must tell the DVLA about your vertigo.

Visit the GOV.UK website for more information on driving with vertigo.

What causes vertigo

Inner ear problems, which affect balance, are the most common causes:

• benign paroxysmal positional vertigo (BPPV) – where specific head movements cause vertigo
• labyrinthitis – an inner ear infection caused by a cold or flu virus
• vestibular neuronitis – inflammation of the vestibular nerve
• Ménière’s disease – a rare inner ear condition, which sometimes involves ringing in the ear (tinnitus) or loss of hearing

Read more about BPPV on the Ménière’s Society website.

Other things that can cause vertigo:

• migraine
• some types of medicine – check the leaflet to see if it’s listed as a side effect

Sometimes the cause is unknown.

Page last reviewed: 02 June 2020
Next review due: 02 June 2023

Benign paroxysmal positional vertigo: What can you do if you have BPPV? – InformedHealth.org

If benign paroxysmal positional vertigo (BPPV) is hard to cope with or doesn’t go away on its own, a simple treatment can be done. The treatment consists of doing certain head and body movements in a specific order. The aim is to make the problems in the organ of balance go away.

In about half of all people who have BPPV, the symptoms go away after only 1 to 3 months. So treatment isn’t always needed.

If the dizzy spells don’t go away on their own or are very difficult for the person to cope with, repositioning maneuvers can help. They are a common treatment for benign paroxysmal positional vertigo.

How do repositioning maneuvers work?

To do a repositioning maneuver, the doctor shows you how to get into various sitting and lying positions while holding your head at certain angles.

In BPPV, the vertigo is caused by loose calcium deposits (crystals or “ear rocks”) in the organ of balance (vestibular system) inside our ear. The aim of following a certain order of head and body movements is to move the loose crystals to a position where they no longer cause dizzy spells.

The vestibular system has three semicircular canals in it. The Epley maneuver and the Semont maneuver are two very simple and effective repositioning procedures for the treatment of BPPV that is caused by crystals in the posterior semicircular canal. The exercises are usually repeated several times under the supervision of a doctor. There are also slightly different versions that you can do on your own at home as well.

This treatment doesn’t have many side effects. But the movements can lead to nausea or vomiting, similar to during an episode of vertigo. Repositioning maneuvers aren’t suitable for some people – for instance, those who can’t move the neck region of their spine freely.

What does a repositioning maneuver involve?

The Epley maneuver is done in the following way (the person in this example has loose crystals in their left ear):

1. Sit upright.

2. Tilt your head back slightly and move it about 45° to the left.

3. Lie on your back, keeping your head turned to the left. Wait for about 30 seconds.

4. Now turn your head to the right by 90°, keeping it tilted back slightly. Wait for about 30 seconds.

5. Now turn your whole body to the right. Your head moves with your body until you are almost facing the floor. Wait for about 30 seconds.

6. Sit upright again.

After having this treatment, you can move or lie down normally again.

Sequence of movements in the Epley maneuver for the treatment of BPPV caused by deposits in the left ear

In most cases the symptoms are caused by loose crystals in the posterior semicircular canal. The crystals only rarely develop in either of the other two semicircular canals of the vestibular system. If they do, other repositioning maneuvers can be done that are a little different to the Epley and Semont maneuvers. One example is the Gufoni maneuver.

Are there other treatment options?

If the Epley or Semont maneuvers don’t help, aren’t possible or the patient doesn’t want to do them, certain exercises can be done. Your doctor can show you how to do them in his or her practice, and then you can do them at home on your own.

Other treatments, such as anti-nausea medication, are only needed in rare cases.

If the symptoms are very severe and don’t go away, surgery on the vestibular system (the organ of balance) may be considered. This involves destroying either the nerve fibers in the affected semicircular canal, or the semicircular canal itself. The sensory hair cells can then no longer pass information on to the brain. As a result, the loose crystals don’t cause dizziness any more, but the organ of balance in that ear is permanently affected by the surgery.

Benign Paroxysmal Positional Vertigo | Cedars-Sinai

Not what you’re looking for?

What is benign paroxysmal positional vertigo?

Benign paroxysmal positional vertigo (BPPV) is a disease of the vestibular system
of your inner ear. When you change your head position, it causes vertigo. Vertigo
is a feeling that the room is spinning around you.

Your vestibular system helps sense
motion and changes in space. It adds to your sense of balance. The vestibular organs
are
inside the innermost part of your ear. They include the utricle, saccule, and 3
semicircular canals. When your head moves, these small organs send this information
to
the brain.

The utricle contains small calcium
crystals. These help you to sense motion. Sometimes these crystals detach from the
utricle and land in one of the semicircular canals. Then the canals may send the wrong
signals to the brain, especially when the crystals move. This confuses the brain and
leads to BPPV symptoms.

The condition is called benign
because it is not life-threatening. It does not get worse with time. Paroxysmal means
that the vertigo comes and goes. Positional just means that symptoms come from a change
in head position.

BPPV is fairly common, especially
in women. Older adults have it more often. But people of any age can get it. It is
one
of the most common vestibular disorders.

What causes benign paroxysmal positional vertigo?

Anything that dislodges the
crystals from the utricle can cause BPPV. Having a past head injury is a major cause.
Other times, BPPV may result from other problems with the vestibular system. These
can
include Ménière disease or vestibular neuritis. Ear surgery is a less common cause.
In
most cases, no one knows exactly what causes BPPV.

Who is at risk for benign paroxysmal positional vertigo?

People with certain health
conditions may have a higher risk for BPPV. But many times the cause is not known.
You
may have a higher risk of developing BPPV if you have any of these:

• Migraine
• Giant cell arteritis
• High blood pressure
• High cholesterol or other blood lipids
• History of stroke
• Head injury

It’s not clear if treating these
conditions might reduce your risk for BPPV.

What are the symptoms of benign paroxysmal positional vertigo?

The most common BPPV symptoms
include:

• A feeling of spinning (vertigo)
• Lightheadedness
• Trouble with balance
• Nausea and vomiting

Certain types of movement can bring
on symptoms. Symptoms then often last a minute or less. Common triggers are rolling
over
in bed or looking up while standing. These symptoms can vary in how often they happen
and how severe they are. In some people, these symptoms are so severe that they disrupt
personal and work life.

Very often, the symptoms go away
and then come back weeks or months later. Without treatment, symptoms might continue
for
a few weeks before going away. In a small number of people, the symptoms never come
back
after the first time.

Unlike some other causes of
vertigo, BPPV doesn’t cause nervous system symptoms such as severe headache, speech
problems, or loss of limb movement. It also doesn’t cause hearing problems.

The symptoms of BPPV may seem like
those of other health conditions. Always see your healthcare provider for a
diagnosis.

How is benign paroxysmal positional vertigo diagnosed?

BPPV may be diagnosed and treated
by your primary healthcare provider. Or by an ear, nose, and throat doctor
(otolaryngologist). Or it may be diagnosed and treated by a neurologist. The provider
will ask about your health history. You may also have a physical exam. This may include
hearing and balance tests. It will also include an exam of the nervous and
cardiovascular systems. Problems with these systems can also cause vertigo.

As part of the exam, your
healthcare provider may have you do certain movements. These will include moving your
head and body in certain ways. If you have BPPV, this test can bring on vertigo. It
can
also bring on quick, involuntary eye movements (nystagmus). Your provider can also
use
this test to find which semicircular canal is most likely affected.

If your healthcare provider is
still not sure about the diagnosis, you may need other tests such as:

• ENG (electronystagmography). This test uses
  electrodes to test your eye movements in response to stimuli that may cause your
  vertigo.
• VNG (videonystagmography). This test is similar
  to an ENG but it uses cameras instead. Your eyes are a part of your sense of
  balance. So ENG and VNG tests may help find the cause of your vertigo.
• Imaging tests. Tests such as an MRI can help
  rule out nervous system problems as a cause.

How is benign paroxysmal positional vertigo treated?

Treatment will depend on your symptoms, age, and general health. It
will also depend on how severe the condition is.

First your healthcare provider may
try to move the calcium crystals out of your semicircular canals. This may be done
with
a series of certain head and neck movements. This often takes about 15 minutes. Your
provider may tell you to do certain movements at home. This treatment often works.
Some
people may still have vertigo with head movement for a few weeks.

Special physical therapy may also
be part of your treatment.

Medicines are not often given for
BPPV. This is because most of them don’t help. In some cases, short-term use of motion
sickness medicines may help to ease nausea.

If these other treatments fail, in
rare cases your healthcare provider may advise surgery. One option is called posterior
canal plugging. It blocks the movement of calcium crystals in the posterior semicircular
canal. The surgery can work well. But in rare cases, it can cause some hearing loss.

Your healthcare provider may also
advise a watch-and-wait approach to your BPPV before trying surgery. BPPV does often
go
away on its own over time. But in many cases it does come back. If you are still having
symptoms from BPPV, your healthcare provider may tell you how to prevent symptoms.
For
example:

• Using 2 pillows in bed to raise your
  head
• Not sleeping on your affected
  side
• Rising slowly out of bed
• Not looking up
• Not bending over to pick things
  up
• Not doing exercises that use head
  rotation, such as swimming laps

Even if you stop having symptoms,
your healthcare provider may suggest that you follow similar instructions, at least
for
a few weeks. This may help prevent your symptoms from coming back.

Key points about benign paroxysmal positional vertigo

• BPPV is a disease that affects the
  vestibular system of the inner ear. With changes of head position, it causes sudden
  vertigo and related symptoms.
• Head injury and past vestibular disorders can cause BPPV. But
  many times the cause is not known.
• Symptoms typically happen with head
  movement. The vertigo lasts only a short while, but it may come back many times.
• BPPV often responds to treatment with
  physical movements. But in rare cases some people with severe BPPV may need
  surgery.
• As you are recovering from BPPV, you
  may need to not make certain head movements to help prevent your symptoms from coming
  back.

Next steps

Tips to help you get the most from a visit to your healthcare provider:

• Know the reason for your visit and what you want to happen.
• Before your visit, write down questions you want answered.
• Bring someone with you to help you ask questions and remember what your provider tells
  you.
• At the visit, write down the name of a new diagnosis, and any new medicines, treatments,
  or tests. Also write down any new instructions your provider gives you.
• Know why a new medicine or treatment is prescribed, and how it will help you. Also
  know what the side effects are.
• Ask if your condition can be treated in other ways.
• Know why a test or procedure is recommended and what the results could mean.
• Know what to expect if you do not take the medicine or have the test or procedure.
• If you have a follow-up appointment, write down the date, time, and purpose for that
  visit.
• Know how you can contact your provider if you have questions.

Medical Reviewer: Ashutosh Kacker MD

Medical Reviewer: Ronald Karlin MD

Medical Reviewer: Daphne Pierce-Smith RN MSN CCRC

© 2000-2021 The StayWell Company, LLC. All rights reserved. This information is not intended as a substitute for professional medical care. Always follow your healthcare professional’s instructions.

Not what you’re looking for?

Epley, Semont, Foster, and Brandt-Daroff

The spinning sensation and dizziness you get from vertigo can limit your activities and make you feel sick. Depending on the cause, though, some simple maneuvers you can do at home might bring relief.

The most common type of this condition is BPPV (benign paroxysmal positional vertigo). It happens when small crystals of calcium get loose in your inner ear. You may feel it when you’re getting in or out of bed, or tilting your head up. People over age 60 are more likely to get BPPV. It’s also the easiest type of vertigo to treat.

Before you try to treat it yourself, see your doctor. If you have vertigo, you’ll need to know what type it is and which ear has the problem. To determine affected side:

• Sit on bed so that if you lie down, your head hangs slightly over the end of the bed.
• turn head to the right and lie back quickly.
• Wait 1 minute.
• If you feel dizzy, then the right ear is your affected ear.
• If no dizziness occurs, sit up.
• Wait 1 minute.
• Turn head to the left and lie back quickly. 8.Wait 1 minute. 9.If you feel dizzy, then the left ear is your affected ear.

If you have BPPV, certain actions can move the calcium crystals that cause the problem out of your ear canal. That should bring relief.

Your doctor or a therapist can show you how to do these moves.

Epley Maneuver

If your vertigo comes from your left ear and side:

1. Sit on the edge of your bed. Turn your head 45 degrees to the left (not as far as your left shoulder). Place a pillow under you so when you lie down, it rests between your shoulders rather than under your head.
2. Quickly lie down on your back, with your head on the bed (still at the 45-degree angle). The pillow should be under your shoulders. Wait 30 seconds (for any vertigo to stop).
3. Turn your head halfway (90 degrees) to the right without raising it. Wait 30 seconds.
4. Turn your head and body on its side to the right, so you’re looking at the floor. Wait 30 seconds.
5. Slowly sit up, but remain on the bed a few minutes.
6. If the vertigo comes from your right ear, reverse these instructions. Sit on your bed, turn your head 45 degrees to the right, and so on.

Do these movements three times before going to bed each night, until you’ve gone 24 hours without dizziness.

Semont Maneuver

This exercise is for dizziness from the left ear and side:

1. Sit on the edge of your bed. Turn your head 45 degrees to the right.
2. Quickly lie down on your left side. Stay there for 30 seconds.
3. Quickly move to lie down on the opposite end of your bed. Don’t change the direction of your head. Keep it at a 45-degree angle and lie for 30 seconds. Look at the floor.
4. Return slowly to sitting and wait a few minutes.
5. Reverse these moves for the right ear.

Again, do these moves three times a day until you go 24 hours without vertigo.

Half-Somersault or Foster Maneuver

Some people find this maneuver easier to do:

1. Kneel down and look up at the ceiling for a few seconds.
2. Touch the floor with your head, tucking your chin so your head goes toward your knees. Wait for any vertigo to stop (about 30 seconds).
3. Turn your head in the direction of your affected ear (i.e. if you feel dizzy on your left side, turn to face your left elbow). Wait 30 seconds.
4. Quickly raise your head so it’s level with your back while you’re on all fours. Keep your head at that 45-degree angle. Wait 30 seconds.
5. Quickly raise your head so it’s fully upright, but keep your head turned to the shoulder of the side you’re working on. Then slowly stand up.

You may have to repeat this a few times for relief. After the first round, rest 15 minutes before trying a second time.

Brandt-Daroff Exercise

Here’s what you need to do for this exercise:

1. Start in an upright, seated position on your bed.
2. Tilt your head around a 45-degree angle away from the side causing your vertigo. Move into the lying position on one side with your nose pointed up.
3. Stay in this position for about 30 seconds or until the vertigo eases off, whichever is longer. Then move back to the seated position.
4. Repeat on the other side.

You should do these movements from three to five times in a session. You should have three sessions a day for up to 2 weeks, or until the vertigo is gone for 2 days.

Follow Up

For the rest of the day after doing any of these exercises, try not to tilt your head too far up or down. If you don’t feel better after a week of trying these moves, talk to your doctor again, and ask them what they want you to do next.

You might not be doing the exercises right, or something else might be the cause of your dizziness.

Benign Paroxysmal Positional Vertigo (BPPV): Causes & Treatment

Overview

What is benign paroxysmal positional vertigo (BPPV)?

Benign paroxysmal positional vertigo (BPPV) is an inner ear disorder in which changes in the position of the head, such as tipping the head backward, lead to sudden vertigo – a feeling that the room is spinning. The vertigo sensation can range from mild to severe and usually lasts only a few minutes. It may be accompanied by other symptoms, including:

Anatomy of the right inner ear

BPPV is not a sign of a serious problem, and it usually disappears on its own within 6 weeks of the first episode. However, the symptoms of BPPV can be very frightening and may be dangerous, especially in older people. About half of all people over age 65 suffer an episode of BPPV. The unsteadiness caused by BPPV can lead to falls, which are a leading cause of fractures in this age range.

Symptoms and Causes

What causes benign paroxysmal positional vertigo (BPPV)?

BPPV develops when calcium carbonate crystals, which are known as otoconia, shift into and become trapped within the semicircular canals (one of the vestibular organs of the inner ear that control balance). The otoconia make up a normal part of the structure of the utricle, a vestibular organ next to the semicircular canals. (See illustration.)

In the utricle, the otoconia may be loosened because of injury, infection, or age. They land in a sac – the utricle – where they are naturally dissolved. However, otoconia in the semicircular canals will not dissolve. As a person’s head position changes, the otoconia begin to roll around and push on the tiny hair-like processes (cilia) within the semicircular canals. Those cilia help to transmit information about balance to the brain. Vertigo develops when the cilia are stimulated by the rolling otoconia.

Movements that can bring about an episode of BPPV include:

• Rolling over or sitting up in bed;
• Bending the head forward to look down, or;
• Tipping the head backward.

In most people, only a single ear is affected by BPPV, although both ears may be involved on occasion.

Diagnosis and Tests

How is benign paroxysmal positional vertigo (BPPV) diagnosed and treated?

With advances in medical technology, BPPV can easily be diagnosed and treated. The diagnosis can usually be made in the office based on medical history and a physical exam. Treatment also involves a short, simple in-office procedure known as the particle repositioning maneuver. (See the treatment section).

How can I identify the side that is affected by benign paroxysmal positional vertigo (BPPV)?

Steps to determine affected side:

1. Sit on bed so that if you lie down, your head hangs slightly over the end of the bed.
2. Turn head to the right and lie back quickly.
3. Wait 1 minute.
4. If you feel dizzy, then the right ear is your affected ear.
5. If no dizziness occurs, sit up.
6. Wait 1 minute.
7. Turn head to the left and lie back quickly.
8. Wait 1 minute.
9. If you feel dizzy, then the left ear is your affected ear.

Right position

Left position

Management and Treatment

What is the particle repositioning procedure for benign paroxysmal positional vertigo (BPPV)?

The particle repositioning procedure takes about 15 minutes to complete and involves a series of physical movements that change the position of the head and body. These actions shift the otoconia out of the semicircular canals and back into their proper location in the utricle.

The particle repositioning procedure begins with the patient sitting up and then lying down on a treatment table. The procedure is very easy to perform. Patients should wear comfortable clothing that will allow them to move freely.

A single particle repositioning procedure is effective in treating about 80% to 90% of cases of BPPV. Additional exercise or repositioning maneuvers may be needed if symptoms continue.

Step-by-step instructions:

Step 1: Start by sitting up on a bed or table. Turn your head 45 degrees toward the affected ear (see how to determine your affected ear above).

Step 2: Quickly lie back, keeping your head turned toward the affected ear as you lie back with your head slightly over the edge of the bed or table. Wait about a minute or until you stop having symptoms.

Step 3: Without raising your head, turn your head quickly in the opposite direction so that your “good” ear is parallel with — but slightly over the edge of — the table or bed. Wait about a minute or until you stop having symptoms.

Step 4: Roll onto your side. Continue to turn your head another 90 degrees in the same direction as step 3 so that your nose is now facing the floor. Wait about a minute.

Step 5: Keeping your chin tucked in toward your shoulder, sit up in the direction your body is facing. Follow any post-particle repositioning instructions given to you by your healthcare provider.

Living With

Can benign paroxysmal positional vertigo (BPPV) return? If so, what can I do?

A new episode of BPPV can develop after successful treatment. On average, the rate of recurrence (new episode) is 15-50%.

However, it may be possible to treat recurrent BPPV at home by performing a series of movements when an episode occurs. Patients will receive information on ways to handle recurrences on their own, or they can work with an audiologist or physical therapist to develop a plan.

In general, if you wake up with positional vertigo, try the following steps:

• Slowly move into the good-ear-down position and wait for a minute.
• Next, slowly move into a face-down position and slide to the foot of the bed.
• Keep your head down until you reach the end of the bed and are kneeling or standing on the floor.
• Slowly bring your head backward into an upright position. (Hold on to the bed at all times.)

Another method is to sit toward the foot of the bed, leaving enough room to lay back with your head resting comfortably at the end of the bed, slightly extended. Be careful not to overextend your neck, as this may aggravate existing neck problems. If your symptoms are severe, you may need assistance to complete the maneuver.

Without treatment, the symptoms of BPPV may persist. However, with time (usually within 6 weeks), the otoconia dissolve on their own. Until then, the number and severity of episodes may be reduced simply by paying careful attention to head position. In addition, anti-motion sickness drugs can control nausea.

However, before drugs are taken, it is usually best to try the particle repositioning procedure first. It is a very safe and rapid way to relieve symptoms and reduce the chance for falls. Medications should not be taken for a long period of time.

Resources

Benign Paroxysmal Positional Vertigo (BPPV): Glossary of Terms

• Semicircular canals: These structures act like a gyroscope, with canals positioned in three dimensions – upward, downward, and horizontal. Together, the canals send signals to the brain about the rotation/positioning of the head (for example, when you bend over or spin around.)
• Cupula: Detects the flow of fluid within the semicircular canals. The flow of fluid gives the body a sense of motion.
• Utricle: An organ located in the inner ear that helps control balance. The utricle contains hair cells, which are covered with otoconia. The otoconia sway with gravity, sending signals to the brain about the position of the head and body (upright, tilted, etc.).
• Otoconia: The tiny calcium crystal particles that become dislodged from within the utricle (where they can dissolve) and move into the semicircular canals (where they can’t dissolve).
• Cochlea: The “snail-shell” sense organ of the inner ear that translates sound into nerve impulses that are sent to the brain.

Physical Therapy Guide to Benign Paroxysmal Positional Vertigo (BPPV)

ChoosePT Guide

Every year, millions of people in the United States develop vertigo. Vertigo is a feeling that you or your surroundings are spinning. This sensation can be alarming and may increase the risk of falling. Benign paroxysmal positional vertigo is one of the most common types of vertigo. If you have BPPV, you are not alone. At least nine out of every 100 older adults are affected by it. The good news is that BPPV is treatable. Your physical therapist will use tests to confirm vertigo. They will teach you specific exercises and use special maneuvers to help you get back to the activities that you enjoy.

What Is BPPV?

Benign Paroxysmal Positional Vertigo is a common inner ear problem that affects the vestibular system. This system works to maintain your balance. BPPV causes short periods of dizziness when moving your head into certain positions. It is more common in females and may be hereditary.

Benign means that this disorder is not life-threatening. Paroxysmal means that the spinning sensation occurs suddenly. Positional means that symptoms are triggered by changes in head position, such as when lying down, turning over in bed, or looking up. This dizzy or spinning sensation is called vertigo.

Inside the inner ear, there is a layer of calcium carbonate material called otoconia. People often refer to pieces of the otoconia as crystals. BPPV occurs when these crystals break off and move to a part of the inner ear called the semicircular canal.

When you move your head a certain way, the crystals move inside the canal and stimulate nerve endings. This causes you to become dizzy. Crystals may become loose due to:

• Trauma to the head.
• Infection.
• Conditions such as Meniere disease.
• Aging.

Most often, the cause of BPPV is not known.

How Does It Feel?

BPPV occurs most commonly after a position change. This dizzy sensation is brief and intense and usually lasts for about 15 to 45 seconds.

Some changes in position that may cause your symptoms include:

• Lying down.
• Turning over in bed.
• Bending over.
• Looking up.

Symptoms may last longer if the crystals become stuck to part of the inner ear. Episodes of vertigo frequently occur for weeks or months at a time. When vertigo occurs, you may feel like the room is spinning around you. You also may feel light-headed, off-balance, or nauseous.

Signs and Symptoms

The signs and symptoms of BPPV usually last less than one minute. They may come and go. They also may go away for a while and then come back. A change in head position often triggers symptoms. Symptoms may include:

• Dizziness .
• A sense that you or your surroundings are spinning or moving (vertigo).
• A loss of balance.
• Unsteadiness.
• Nausea.
• Vomiting.

How Is It Diagnosed?

BPPV is diagnosed if you have a particular kind of involuntary eye movement called nystagmus, and whether you have vertigo when your head is moved into certain positions. Your physical therapist will perform tests to see whether vertigo and involuntary eye movement are present.

Physical therapists use positional tests to recreate BPPV symptoms. These tests require moving your head in specific ways. They will help your physical therapist determine the cause and type of your dizziness. During these tests, your physical therapist will watch your eyes for specific movements. This will help them determine the right treatment maneuver to reduce or eliminate your vertigo.

There are many causes of dizziness. Dizziness is often hard for people to describe. This can make the source of dizziness challenging to diagnose.

It is important to be as specific as possible when describing your symptoms to your health care provider.

For example, explain if you have light-headedness or if you see or feel the room spinning during an episode. And describe how long your symptoms last (seconds, minutes, hours, or days). Do your best to explain what makes your dizziness better or worse. For example, is your dizziness made worse by movement or position changes? Is your dizziness eased by stillness or rest?

Be sure to discuss any recent illnesses or injuries, problems with your immune system, changes in medications or hormones, and whether you have headaches. These clues will help your physical therapist make an accurate diagnosis, or indicate the need for a referral to another specialist.

How Can a Physical Therapist Help?

Fortunately, the majority of people with BPPV can be treated with simple and specific maneuvers that involve moving the head and body. Your physical therapist will perform an evaluation and determine which maneuver is right for you. These maneuvers are designed to move the crystals from the semicircular canal back into the appropriate area in the inner ear (the utricle).

No medication has been found to cure BPPV. In some cases, medicine can actually delay recovery.

Most cases of BPPV can be managed with treatment maneuvers by a physical therapist. In very rare cases, a surgical procedure called a posterior canal plugging may be considered. Surgery for BPPV is very rare.

Can This Injury or Condition Be Prevented?

There are no known ways to prevent BPPV. After treatment, symptoms can return if new crystals break off and get into the semicircular canal. Some people report that their BPPV symptoms recur predictably, perhaps seasonally, or with changes in the weather. Within three years of having a bout of BPPV, symptoms will return for about 50% of people.

If BPPV results from head trauma, it is more likely to recur. Although your BPPV may return, you will be able to recognize the symptoms and keep yourself safe until you can get help. Your physical therapist will apply the appropriate maneuver to return the crystals to their correct position in the inner ear. They also may teach you exercises that can reduce or end your symptoms and improve your balance.

What Kind of Physical Therapist Do I Need?

Physical therapists use their education and experience to evaluate and treat dizziness and imbalance. You may want to consider:

• A physical therapist who is experienced in treating people with neurological problems.
• A physical therapist with specialized training and experience in vestibular rehabilitation.
• A physical therapist who is a board-certified neurological clinical specialist, who completed a residency or fellowship in neurologic physical therapy, or who has advanced knowledge, experience, and skills that may apply to your condition.

You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.

General tips when you’re looking for a physical therapist (or any other health care provider):

• Get recommendations from family, friends, or from other health care providers.
• When you contact a physical therapy clinic for an appointment, ask about the physical therapists’ experience in helping people with inner ear problems.
• During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible and say what makes your symptoms better or worse.

Further Reading

The American Physical Therapy Association believes that consumers should have access to information that could help them make health care decisions and also prepare them for a visit with a health care provider.

The following articles provide some of the best scientific evidence about treatment of BPPV. The articles report recent research and give an overview of the standards of practice for treatment both in the United States and around the world. The article titles are linked either to a PubMed abstract of the article or to free full text, so that you can read it or print out a copy to bring with you to your health care provider.

Vestibular Disorders Association. Benign paroxysmal positional vertigo (BPPV). Accessed January 13, 2020.

Bhattacharyya N, Gubbels SP, Schwartz SR, et al. Clinical practice guideline: benign paroxysmal positional vertigo (update). Otolaryngol Head Neck Surg. 2017;156(3_suppl):S1–S47. Article summary in PubMed .

Reviewed and revised in 2020 by Carrie W. Hoppes, PT, PhD, board-certified clinical specialist in neurologic and orthopaedic physical therapy, and Karen H. Lambert, PT, DPT, board-certified clinical specialist in neurologic physical therapy, on behalf of APTA’s Academy of Neurologic Physical Therapy.

Authored in 2011 by Susan J. Herdman, PT, PhD; Shannon L.G. Hoffman, PT, DPT; Marcia Thompson, PT, DPT; Bob Wellmon, PT, PhD, board-certified clinical specialist in neurologic physical therapy; and APTA’s Section on Neurology.

Dizziness with arterial hypertension

Professor Olga Dmitrievna Ostroumova gave a lecture “Dizziness in arterial hypertension: is antihypertensive therapy sufficient?”

00:00

Drapkina Oksana Mikhailovna , Executive Director of Internet Sessions, Secretary of the Interdepartmental Council for Therapy of the Russian Academy of Medical Sciences :

– Now we turn to a very interesting new section “Dizziness in the practice of the therapist.”

Section, consisting of one lecturer and discussion. Professor Olga Ostroumova. The lecture is called “Dizziness in hypertension: is antihypertensive therapy sufficient?”

Olga Dmitrievna Ostroumova , Professor :

– Good afternoon, dear colleagues.

We will talk to you about dizziness. Dizziness is at least one of the most common complaints that patients present (if not the most common complaint).

If you look at any textbooks on internal medicine (and not only internal medicine), in the description of the clinical picture of almost every disease there will be dizziness. It turns out that the number of diseases that cause dizziness is in the thousands, if not tens of thousands.

But dizziness is not always correctly diagnosed. It is very difficult to treat it. This is the kind of complaint that almost always remains the last. Other complaints have already disappeared, and the patient complains and complains about dizziness.It feels like a saving straw.

Questions of polypharmacy. In order to relieve dizziness, doctors use many medicines not according to indications. In general, the problem, at first glance, is simple, but it turns out that it is very difficult.

The main problem is what the patient understands by dizziness, what the doctor understands by dizziness and the formal definition of dizziness are completely different things.

In fact, the patient uses the word “dizziness” most often where it does not exist.He has “faintness”, weakness, darkening of the eyes, light-headedness. The complex of sensations preceding fainting is called such a beautiful word “lipotimia”. This is either a decrease in cerebral blood flow, or a change in the direction of a decrease in its supply of oxygen and glucose.

It happens with orthostatic hypotension, hypoglycemia and a number of diseases of the cardiovascular system (CVS): aortic stenosis, sick sinus syndrome, tachyatrhythmia.

02:41

By dizziness, the patient very often understands instability, unsteadiness.When walking, he staggers, throws, especially when turning, changing the pace of walking, when initiating walking. In particular, this happens with damage to the cerebellum, with peripheral neuropathy, with a number of diseases of the spinal cord.

Vague sensations that are difficult for the patient to describe: feeling of heaviness, drunkenness, discomfort inside the head. The patient also uses the word “dizziness” very often. In such a situation, most often we will talk about psychogenic dizziness (depression, phobia, anxiety).But not only this, of course. These are the most common options.

The first moment when the patient pronounces this word, one must try very carefully, with leading questions, to understand what kind of complex of sensations bothers him. Is it really dizziness.

True dizziness is an illusion of movement of people or objects around a person. Or, conversely, a person around people or objects. This is understood as true vertigo.

Accordingly, all diagnostic search algorithms that are described in various manuals, monographs refer to true dizziness.Once again, as taught in propaedeutics. Very careful history taking. Try to understand, I emphasize again, with leading questions, what kind of complex of sensations the patient has, is it really true dizziness.

Believe me, most likely it will not turn out to be true dizziness. Further, based on the complex of sensations, the diagnostic search will go completely in different directions, completely not matching the algorithm in case of true dizziness.

Our task is to talk about true vertigo.If this is really dizziness, if completely simplified without prejudice to the patient, then vestibular dizziness (true, which is associated with the vestibular apparatus) and non-vibular, that is, outside of it, is distinguished.

Vestibular vertigo. Vestibular apparatus. What is it, what are the options. The first is peripheral (damage to the labyrinth). The second is intermediate (vestibular nerve, transmission of impulses from receptors to the brain). Finally, the central one is where the impulses about the position of our body in space come (this is the central nervous system).

05:54

Arterial hypertension is practically the most frequent complaint of patients with dizziness. Moreover, both before the start of antihypertensive therapy, and in its process. Including, with the formal stabilization of blood pressure, when we reach the target figures. It seems that this complaint haunts both patients and doctors.

If we look at whether these are really interrelated things, it turns out that, most likely, according to the available data, arterial hypertension itself is not the cause of dizziness.We must look for other reasons. While examining not the disease, but the patient, then treat.

We have already agreed that dizziness is a strictly defined thing – the illusion of objects moving around a person or, conversely, a person around objects or other people. The most common cause of true vertigo in hypertensive patients is the same as in the population.

Relatively speaking, since hypertension often occurs in the elderly (more than 80%), then involuntarily this population of patients with hypertension is transferred to the most common cause of true vertigo that is present in the population.This is benign paroxysmal positional vertigo. We will return to it later.

The most common cause of non-systemic (non-vibular) vertigo is psychogenic vertigo. We will not comment on this.

Much more often it is not she who leads to dizziness with arterial hypertension, but, on the contrary, an excessive decrease in pressure. I would say, not even so much in terms of numbers (although this is the case, they have lowered too much in millimeters of mercury), but would rather focus your attention on an unnecessarily rapid decrease in blood pressure.The pace, the pace, and again the pace. Even in a state of hypertensive crisis.

Of course, if there is concomitant diabetes mellitus, it is hypoglycemia, disturbance of rhythm and conduction, which are partially associated with hypertension, if there is myocardial hypertrophy. But very often with concomitant cardiovascular diseases (CVD) in the patient.

Orthostatic reactions, of course. They generally occur with arterial hypertension. But it is much more common in elderly hypertensive patients and with a combination of arterial hypertension with diabetes mellitus. They come without treatment. One of the features of hypertension in the elderly is an increase in orthostatic reactions.

Some antihypertensive drugs cause orthostatic hypotension, collapse as side effects. These are β-blockers. We rarely use these drugs to treat hypertension. But now these drugs are gaining popularity among urologists. Very often we began to deal with this indirectly.

09:29

In my opinion, extremely indicative and one of the fundamental works is the work performed under the guidance of Professor V.A. Parfenova. This is a professor at the Department of Nervous Diseases at the First Moscow Medical University. Department headed by Academician Yakhno. He deals with this problem a lot.

A very interesting and thorough study. 60 hypertensive patients were taken with a complaint of dizziness. The vast majority of situations (80%, four out of five patients) – nothing was found in patients at all during the most thorough examination. There are no somatic and neurological disorders.

Thus, the first assumption that needs to be confirmed is psychogenic dizziness (anxiety, depression, phobias, and so on).

17% – diseases of the peripheral vestibular apparatus (benign paroxysmal positional vertigo or vestibular neuronitis). We’ll talk about it a little bit.

In one patient, at the most careful examination, a tumor of the cerebellar angle was found, in one patient – a migraine. One patient has AV block. He was put on a pacemaker, after which the dizziness disappeared.

11:03

None of the patients showed a connection between dizziness and increased blood pressure.

Let us say a few words about this peripheral vertigo. True vertigo is the defeat of the maze. Peripheral cause, vestibular apparatus.

There are also several reasons for dizziness. But we are internists, not ENT specialists or neurologists. A few words about benign paroxysmal positional vertigo (the most common cause of vertigo, in general in the population, in a patient with arterial hypertension. After psychogenic).

How does this dizziness manifest itself? Poll, poll and poll again. I will not tell you anything new after your completion of the course of propaedeutics. 50% of the success of the diagnosis is a correctly collected analysis and complaints.

Benign paroxysmal positional vertigo (BPPV) is a short, no more than a minute, attacks of systemic vertigo that occur only when the head is in a certain position. More often in the supine position.

A single seizure or a series of seizures with the slightest movement of the head.When you interview, accordingly, the patient draws something like this to you. Despite the extreme pressure of time, do not forget to ask leading questions.

There are no neurological or any other symptoms; with repeated provocation of seizures, their severity decreases.

The presence of particles freely moving in the semicircular canals is the most common cause of dizziness.

There are the simplest tests for its diagnosis, which can be mastered by every internist. Treatment is a special exercise that is up to 90% effective. Usually, drug treatment is not even required.

How to be. Of course, the main treatment should be aimed at eliminating the causes that caused the dizziness. Vertigo treatment is a comprehensive treatment. No matter how safe it may seem (when almost everyone has a symptom, an involuntarily easy attitude towards it), we know how difficult it is to treat it. The drugs should be used in a complex.

13:59

We have the drug “Betahistine” – an analogue of histamine.There are histamine receptors in different organs. I want to draw particular attention to the H3 receptors that have been found in the cerebral cortex of rats. Accordingly, high histamine levels cause negative feedback and decreased histamine release.

Histamine receptors are located not only in the central nervous system (CNS), but also in the vestibular apparatus. The vestibular nuclei are very rich in histamine receptors.

Histamine is a very effective agent in the treatment of dizziness and Meniere’s disease, for example. But it is administered intravenously. It has a number of side effects. I think you represent them perfectly. I will not repeat myself. Treating patients with dizziness with histamine is obviously unrealistic.

The corresponding searches were going on. Betahistine was created. A major study has begun. The drug has been used for a long time.

How does it affect different types of receptors. Basically, it acts on type 3 receptors (H3 receptors). A powerful antagonist. It does not affect H2 at all.On H1, it is a very weak agonist. This action can also be neglected.

A very good safety profile immediately follows from this. Low incidence of side effects. It does not act on other types of receptors (non-histamine).

The drug that I think you know, “Betaserc”, shows a complex mechanism of action. It improves regional blood flow in the inner ear area. Normalizes the excitation of peripheral receptors. Normalizes the process of excitation in the region of the vestibular nuclei of the brain stem. A fairly wide range of mechanisms of action.

16:10

Appropriate placebo-controlled studies were conducted, where it was shown that Betaserc was significantly different from placebo. It reduces the incidence of vertigo attacks. It also differs from placebo in reducing the severity and duration of vertigo.

I think you all have your own experience with this drug. For the sake of order, we talked about how it differs from a placebo.Patients of this kind are very prone to placebo effects. We do not doubt the effectiveness of Betaserk.

Let me remind you of the indications very briefly: treatment and prevention of vestibular vertigo of various origins, as well as a syndrome including dizziness and headache, tinnitus, progressive hearing loss, nausea and vomiting, Meniere’s disease and syndrome.

The only contraindication is hypersensitivity to any of the components of the drug.

Like the vast majority of drugs, Betaserc has a dose-dependent effect, including in the treatment of vertigo. The most effective dose is 48 mg / day.

The drug is very good in the speed of the onset of the effect. Maybe not quite until the complete disappearance of dizziness, but palpable. Almost 80% (this is four out of five patients) feel either the complete disappearance of dizziness (depending on the severity), or a decrease in the severity and frequency of attacks. Almost everyone else feels the effect on the second or third day. It is extremely rare that the effect develops within the first week.Basically, the drug works on the first day or in the first days.

A new dosage of 24 mg has recently appeared. It is taken twice a day. You do not need to take the daily dose. The lower the frequency of admission, the better the adherence of patients to therapy. Accordingly, the effectiveness of the treatment is higher. There are economic benefits.

Were not too lazy, we counted. It turned out that the new dosage of 24 mg is 13% more economical than the dosage of 16 mg. In the old dosage of 8 mg, almost 50%.

The age-old and very difficult question: brand or generic.We will not delve into this painful topic. You understand that the price should not compromise quality.

In pharmacoeconomic research there is such an indicator as “cost-effectiveness” (ratio of quality and price). Are we really gaining something by paying less money? Or you get “money down the drain”.

There was such a pharmacoeconomic study of a number of generics of Betaserc. In short, the drugs “Betaver”, “Vestibo” and so on have significant differences in clinical efficacy.

Thus, Betaserc wins in pharmacoeconomic terms. It has proven to be most effective in relieving vertigo. Better portability. The costs also suggest that the original Betaserc was the economically viable among the three investigational drugs due to its effectiveness. Unfortunately, this is a very common reason.

This is what I wanted to discuss with you within the framework of the allotted time limit. I wish you dizziness only from success.

20:29

Dizziness can be a prophet of various diseases.

2019.11.06

Vertigo is a condition that creates the illusion of the environment or body rotation. There are two forms of this: vertigo and fake.
The duration of the vertigo can be described as acute or chronic. Acute dizziness lasts from a few seconds to several hours and can last for days or weeks.Chronic dizziness is diagnosed when you have been suffering from it for a month or more.

Dizziness may be accompanied by changes in nausea, vomiting, sweating, pulse rate and blood pressure. This is one of the most common and unpleasant symptoms for doctors, as it occurs in various conditions.
Since it can be a symptom of a number of serious medical conditions, people suffering from this disorder are advised to seek treatment from a specialist who, after examining the patient and finding out the cause of the disorder, rather than waiting for the condition to pass.

Common causes of dizziness.

Dizziness is sometimes misleading in terms of general weakness, distraction, fatigue, lack of sleep, or lack of regular exercise.
The causes of vertigo are different. Dizziness is often also caused by diseases of the brain. These include conditions such as migraine, cerebrovascular disease, epilepsy, or multiple sclerosis.
Dizziness in the head can also be a warning of serious medical conditions such as a cerebrovascular accident, and although a cerebrovascular accident is not a common cause of dizziness, it is very dangerous, you should see your doctor immediately if you experience such medical conditions.
False dizziness can also be caused by a malfunction of other body systems: respiratory or heart failure, high blood pressure, or anemia can also be accompanied by dizziness. The head can be dizzy, even if it is in good health, due to alcohol, drug poisoning, extreme stress, instability, hesitation, or fear of falling. Anxiety-related dizziness often occurs in certain conditions, such as in supermarkets or while driving.
Dizziness, nausea, sweating, hand tremors, rapid heart rate, and changes in blood pressure are often associated with both true and false dizziness.

Significantly more frequent dizziness and imbalance in the elderly. They may also feel dizzy due to various medications used to treat other conditions, such as prolonged sedation,
medicines that lower your blood pressure or increase your heart rate. As a result, when a person suddenly gets up from a standing or lying position, his head is spinning, he becomes blind and loses consciousness.Sometimes it is enough to give up unnecessary medications and the dizziness decreases.

Diagnosis of the cause of dizziness
In the polyclinic, patients with vertigo are examined by a family doctor, and then, according to the suspected cause of the vertigo, the patient is consulted with a specialist. The complaints of “dizziness” are very widespread. Therefore, the patient’s complaints should first be listened to and analyzed so that we can distinguish between dizziness, when everything revolves around, dizziness, instability, fainting, and the like. When explaining possible causes of dizziness, patients are asked if it is difficult for them to stand up, walk when they feel dizzy, or maybe they stand like a revolving room feeling weak. The patient is also asked how often his head is spinning, how long it lasts. The examination evaluates the movements of the eyeball, the patient’s balance, and coordination.

When examining the cause of dizziness, neurologists or otoneurologists prescribe a videoonystagmograph to patients. This is one of the most reliable ways to find out the cause of dizziness.This study evaluates involuntary eye movements. This helps to more accurately determine the cause of the disorder, find the lesion and the side of the labyrinth or vestibular nerve of the inner ear.
To understand why a patient is dizzy, doctors always evaluate their balance or coordination.

Video onystagographic research – how does it work?
The patient is placed, his head is raised 30 degrees, and special glasses with an infrared camera are worn over his eyes. The patient’s eye is then illuminated with infrared light in complete darkness. The eye, illuminated by the beam, is removed and the image is transmitted directly to the monitor. Color stimulation is used to test eye movements, i.e. at. a stream of warm or cold air blowing into the patient’s ear canal for a period of time, which causes nystagmus, that is. causes eye movements. When the air stops blowing, eye movements are monitored for a specified period of time. Eye movements are converted into digital signals, processed by specialized computer programs and presented in the form of standardized graphs, which are then analyzed by a physician.
Dr. Kilda’s Clinic conducts research using the latest generation VN415 video nistography camera, which uses an ultra-sensitive camera that records every movement of the pupil of the eye, resulting in extremely accurate test results.
How is vertigo treated?
Dizziness drug, vestibulosuppressant, should be suppressed only with very sudden and severe dizziness. Such drugs should not be used for more than 3-5 days.Due to the wide variety of causes of vertigo, vertigo can be reduced by using drugs to improve circulation or nerve swelling, or in the case of vestibular migraines, to reduce the frequency of migraines, or special exercises during benign paroxysmal vertigo.
There are cases when the treatment of vertigo in the elderly, who are already taking a large number of different drugs, does not help with the appointment of new drugs, but with the refusal of unnecessary ones.For this reason, you should not take medication for dizziness and choose your own medication – your doctor may recommend the best treatment for you after complaints, examinations and examinations.
Experienced doctors conduct consultations and research at the clinic of Dr. pa Kilda.

90,000 clinical manifestations and possibilities of therapeutic correction

Authors:
O.G. Morozova, A.A. Yaroshevsky, A.V. Logvinenko

Dizziness is the second most frequent complaint (after headache) with which patients seek medical advice [1-3].Dizziness complaints are presented by over 20% of the world’s population aged 18 to 65 years. Dizziness often causes falls and injuries, has a traumatic effect, reduces adaptive capacity, limits work and social activity, worsens the patient’s quality of life and leads to significant economic and social losses across the country.

The most common diagnosis, which is established in our country to a patient who consults a doctor with complaints of dizziness, is vertebrobasilar insufficiency.At the same time, according to data from epidemiological studies, including the last one conducted in the United States, the most common cause of vestibular disorders is benign paroxysmal positional vertigo (BPPV), which occurs in about 50% of patients with complaints of dizziness, aged 65 years and older and older [3-5].

Lack of knowledge of practitioners regarding the diagnosis and treatment of BPPV leads to errors in diagnosis and unsatisfactory provision of medical care for this category of patients, which inevitably entails negative social and economic consequences throughout the country.

BPPV was first described by Barany in 1921. The disease is called benign because it usually goes away on its own after a few weeks or months, but sometimes it can last for years. Without treatment, BPPV has a continuous course in 30% of cases, and recurrent in 20-30% of cases (the risk of recurrence is 15% per year) [1-3, 5-9].

BPPV is characterized by attacks of systemic vertigo, which occurs when the head position is changed, and is caused by the penetration of otolith particles into the semicircular canals of the inner ear.

There are two forms of DPPV : idiopathic (degenerative) and symptomatic.

Idiopathic forms account for up to 90% of all cases of the disease. BPPV occurs at any age –
from childhood to senile, but the idiopathic form is most common in patients aged 50 to 70 years. Women get sick twice as often as men, which is explained by the more frequent development of osteoporosis in them, leading to impaired calcium metabolism and changes in the composition of otoliths, which facilitates their separation from the elliptical sac [1-3, 5, 6].

The symptomatic form of BPPV is equally common in both men and women. It is common in all age groups. The main reasons for the development of this form of the disease are: middle ear infections, craniocerebral trauma, otological and other surgical interventions, labyrinth infarctions, vestibular neuritis, Meniere’s disease, migraine, osteopenia, osteoporosis [1, 9]. Several studies have shown a link between BPPV and low plasma vitamin D levels [10].

BPPV is often a complication of prolonged bed rest with a serious illness or after surgery, as well as a long stay in a forced position with the head thrown back (in the dentist’s chair, at the hairdresser’s) [1, 6].

Pathogenesis of DPPV

There are two main concepts of the pathogenesis of BPPV: the theory of cupulolithiasis, put forward by Schuchnecht in 1969, and the theory of canalolithiasis, proposed by Parnes and McClure in 1991, and also by Apley in 1992, and then confirmed by Brant and Stein in 1993 [1, 2, five].

According to the theory of cupulolithiasis, which is histologically confirmed, but does not fully explain many of the features of nystagmus in BPPV, in the ampulla of the posterior semicircular canal, located below the ampullae of other semicircular canals, otoliths (statoconia), separated from the otolith membrane of the elliptical sac due to trauma or degenerative process, settle … Normally, the specific gravity of the cupula is equal to the specific gravity of endolymph, and the specific gravity of otoliths consisting of calcium crystals exceeds the specific gravity of endolymph.Loaded with otoliths, the cupula becomes heavier than the endolymph and from a structure sensitive to angular acceleration turns into a transmitter of angular acceleration [1, 2, 5, 6].

According to the theory of canalolithiasis, in full, unlike the first theory explaining the clinical features of BPPV, otoliths separated from the otolith membrane do not attach to the cupula, but float freely in the endolymph, gathering in conglomerates approximately equal in diameter to the semicircular canals. Once in the semicircular canal, these conglomerates cause abnormal flows of endolymph and the development of an attack of systemic vertigo [1, 2, 5].

The right posterior semicircular canal is most often affected in BPPV. Most researchers associate this with the fact that people often sleep on their right side (Lopez-Escamez et al., 2002). The defeat of both posterior semicircular canals in the idiopathic variant is rarely observed, but it is common in post-traumatic BPPV [1, 6-9].

Clinical manifestations of BPPV of the posterior semicircular canal

DPPV of the posterior semicircular canal occurs in 85-90% of all cases of DPPV, which is associated with the anatomical features of the posterior semicircular canal.

With BPPV of the posterior semicircular canal, patients note the occurrence of systemic dizziness when performing certain movements:

• turns in bed;
• transition from a supine position to a sitting position or vice versa;
• when the head is thrown back or tilted forward;
• when tilting the head and trunk towards the affected ear;
• for any sharp or quick turns of the head.

Dizziness and nystagmus do not appear immediately, but a few seconds after these movements (latency period lasting 1-5 s, during which the cupula displacement caused by otoliths becomes sufficient to activate receptor cells) [1, 6].

The illusion of movement is usually rotatory. Dizziness and nystagmus at the beginning of the attack increase and then subside, which is explained by the fact that otoliths, after changing the position of the head under the influence of gravity, first accelerate, reach their maximum speed, and then stop at the lowest point of the canal.

The duration of an attack usually does not exceed 5-30 s (the maximum duration is 60 s), which is explained by the time required to move the otoliths to the lowest point of the canal (depending on the size and composition of the otoliths, it usually takes 10 s), and the time required to return the cupula to rest.

Nystagmus with damage to the posterior semicircular canal is rotator-vertical, lasting from 5 to 20 s, exhausted. The direction of nystagmus is explained by the deviation of the cupula of the posterior semicircular canal from the elliptical sac, which stimulates the torsional vestibulo-ocular reflex – turning the eyes around an axis perpendicular to the plane of the canal [1, 2].

An attack may be accompanied by imbalance, oscillopsia, nausea, vomiting (extremely rare). Often, patients tend to avoid positions that cause dizziness (sleeping on orthopedic pillows, wearing a Chance collar that restricts neck mobility), which only contributes to the protracted course of the disease [1, 6].

The disease is often accompanied by the onset of secondary anxiety disorder, which can persist for a long time, even after the BPPV is cured.

Diagnosis of DPPG of the posterior semicircular canal

Diagnosis of BPPV is based on positioning tests (maneuvers), the purpose of which is to maximize stimulation of the affected canal, provocation of dizziness and typical nystagmus. It should be remembered that it is not always possible to see nystagmus with the naked eye.In the case of BPPV caused by a small mass of otoliths, it is rather difficult to see nystagmus (especially its rotator component) without the use of special means. For this reason, when diagnosing BPPV, it is preferable to use Frenzel glasses (glasses with lenses of +16 diopters and an integrated light source that prevent fixation of the gaze, suppressing spontaneous nystagmus) or videonystagmography.

For successful positioning tests, a number of conditions must be met:

• before the examination, the patient needs to explain the peculiarities of the technique and the possibility of dizziness during its implementation;

90,254 patients are asked not to close their eyes if dizziness occurs;

• the first test is carried out in the direction of the ear, the likelihood of affecting which is maximal;
• the faster the maneuver is performed, the higher the likelihood of visualizing nystagmus;
• with negative results of the maneuver and a high probability of BPPV, repeat it after shaking the head.

The gold standard in the diagnosis of BPPV of the posterior semicircular canal is Dix-Hallpike test , during which the affected semicircular canal rotates in a plane parallel to the gravity vector, which ensures its maximum stimulation [1, 2, 5, 6, 8 ].

Dix-Hallpike test procedure (Fig. 1) . Starting position: the patient sits on a couch, the head is turned to the investigator by 45 °. The patient is recommended to fix his gaze on the bridge of the doctor’s nose (the direction of the gaze influences the direction of nystagmus, therefore the patient’s eyeballs should be in the middle position).The doctor then quickly moves the patient to a horizontal position, with the patient’s head hanging from the couch, keeping the 45 ° rotation to the side.

Signs of a positive Dix-Hallpike test [1, 6, 8]:

• After a latency period lasting a few seconds, the patient experiences an attack of vertigo.
• The researcher at this time observes rotator-vertical nystagmus, which appears when the patient is positioned towards the lesion.The rotator component is most pronounced, with the upper pole of the eyeball shifting to the lower ear.
• The intensity of nystagmus increases rapidly and then decreases (crescendo and decrescendo).
• The duration of nystagmus does not exceed 30 s.
• Reverse nystagmus: a few seconds after the patient returns to the starting position, he may have a transient nystagmus of less intensity, directed in the opposite direction.
• Exhaustion – the intensity of dizziness and nystagmus decreases with repeated tests.

In 2016, a group of researchers [13] proposed modification of the Dix-Hallpike diagnostic test , which is more convenient for diagnosing BPPV in an outpatient setting.

Procedure for the modified Dix-Hallpike test (Fig. 2):

1. The patient is seated on the edge of the chair. At the same time, his back is turned towards the back of the chair.
2. The patient’s head is rotated 45 ° towards the investigator.The patient fixes his gaze on the bridge of the doctor’s nose.
3. The doctor, holding the patient’s head, helps him to lean back, on the back of the chair and produces extension in the cervical spine.
4. In this position, the head is held for 30 s, after which the patient returns to its original position.
5. Repeat the sample from the opposite side.

It should be remembered that repeated Dix-Hallpike maneuvers are usually poorly tolerated by patients.

A simpler diagnostic test, widely used to diagnose BPPV of the posterior semicircular canal at an outpatient visit, is the “lateral lying test”, or a modified Brandt-Daroff exercise [6, 8, 11].

Technique for performing the “test of laying on the side” (Fig. 3) . The patient’s head is turned to the side at an angle of 45 °, and he is laid on his side on the opposite side. The patient’s legs may hang down.Two sides are tested. If the test is positive, the patient experiences dizziness and nystagmus, similar to those described above.

Treatment of BPPV of the posterior semicircular canal

For the treatment of BPPV, positional maneuvers are used to remove the otolith conglomerate from the semicircular canal into an elliptical pouch (Brandt et al., 1994). In the treatment of BPPV of the posterior semicircular canal, two positional maneuvers are used – Epley and Semont, as well as the Brandt-Daroff exercise, which the patient independently performs at home.Treatment begins with the Epley maneuver, which has been shown to be more effective in most studies [12].

Epley Positioning Maneuver. A maneuver consists of a series of successive changes in the position of the head, during each of which it is displaced by approximately 90 °. To observe nystagmus, the patient must keep his eyes open. Positional nystagmus appears in the second and third positions and is directed towards the movement of the head, which indicates the successive movement of particles towards the elliptical sac and the effectiveness of the procedure.A frequent reason for its ineffectiveness is insufficiently fast movement of the head during the transition from one position with a hanging head to another, which allows otoliths to shift to the cupular end of the semicircular canal [1, 5, 6].

Technique of the Epley maneuver (Fig. 4) [1, 5, 6, 14]:

1. The patient sits on a couch, the doctor turns his head 45 ° towards the affected ear.
2. The patient is placed on his back so that his head is slightly thrown back (hanging from the couch).In this case, the otoliths move into the canal, the cupula deviates downward and positional vertigo occurs. The patient should be in this position for 90 seconds.
3. The patient turns his head 90 ° in the opposite direction (in the direction of a healthy labyrinth; a healthy labyrinth in this case turns out to be facing downward, the head hangs from the couch) and remains in this position for 90 s.
4. Simultaneously turn the patient’s head and torso 90 ° in the opposite direction (the face should be at an angle of 45 ° relative to the floor plane, the head hangs down).In this position, the patient should be for another 90 seconds.
5. The patient is seated with his head down for 2 minutes.

The emergence of positional nystagmus at the third and fourth stages indicates the removal of otoliths from the semicircular canal.

Features of the Epley maneuver:

• Before performing the maneuver, the doctor may recommend the patient to take vestibulolytic drugs to reduce the severity of dizziness and nausea (dimensionhydrinate at a dose of 100 mg 30 minutes before the procedure).
• Perform all steps of the maneuver as quickly as possible.
• When performing the maneuver, the neck should be extended as much as possible, which excludes repeated ingress of otoliths into the semicircular canal.
• The patient may need to repeat the maneuver within one session (up to 5 times during one treatment session).

Complications of the Epley maneuver:

• Entry of otoliths into the horizontal semicircular canal.
• Severe nausea and vomiting during the maneuver.
• Neck pain after performing the maneuver.

Reasons for ineffectiveness of the Epley maneuver:

• Insufficient extension of the neck, as a result of which the otoliths “roll” back to the cupula.
• Blockage of the posterior semicircular canal by a conglomerate of otoliths (otolithic plug, canal jam).
• Cupulolithiasis, not canalolithiasis of the posterior semicircular canal, resulting in backward pressure on the cupula after the Epley maneuver.
• Transformation of DPPV of the posterior semicircular canal into DPPV of the anterior semicircular canal.

Ways to solve the problem:

To exclude the transformation of BPPV (movement of otoliths from the posterior semicircular canal to the anterior or lateral canal), it is necessary to re-conduct the Dix-Hallpike diagnostic test.

• In case of insufficient throwing back of the head – a repeated Epley maneuver with a technically correct execution.
• When the canal is blocked by a conglomerate of otoliths, a repeated Epley maneuver (up to 5 times), after which the patient performs the modified Semont maneuver and the Brandt-Daroff exercise at home.
• In case of cupulolithiasis of the posterior semicircular canal, the Epley maneuver is repeated up to 5 times, maintaining a pause of 2 minutes between maneuvers, after which the patient is recommended to perform the modified Semont maneuver and Brandt-Daroff exercises at home, as well as re-examination.
• With BPPV transformation, a repositioning maneuver for the involved canal.

The patient should be informed that even after a successfully completed maneuver, the feeling of unsteadiness during walking can persist for 2 weeks, which is explained by the displacement of a part of the otoliths to the otolith membrane of the elliptical sac and the development of otolith dysfunction [1, 2, 5, 6, 16] …

Technique of the Semont maneuver (Fig. 5) [1, 5, 6].

During the entire procedure, the patient’s head should be turned 45 ° towards the healthy side.

1. The patient is sitting on a couch. The doctor turns his head 45 ° towards the healthy ear (otoliths, the specific gravity of which exceeds the specific gravity of endolymph, settle in the ampulla of the affected posterior semicircular canal).
2. The patient is quickly laid on his side towards the affected ear and held in this position for 1 min (a change in the position of the head relative to the gravity vector causes the otoliths to move to the lowest point of the semicircular canal, with nystagmus and dizziness occurring).
3. The patient is quickly moved to the opposite side, keeping the head turned by 45 °, and held in this position for 2 min (while the otoliths move to the exit from the canal).
4. The patient sits down slowly (the otoliths move into the cavity of the elliptical sac).

A feature of the Semont maneuver is that the patient must be transferred from the second to the third position in no more than 1 s. With an increase in the time of the change in the position of the body, the otoliths “roll down” to the cupula.

When treating elderly or overweight patients, the Epley maneuver is more preferable [6, 12, 14], since the Semont maneuver requires the fastest possible movement of the patient to the other side without stopping in the central position.

The effectiveness of maneuvers in the treatment of BPPV is confirmed by clinical studies and ranges from 50 to 70% [1-3, 5, 6, 13, 14]. After completing the maneuvers, most authors recommend staying upright for 20 minutes.It is also recommended to sleep with the raised head end of the bed on the healthy side. Recommendations for the need for any restrictions after performing the procedure have not been confirmed in clinical trials.

Doctor’s tactics in case of ineffectiveness of the performed maneuvers:

• Repeat the maneuver at least 5 times (or until the Dix-Hallpike test becomes negative).
• If there is an alternative (for example, if the posterior semicircular canal is damaged), change the maneuver (Epley to Semont or vice versa).
• During the maneuver, use vibration in the mastoid area (or tap the mastoid bone with your finger).
• Use head shake before performing the maneuver.
• At home, the patient must independently perform the modified Semont maneuver and the Brandt-Daroff exercise.
• The patient is recommended to lie on a healthy side for a long time (at least 12 hours).
• In the case of recurrent BPPV, betahistine is indicated at a dose of 48 mg / day in 2 divided doses for 2 months.

Absolute contraindications for carrying out positional maneuvers are:

• Injury of the cervical spine.
• Postponed operations on the cervical spine.
• Instability of the atlanto-axial joint.
• Arnold-Chiari Syndrome.
• Cervical myelopathy.
• Severe rheumatoid arthritis.
• Relative contraindications:
• Carotid sinus hypersensitivity.
• Spondylosis of the cervical spine.
• Severe obesity.

Self-medication of BPPV of the posterior semicircular canal at home

The effectiveness of BPPV treatment is significantly increased if the patient independently performs at home the modified Epley procedure and the Brandt-Daroff exercise. The Epley procedure is repeated three times a day, daily, until the dizziness disappears completely for 24 hours.The exercise is recommended for 10-15 days, three times in the morning and three times in the afternoon at a fast pace [1, 5, 6, 15].

Technique for performing a modified Epley test for self-treatment (M. von Breven, T. Lempert, 2004):

1. Starting position: sitting on the bed, head turned 45 ° towards the affected semicircular canal. The pillow must be positioned in such a way that it is under the shoulders when moving to a horizontal position.
2. Lean back quickly so that your shoulders are resting on the pillow, your head is hanging off the pillow, resting on the bed, and the affected ear is at the bottom. The neck should be extended. In this position, wait 30 seconds.
3. Without raising your head, turn it 90 ° in the opposite direction and wait another 30 seconds.
4. Turn onto your good side (that is, 90 °), turning your head at the same time, and wait another 30 seconds.
5. Sit down.

Methodology for performing the Brandt-Daroff exercise for self-treatment (Fig.3):

1. Starting position: sitting on the bed, head turned 45 ° towards the affected semicircular canal.
2. It is necessary to quickly lie down on the affected side, without changing the rotation of the head and stay in this position for 30 s (or until the dizziness disappears).
3. Return to starting position: sitting on the bed.
4. It is necessary to quickly lie down on the healthy side, without changing the rotation of the head and stay in this position for 30 s.
5. Return to starting position: sitting on the bed.

As a result of the described exercises, the otoliths gradually leave the semicircular canal, moving on the threshold of the labyrinth. Another mechanism explaining their effectiveness is the phenomenon of habituation: repeated provocation of positional vertigo leads to a decrease in the response of the central nervous system to stimulation of the ampullary receptor of the semicircular canal [1, 16].

Literature

1. Bronstein A.Dizziness / A. Bronstein, T. Lempert. – M .: GEOTAR-Media, 2010 .– 216 p.
2. Brandt T. Vertigo: its multisensory syndromes / Thomas Brandt. – London: Springer-Verlag, 2012 .– 329 p. (2nd edition).
3. Trinus K.F. Guide to vertigo and spatial orientation disorders / K.F. Trinus, K.F. Klaussen // Neuronews. – 2013. – No. 9. – S. 50-59.
4. Burden of dizziness and vertigo in the community / H.K. Neuhaser, A. Radtke, M. von Brevern et al. // Archives of Internal Medicine.- 2008. – No. 168. – P. 2118-2124.
5. Brandt T. Vertigo / T. Brandt, M. Dieterich, M. Shtrupp. – M .: Practice, 2009 .– 200 p.
6. Palchun V.T. Benign paroxysmal positional vertigo: clinical aspects of diagnosis and treatment / V.T. Palchun, A.L. Guseva, S.D. Chistov // Consilium Medicum. – 2015. – No. 3. – S. 46-52.
7. Practice parameter: therapies for benign paroxysmal positional vertigo (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology / T.D. Fife, D.J. Iverson, T. Lempert et al. // Neurology. – 2008. – No. 70. – P. 2067-2074.
8. Benign paroxysmal positional vertigo: diagnostic criteria / M. von Brevern, P. Bertholon, T. Brandt et al. // Journal of Vestibular Research. – 2015. – P. 105-117.
9. Fife T.D. Benign Paroxysmal Positional Vertigo in the Acute Care Setting / Terry D. Fife, Michael von Brevern // Neurologic Clinics. – 2015. – P. 601-617.
10. Reduction of recurrence rate of benign paroxysmal positional vertigo by treatment of severe vitamin D deficiency / Hossam Sanyelbhaa Talaat, Abdel-Magied Hasan Kabel, Lobna Hamed Khaliel et al.// Auris Nasus Larynx. – 2016. – P. 237-241.
11. Quix Test Predicts Canal Sidedness in BPPV / K. Coughlin, K. Sherrod, J. Miles et al. // Neurology. – 2015.
12. Epley and Semont maneuvers for posterior canal benign paroxysmal positional vertigo: A network meta-analysis / Yun Liu, Wei Wang, Ao-bo Zhang et al. // Laryngoscope. – 2016. – No. 126. – P. 951-955.
13. An Abbreviated Diagnostic Maneuver for Posterior Benign Positional Paroxysmal Vertigo / P. Michael, C.E. Oliva, M.Nunez et al. // Frontier in Neurology. – 2016. – No. 7. – P. 115.
14. Domingues R. Epley Maneuver for Vertigo (Particle Repositioning or Canalith Repositioning Procedure) / R. Domingues, M. Waseem // Atlas of Emergency Medicine Procedures. – New York: Springer, 2016. – P. 259-260.
15. A safe-repositioning maneuver for the management of benign paroxysmal positional vertigo: Gans vs. Epley maneuver; a randomized comparative clinical trial / A. Saberi, S. Nemati, F. Mollahoseini et al.// European Archives of Oto-Rhino-Laryngology and Head & Neck. – 2016. – No. 8. – P. 1-7.
16. Features of residual dizziness after canalith repositioning procedures for benign paroxysmal positional vertigo / S. Martellucci, G. Pagliuca, M. de Vincentiis et al. // Otolaryngology – Head and Neck Surgery. – 2016. – No. 154. – P. 693-701.

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90,000 Benign paroxysmal positional vertigo: disease treatment

Fast passage

Benign paroxysmal positional vertigo (BPPV) is one of the most common diseases of the peripheral vestibular analyzer.

The main symptom is a sudden short-term attack of systemic vertigo when changing the position of the head.

The incidence of BPPV varies from 11 to 64 cases per 100,000 population. Women get sick 2-3 times more often than men. The risk of developing BPPV increases after 35 years, the peak incidence is at 60 years.

In the structure of all causes of dizziness, BPPV ranks first and accounts for 18-25% of all cases of dizziness.

About 90% of cases of BPPV are idiopathic (cause remains unknown).Only in 10% of cases it is possible to identify the predisposing factors for the development of the disease: head trauma, whiplash or operations on the bones of the skull, dental implantation, diseases of the middle and inner ear, their surgical treatment, prolonged bed rest.

Anatomy

The inner ear is represented by a labyrinth located in the temporal bone. The labyrinth consists of three semicircular canals (anterior, posterior, horizontal) and a cochlea. The semicircular canals are located in three mutually perpendicular planes: the horizontal (HPC) is located at an angle of 30 ° to the horizontal plane, and the anterior (PPK) and posterior (ZPC) – at an angle of 45 ° to the sagittal plane.The hairs of the sensitive cells of the otolith receptor form a network that is immersed in a jelly-like mass containing otoliths – crystals of phosphate and calcium carbonate, which together form the otolith membrane.

According to one of the BPPV theories, an attack of dizziness occurs when the otoliths detach from the membrane and enter the lumen of one or more semicircular canals. During the displacement of the otoliths in the lumen of the semicircular canal, under the influence of gravity when turning the head, movement of the endolymph occurs, which leads to excitation of nerve endings, the appearance of nystagmus (involuntary oscillatory eye movement) and dizziness.

With BPPV, each of the semicircular canals can be affected, and in some cases, several canals at once.

Most often (85-90% of cases), BPPV of the posterior semicircular canal is detected – due to its anatomical location relative to the action of gravity, in 5% of cases the HPC is affected, in 1% of cases – the PPK.

Symptoms of the disease

Patients complain of an attack of systemic (rotational) dizziness after a change in head position: turning the head from side to side in bed, getting out of bed, going to bed, throwing the head back when looking up, any sharp turns of the head.The dizziness attack lasts about a minute and is usually not accompanied by other symptoms. Rarely, patients experience nausea, even more rarely vomiting. In most cases, patients feel good between attacks.

Diagnostics

The main method for diagnosing BPPV is to evaluate the results of positional tests, during which successive turns and tilts of the head are made, which leads to displacement of free otoliths, nystagmus appears and an attack of dizziness may occur.The most common test for diagnosing BPPV is the Dix-Hallpike test. The test is considered positive if the doctor records a certain type of nystagmus. For each semicircular canal, its own diagnostic tests have been developed.

In typical cases, there is no difficulty in diagnosing BPPV, since nystagmus has a strict specificity in carrying out positional maneuvers. If positional nystagmus and vertigo do not fit within the parameters expected on positional tests, and the disease cannot be treated with positional maneuvers, central genesis of vertigo should be suspected and additional examinations should be prescribed.

Differential Diagnostics

Central vestibular disorders affecting the cerebellum and brainstem (stroke, transient ischemic attack, multiple sclerosis, tumors).

Vestibular migraine – usually accompanied by a headache.

Vestibular neuronitis is a lesion of the vestibular ganglion, presumably of inflammatory genesis. It manifests itself as an acute episode of dizziness, accompanied by a disorder of balance with preserved hearing.

Meniere’s disease is a disease of the inner ear, manifested by a triad of symptoms: systemic dizziness, sensorineural hearing loss, subjective ear noise.

BPPV Treatment

BPPV often goes away on its own before going to the doctor. About 20-28% of patients with BPPV experience spontaneous disappearance of symptoms within 1 month.

Therapeutic tactics consists in using a certain sequence of head turns (repositioning maneuvers), in which the otoliths move from the affected canal back to the threshold of the labyrinth.

If the effectiveness of repositioning maneuvers is insufficient, the patient may be additionally recommended to perform the necessary set of exercises at home.

Surgical treatment is used only if the maneuvers are ineffective, when BPPV disables the patient.

According to various studies, the risk of BPPV recurrence is 15% during the first year and 37-50% during the next 5 years.

How is BPPV treated at the Rassvet clinic?

Since BPPV is a mechanical disease, its treatment is based solely on repositioning maneuvers.Antiemetics may be prescribed for severe nausea and vomiting.

We do not prescribe vascular therapy, homeopathic remedies or other drugs and treatment methods (acupuncture, osteopathy) to patients with BPPV with unproven efficacy.

Specific prophylaxis of the disease has not yet been developed. Currently, there is an active study of the connection between BPPV and vitamin D deficiency.

Author:

Chekaldina Elena Vladimirovna
otorhinolaryngologist, Ph.M.Sc.

90,000 causes and treatment. Why dizzy and how to get rid of it – health articles

Table of Contents

Dizziness is not a disease, but a symptom that occurs in a number of very different diseases, causing the patient to disorientate in space, a false sensation of mobility of objects and stationary objects relative to him or the person himself relative to the objects around him. It is extremely common, especially among elderly patients and females: in terms of the frequency of medical complaints, it is in second place after headache.

Diagnosis of vertigo is difficult, since the sensation of instability in space is extremely subjective and can differ significantly in different patients both in the degree of manifestation and in the sensory phenomena that arise in this case.

The condition can arise suddenly, be of an episodic nature: the patient experiences something like a jolt, as if he is “led” to one side.

Status Description

The condition can arise suddenly, be of an episodic nature: the patient experiences something like a jolt, as if he is “led” to one side.In other cases, there may be a feeling of movement of surrounding objects in a circle or a feeling of rotation of the person himself, as after a long spin on a carousel. This state can persist long enough, up to an hour. But more often dizziness is expressed in a feeling of general instability of objects and the person himself, a violation of a sense of balance. The patient experiences uncertainty when walking, it seems to him that he is about to fall or stumble, the earth is slipping from under his feet. Sometimes the symptoms become so severe that the patient grasps objects and feels lightheaded, as before losing consciousness.

When should I see a doctor immediately?

• First-time dizziness, accompanied by nausea, vomiting or headache
• Dizziness led to loss of consciousness
• Weakness, tremors (tremors) of the extremities, tachycardia, sweating, feeling of shortness of breath, chest pain
• Condition lasts more than an hour
• Along with dizziness, sensitivity sharply decreased or weakness occurred in one half of the body, face or limb

These symptoms indicate a possible development of an emergency and require urgent medical attention.

What kind of diagnostics can be prescribed by a doctor?

Symptomatic treatment of dizziness is possible only after the doctor has established the cause that caused it.

To determine the type of dizziness and its possible causes, it is necessary to perform laboratory and instrumental diagnostics. It is:

• cardiogram
• blood tests (general, biochemical, for coagulation)
• Ultrasound of the vessels of the head and neck
• MRI or CT of the brain

Drug therapy

• In case of circulatory disorders, drug therapy will include the use of vasodilators and antihistamines and drugs that improve the rheological properties (fluidity) of blood
• Neurogenic dizziness requires taking nootropics (Picamilon, or gamma-aminobutyric acid), which improve blood circulation and nerve conduction
• Vertigo caused by osteochondrosis requires taking muscle relaxants to relieve muscle spasm
• In women, the treatment of dizziness caused by menopausal changes or irregularities in the cycle is carried out with hormonal drugs that return the hormonal background of the body to normal

Mode. Reduces to adherence to the daily routine, the correct alternation of mental and physical exertion, sleep and wakefulness.

Diet. Eliminates the use of foods that increase blood pressure and cause vasospasm, stimulating the nervous system (coffee, strong tea, alcohol, nicotine, very salty or spicy foods).

Gymnastics. To train the vestibular apparatus outside the attack, it is recommended to perform some exercises:

• Rotation of the head, trunk from side to side with closed and open eyes
• Swing on a swing with a gradual increase in amplitude
• Balance Exercises (Stand on one leg with eyes open and closed)
• Rotation of eyes in different directions
• Swimming

Home treatment for vertigo

If vertigo attacks occur intermittently and the cause is known, you can relieve the symptoms yourself.

If vertigo attacks occur intermittently and their cause is known, you can relieve symptoms yourself using the following techniques:

• If your head is dizzy after getting up suddenly, tilt your head forward and exhale completely
• While sitting, bend over to the knees, maintain the position until symptoms stop
• Take a stable position (sitting with your legs apart, rest on the floor) and focus your gaze at one point on a stationary object
• Splash cold water on your face
• Inhale ammonia vapors
• Drink some hot sweet tea
• In the future, care should be taken when changing the position of the body: slowly lie down, bend over and get up

Benefits of treatment at MEDSI

• Receptions are conducted by qualified neurologists with extensive practical experience
• Clinics are equipped with equipment that allows for a complete diagnosis of vertigo
• Treating a dizziness emergency

To make an appointment, call the round-the-clock phone 8 (495) 023-60-84.

Our doctors

Head of the Neurology Center, doctor MEDSI Premuim

Doctor of Medical Sciences, Professor, Doctor of the highest qualification category

Head of the Center for Neurology, Vertebrology and Psychosomatics, neurologist

Neurologist

Neurologist, chiropractor

• Diagnostics and treatment of insomnia
• Diagnosis and treatment of sleep apnea
• Treatment of anxiety disorders

90,000 Benign paroxysmal positional vertigo: modern approaches to diagnosis and treatment uMEDp

Benign paroxysmal positional vertigo (BPPV) is a common disease and one of the most common causes of vestibular vertigo.Positional tests are used to diagnose BPPV, which are highly sensitive and specific. BPPV treatment involves special repositioning maneuvers, the effectiveness of which reaches 95%. In the absence of an effect and with a recurrent course of the disease, drug therapy is prescribed, in particular vitamin D, betahistine, transtympanic administration of corticosteroids. The article presents a clinical case: a patient complained of attacks of rotational dizziness.

Fig. 1. Dix test – Hallpike

Fig. 2. Test McClure – Pagnini

Fig. 3. Epley maneuver with BPPV with damage to the left posterior semicircular canal

Fig. 4. Lempert’s maneuver with BPPV with damage to the right horizontal semicircular canal

Benign paroxysmal positional vertigo (BPPV) is the most common cause of vertigo.The incidence of pathology varies from 10.7 to 64.0 cases per 100 thousand population, the risk of transferring it during life reaches 2.4% [1, 2]. The peak incidence occurs at the age of 50-60, women suffer from BPPV two to three times more often than men [1].

BPPV is characterized by bouts of vestibular vertigo when the head position is changed [3-5]. The attack develops due to the appearance of otolith particles in the semicircular canals, freely moving, less often – fixed on the cupula of the ampullary receptor.In 70–80% of cases, the reasons for the appearance of particles remain unclear.

BPPV can be caused by traumatic brain injury (post-traumatic), labyrinthitis, or, for example, vestibular neuronitis [6-8]. BPPV is associated with osteopenia, osteoporosis and decreased plasma vitamin D levels, as well as migraine [9–11].

The proportion of idiopathic forms of the disease exceeds the proportion of secondary forms, for example, post-traumatic BPPV, with the former prevailing in elderly patients, the latter in young patients.

An attack of dizziness is accompanied by a specific positional (vertical-torsion or horizontal) nystagmus, the direction of which depends on which of the semicircular canals is affected. Dizziness is characterized by high intensity, short duration (no more than a minute), may be accompanied by nausea and vomiting (especially if the attacks follow one another at short intervals, or instead of avoiding unnecessary movements, the patient begins to actively move, change the position of the head).

In some cases, more often in elderly patients, instability and imbalance are noted instead of the classic positional vertigo [12].

With BPPV, there is no tinnitus, hearing impairment, and focal neurological disorders.

Diagnostics

The diagnosis of BPPV is confirmed by the results of positional tests (Dix-Hallpike and McClure-Pagnini tests) [13, 14].

The Dix-Hallpike test is designed to detect BPPV with damage (canalolithiasis) of the posterior semicircular canal.The patient should be seated on a couch and his head should be turned 45º to the side to be examined. Then the patient is placed on his back and his head is thrown back (so that it hangs slightly over the edge of the couch) (Fig. 1). The test is considered positive if, in the supine position, after a short latency period (1–15 seconds), dizziness and vertical nystagmus appear upward with a rotator component directed towards the underlying ear.

McClure-Pagnini test allows to establish damage to the horizontal semicircular canal.During this test, the patient is placed on his back, his head is raised by 30º. Then the doctor turns his head to one side by 90º and waits for at least 30 seconds for the appearance of vertigo and nystagmus , noting their duration and direction. Then the procedure is repeated in the opposite direction (Fig. 2).

Differential diagnosis is carried out with diseases in which vertigo is also positional in nature, primarily with central positional vertigo caused by neurological diseases affecting the brain stem and cerebellum.

Patients with central positional vertigo have neurological disorders in addition to vertigo. In addition, central positional nystagmus can be strictly vertical (without the torsion component characteristic of BPPV), monocular, without a latency period, not fading over time, or not accompanied by dizziness [15–17].

Treatment

Repositioning maneuvers. Therapy BPPV involves performing repositioning maneuvers in order to return otolith particles from the semicircular canal on the eve of the labyrinth.At the same time, for each semicircular canal, its own therapeutic maneuver has been developed [6, 14, 18–20]. The efficiency of repositioning maneuvers in BPPV reaches 95% [18].

In BPPV with damage to the posterior semicircular canal, the Epley maneuver is most widely used. The maneuver is carried out in several stages. First, the patient is seated on a couch and his head is turned 45º to the affected side. Then he is laid on his back so that his head hangs from the edge of the couch by 30 degrees, while maintaining its turn at 45 degrees.After the cessation of dizziness and the disappearance of positional nystagmus, the patient is left in this position for another 30 seconds. Then the patient’s head is turned 90º to the opposite (healthy) side. This position is also held for 30 seconds after the leveling of symptoms. Then the patient is placed on the side so that the head can be turned 90º towards the healthy side, and left in this position for 30 seconds after the cessation of dizziness and disappearance of nystagmus. At the end of the maneuver, the patient is returned to a sitting position, while his head should be tilted forward, and his chin should touch the chest (Fig.3).

For BPPV with damage to the horizontal semicircular canal, the Lempert maneuver is most widely used. Procedure: the patient is laid on his back, then his head is turned to the side to the injured side and held in this position for 90 seconds. Then the patient is sequentially turned to the healthy side by 360º around the longitudinal axis in 90º increments. Each position is fixed for 90 seconds. At the end of the rotation, the patient is returned to the sitting position (Fig.four).

Drug treatment. The efficacy of vitamin D, betahistine, is currently being studied [21, 22]. There are few data on the effectiveness of transtympanic administration of corticosteroids for refractoriness to repositioning maneuvers [23]. However, research is needed to confirm the effectiveness of drug treatment for BPPV.

Clinical case

Patient L., 57 years old, consulted a neurologist with complaints of rotational vertigo attacks that occur in the morning after sleep when getting out of bed.Dizziness is especially severe when turning to the left side. Dizziness is accompanied by nausea, less often gagging, instability. The duration of the attack is about a minute. Between attacks, nausea and unsteadiness when walking persist. At rest, the condition improves, but even with minor movements of the head, dizziness and nausea return. Vertigo is not accompanied by hearing loss, tinnitus or tinnitus, headache, or neurological impairment.The symptom appeared about two weeks ago.

History of mild arterial hypertension for 15 years, varicose veins of the lower extremities.

Based on complaints, anamnesis, results of cervical spine X-ray (revealed signs of uncovertebral arthrosis of the facet joints) and ultrasound duplex scanning of the brachiocephalic arteries (revealed hypoplasia of the left vertebral artery), a diagnosis of vertebral artery syndrome was made.

Vasoactive agents were prescribed and it was recommended to wear a Shants collar to stabilize the cervical spine.

During therapy, the patient noted a decrease in dizziness (which is probably due to the limitation of movement in the cervical spine when wearing a collar), but it persisted.

On examination: the general condition is satisfactory. Blood pressure is 140/90 mm Hg. Art., heart rate – 80 beats per minute, rhythmic pulse.

Neurological status: no focal neurological symptoms were detected – the patient clearly performs coordination tests, while walking and in the Romberg position is stable. However, when the Dix-Hallpike test is performed with a head turn to the left, after a short (two to three seconds) latency period, the latent period increases for several seconds, and then the vertical torsion geotropic nystagmus (duration 15–20 seconds) decays. Nystagmus is accompanied by severe dizziness, nausea and urge to vomit.When it subsides, dizziness decreases, but nausea and weakness persist. Repetition of the test leads to dizziness and nystagmus, but less severity.

Based on the peculiarities of dizziness (attacks are provoked by a change in the position of the head, dizziness lasts less than a minute and stops at rest), the absence of other focal neurological disorders, a positive Dix-Hallpike test and some depletion of nystagmus recorded when the test is repeated, the diagnosis was made of canalolithiasis of the left posterior semicircular canal “.

The patient underwent Epley’s repositioning maneuver for the left posterior semicircular canal.

The result of treatment is regression of dizziness and nystagmus.

The previously prescribed vasoactive agents and the wearing of the Shants collar were canceled.

On re-examination a week later, the patient noted the absence of nystagmus and dizziness. Those were not revealed during the Dix-Hallpike test.

Conclusion

BPPV is one of the common causes of vertigo.The disease is easily diagnosed with positional tests and responds well to repositioning maneuvers. Therefore, the role of drugs in the treatment of BPPV is small. Medicines are advisable in the event of relapses or ineffective repositioning maneuvers.

90,000 Sudden dizziness

Getting up suddenly or moving your head quickly can cause a storm of discomfort. One gets the impression that the world is turning upside down.To maintain balance, there is a need for support. A familiar state? It’s about dizziness. Almost everyone encounters this from time to time. What is the reason for this phenomenon? What is the cause of dizziness in women and men?

When does your head spin?
Dizziness is a rather unpleasant sensation in which a person, being in a state of immobility, perceives the surrounding objects as moving. This state resembles a carousel. In medicine, the feeling of dizziness is called vertigo.

Dizziness is often not dangerous to humans. It can develop as a response to the impact of safe factors, after the cessation of exposure to which the discomfort completely disappears. However, sometimes vertigo indicates the presence of a serious pathology that requires correct and timely treatment.

Mechanism of development of vertigo
The causes of vertigo are quite simple from an anatomical point of view. The vestibular system, which is responsible for balance and sense of orientation in space, is located in the inner ear.In the matter of orientation in the surrounding space, vision and muscle reflexes help a person. All the information received is transmitted to the brain, which controls the functioning of the vestibular system.

The connection between the inner ear and the human brain is sometimes interrupted. A person ceases to navigate in space – dizziness arises. To restore the broken connection, the brain immediately sets in motion special mechanisms. Some of them can involve neighboring centers of the brain in the process (for example, the emetic mechanism).This leads to the development of unpleasant accompanying symptoms.

Sudden Vertigo: Five Everyday Causes

Usually, communication between the brain and the vestibular system is infrequent and does not last long.

Dizziness is not a pathology in the following cases:

1. When riding a carousel. Such entertainment creates a serious load on the vestibular apparatus. And if she is naturally weak and not trained, then her function may be disrupted.Such dizziness occurs, as a rule, in women, since psychoemotional experiences are added to their physical activity.
2. Stress, worries. If dizziness occurs when speaking in front of a large audience or after a comment from a supervisor, then the cause of vertigo is the release of a large amount of adrenaline. This hormone causes vasospasm, which leads to a temporary disruption of the blood supply to the brain.
3. Ascent to the height. In this case, discomfort is also considered a physiological norm.When raised to a height, the human eye cannot quickly refocus from close to distant objects. A sharp reorientation of gaze fixation on objects leads to dizziness.
4. Hunger. This problem is inherent in all lovers of strict diets. If a person does not receive adequate nutrition, a glucose deficiency occurs in his body. The lack of the main “fuel” leads to a deterioration in the functioning of the brain and the occurrence of dizziness.
5. Active exercise.Workout enthusiasts should remember about a sense of proportion. Excessive exercise can lead to a drop in blood pressure. This leads to a feeling of dizziness and, at times, even fainting. Unpleasant sensations can be based on abrupt, “unsuccessful” movements of the head, which lead to disruption of the blood supply to the brain.

Dizziness attacks may occur in response to certain medications. Often the cause of an unpleasant symptom is antidepressants, antibiotics, chemotherapy drugs.If the cause of dizziness is medication, be sure to contact your doctor for a replacement medication.

Sudden dizziness: six pathological causes.

The causes of dizziness are not always harmless. Sometimes illness is at the root of the unpleasant sensation. In this case, dizziness occurs quite often and can last longer than a few seconds. To combat this phenomenon, you must consult a doctor. A decrease in the intensity of a symptom, and sometimes its complete disappearance, is possible only with proper treatment of the underlying disease.

So, the following pathological conditions can become the cause of dizziness:

1. Vegeto-vascular dystonia. A complex disorder during which a person has multiple deviations. All these deviations are associated with the peculiarities of the functioning of the autonomic nervous system. Dizziness is a common symptom of vegetative-vascular dystonia. These symptoms are often associated with sudden movements, rapid changes in body position. Dizziness in this case is short-lived, and goes away on its own, without any intervention.
2. Disorders of the cervical spine. Various injuries, osteochondrosis, herniated intervertebral discs can periodically remind of themselves with bouts of sudden dizziness. They usually occur after sudden neck movements. The attack is accompanied by pain in the affected area, sometimes a crunch is heard.
3. Anemia. Dizziness can occur with iron deficiency. More often this pathology is observed in women and children. With anemia, an attack is accompanied by fatigue, general weakness, pallor of the skin, and light-headedness.
4. Psychogenic dizziness. The cause of this pathology is anxiety in a patient with a labile psyche or stress. These people usually complain of sleep disturbances, fear of loss of consciousness, occasional feeling of shortness of breath, and increased heart rate.
5. Vertebrobasilar insufficiency. With this pathology, the intensity of blood supply through the basilar or vertebral arteries decreases. These deviations lead to disruption of the brain, which is characterized by regular attacks of dizziness, lasting up to one hour.In addition, patients complain of nausea, vomiting, and sometimes visual disturbances. They are often tormented by headaches.
6. Hypotension. The decrease in pressure is often accompanied by attacks of dizziness. Sometimes light-headedness can also be observed.

Alcohol intoxication, dehydration, hyperthermia of the body can cause headache. The unpleasant phenomenon may be based on vision problems or an ear infection.

Severe dizziness: six dangerous causes.

In some cases, vertigo warns of the development of serious conditions that require immediate medical attention.

The causes of intense dizziness can be:

1. Labyrinthitis (internal otitis media). A viral infection of the inner ear may initially be asymptomatic. The only sign of otitis media is dizziness that lasts a few minutes. Such episodes are repeated quite often. Further development of the viral process can involve the nervous system or the brain.
2. Concussion. Sometimes after a brain injury, only dizziness is observed. This symptom cannot be ignored. It is direct evidence of the presence of a concussion. It is necessary to see a doctor immediately to rule out serious injury and the risk of developing cerebral edema.
3. Stroke. If dizziness is accompanied by sudden onset of weakness, numbness of body parts, speech impairment, then there is a high risk of developing a stroke. This is a serious pathology in which the blood supply to the brain is disrupted
4. Migraine.Dizziness, accompanied by a severe headache, can be a signal of the presence of a migraine. Many people think this condition is harmless. However, doctors say that migraine, especially in a neglected state, can lead to severe pathology (sometimes even to the development of heart attack and stroke).
5. Cardiovascular diseases. These pathologies are characterized by a feeling of dizziness every time you get up. This is due to the sharp drop in pressure. Symptoms like these may indicate dehydration, leading to blood clots.However, if the issue is not a lack of fluid, then this may be due to arrhythmias or heart failure.
6. Tumors. Regular attacks of vertigo, especially in combination with a headache, can be a “wake-up call” for the development of a tumor in the brain.

What to do?

It is often almost impossible to find out the cause of dizziness on your own. For this reason, patients who frequently experience vertigo are strongly advised to see a therapist or neurologist.The specialist will carefully examine the patient’s complaints and prescribe an appropriate diagnostic study. If necessary, the doctor will refer the patient to a consultation with an otorhinolaryngologist, ophthalmologist, cardiologist, endocrinologist.

To find out the causes of vertigo, the patient may be prescribed the following examinations:

1. Neurological tests: allow you to assess the functional state of the vestibular apparatus.
2. MRI or CT: detect various disorders (hemorrhages, tumors, vascular pathology).
3. Doppler ultrasound: examines the state of the vessels of the head and neck.
4. Audiometry: allows you to evaluate your hearing function.
5. EEG : Your doctor may order electroencephalography to assess the activity of the cerebral cortex.

For quick relief of dizziness, if it is, of course, not caused by dangerous reasons, you can sit on any suitable surface, relax a little and take 5-6 deep breaths.When you are indoors, be sure to open a window to provide fresh air. If the causes of vertigo are harmless, then the execution of these actions is completely sufficient for the rapid disappearance of the feeling of dizziness.

.