Vertigo (medical)
Encyclopedia
Vertigo ˈvɜrtɨɡoʊ is a type of dizziness
Dizziness
Dizziness refers to an impairment in spatial perception and stability. The term is somewhat imprecise. It can be used to mean vertigo, presyncope, disequilibrium, or a non-specific feeling such as giddiness or foolishness....

, where there is a feeling of motion when one is stationary. The symptoms are due to a dysfunction of the vestibular system
Vestibular system
The vestibular system, which contributes to balance in most mammals and to the sense of spatial orientation, is the sensory system that provides the leading contribution about movement and sense of balance. Together with the cochlea, a part of the auditory system, it constitutes the labyrinth of...

 in the inner ear. It is often associated with nausea
Nausea
Nausea , is a sensation of unease and discomfort in the upper stomach with an involuntary urge to vomit. It often, but not always, precedes vomiting...

 and vomiting
Vomiting
Vomiting is the forceful expulsion of the contents of one's stomach through the mouth and sometimes the nose...

 as well as difficulties standing or walking.

The most common causes are benign paroxysmal positional vertigo
Benign paroxysmal positional vertigo
Benign paroxysmal positional vertigo is a disorder caused by problems in the inner ear. Its symptoms are repeated episodes of positional vertigo, that is, of a spinning sensation caused by changes in the position of the head.-Classification:...

, concussion and vestibular migraine while less common causes include Ménière's disease
Ménière's disease
Ménière's disease is a disorder of the inner ear that can affect hearing and balance to a varying degree. It is characterized by episodes of vertigo and tinnitus and progressive hearing loss, usually in one ear. It is named after the French physician Prosper Ménière, who, in an article published...

 and vestibular neuritis. Excessive consumption of ethanol
Ethanol
Ethanol, also called ethyl alcohol, pure alcohol, grain alcohol, or drinking alcohol, is a volatile, flammable, colorless liquid. It is a psychoactive drug and one of the oldest recreational drugs. Best known as the type of alcohol found in alcoholic beverages, it is also used in thermometers, as a...

 (alcoholic beverages) can also cause notorious symptoms of vertigo. (For more information see Short term effects of alcohol
Short-term effects of alcohol
Short-term effects of alcohol on the human body can take many forms. The drug alcohol, to be specific ethanol, is a central nervous system depressant with a range of side-effects. The amount and circumstances of consumption play a large part in determining the extent of intoxication; for example,...

). Repetitive spinning, as in familiar childhood games, can induce short-lived vertigo by disrupting the inertia of the fluid in the vestibular system.

Classification

Vertigo is classified into either peripheral or central depending on the location of the dysfunction of the vestibular pathway, although it can be established through mental thoughts.

Peripheral

Vertigo caused by problems with the inner ear
Inner ear
The inner ear is the innermost part of the vertebrate ear. In mammals, it consists of the bony labyrinth, a hollow cavity in the temporal bone of the skull with a system of passages comprising two main functional parts:...

 or vestibular system
Vestibular system
The vestibular system, which contributes to balance in most mammals and to the sense of spatial orientation, is the sensory system that provides the leading contribution about movement and sense of balance. Together with the cochlea, a part of the auditory system, it constitutes the labyrinth of...

 is called "peripheral", "otologic" or "vestibular". The most common cause is benign paroxysmal positional vertigo (BPPV) but other causes include Ménière's disease
Ménière's disease
Ménière's disease is a disorder of the inner ear that can affect hearing and balance to a varying degree. It is characterized by episodes of vertigo and tinnitus and progressive hearing loss, usually in one ear. It is named after the French physician Prosper Ménière, who, in an article published...

, superior canal dehiscence syndrome
Superior canal dehiscence syndrome
Superior canal dehiscence syndrome is a rare medical condition of the inner ear, first described in 1998 by Dr. Lloyd B. Minor of Johns Hopkins University, Baltimore, USA, leading to hearing and balance disorders in those affected....

, labyrinthitis
Labyrinthitis
Labyrinthitis is an inflammation of the inner ear, and a form of unilateral vestibular dysfunction. It derives its name from the labyrinths that house the vestibular system . Labyrinthitis can cause balance disorders....

 and visual vertigo. Any cause of inflammation such as common cold
Common cold
The common cold is a viral infectious disease of the upper respiratory system, caused primarily by rhinoviruses and coronaviruses. Common symptoms include a cough, sore throat, runny nose, and fever...

, influenza
Influenza
Influenza, commonly referred to as the flu, is an infectious disease caused by RNA viruses of the family Orthomyxoviridae , that affects birds and mammals...

, and bacterial infections may cause transient vertigo if they involve the inner ear, as may chemical insults (e.g., aminoglycoside
Aminoglycoside
An aminoglycoside is a molecule or a portion of a molecule composed of amino-modifiedsugars.Several aminoglycosides function as antibiotics that are effective against certain types of bacteria...

s) or physical trauma (e.g., skull fractures). Motion sickness
Motion sickness
Motion sickness or kinetosis, also known as travel sickness, is a condition in which a disagreement exists between visually perceived movement and the vestibular system's sense of movement...

 is sometimes classified as a cause of peripheral vertigo.

Central

If vertigo arises from the balance centers of the brain, it is usually milder, and has accompanying neurologic deficits, such as slurred speech, double vision
Diplopia
Diplopia, commonly known as double vision, is the simultaneous perception of two images of a single object that may be displaced horizontally, vertically, or diagonally in relation to each other...

 or pathologic nystagmus. Brain pathology can cause a sensation of disequilibrium
Disequilibrium
Disequilibrium is a term used to describe the lack of or opposite of an equilibrium.* in medicine:** Disequilibrium in cerebral palsy - a syndrome described by Hagberg & all** lack of equilibrioception...

 which is an off-balance sensation.

A number of conditions that involve the central nervous system
Central nervous system
The central nervous system is the part of the nervous system that integrates the information that it receives from, and coordinates the activity of, all parts of the bodies of bilaterian animals—that is, all multicellular animals except sponges and radially symmetric animals such as jellyfish...

 may lead to vertigo including: migraine headaches
Migraine
Migraine is a chronic neurological disorder characterized by moderate to severe headaches, and nausea...

, lateral medullary syndrome
Lateral medullary syndrome
Lateral medullary syndrome is a disease in which the patient has a constellation of neurologic symptoms due to injury to the lateral part of the medulla in the brain, resulting in tissue ischemia and necrosis.-Signs and symptoms:This syndrome is characterized by sensory deficits affecting...

, multiple sclerosis
Multiple sclerosis
Multiple sclerosis is an inflammatory disease in which the fatty myelin sheaths around the axons of the brain and spinal cord are damaged, leading to demyelination and scarring as well as a broad spectrum of signs and symptoms...

.

Signs and symptoms

Vertigo is a sensation of spinning while stationary. It is commonly associated with vomiting
Vomiting
Vomiting is the forceful expulsion of the contents of one's stomach through the mouth and sometimes the nose...

 or nausea
Nausea
Nausea , is a sensation of unease and discomfort in the upper stomach with an involuntary urge to vomit. It often, but not always, precedes vomiting...

, unsteadiness
Balance disorder
A balance disorder is a disturbance that causes an individual to feel unsteady, for example when standing or walking. It may be accompanied by feelings of giddiness or wooziness, or having a sensation of movement, spinning, or floating...

, and excessive perspiration. Recurrent episodes in those with vertigo are common and they frequently impair the quality of life
Quality of life
The term quality of life is used to evaluate the general well-being of individuals and societies. The term is used in a wide range of contexts, including the fields of international development, healthcare, and politics. Quality of life should not be confused with the concept of standard of...

.

Blurred vision
Blurred vision
-Causes:There are many causes of blurred vision:* Use of atropine or other anticholinergics* Presbyopia -- Difficulty focusing on objects that are close. The elderly are common victims....

, difficulty speaking, a lowered level of consciousness
Consciousness
Consciousness is a term that refers to the relationship between the mind and the world with which it interacts. It has been defined as: subjectivity, awareness, the ability to experience or to feel, wakefulness, having a sense of selfhood, and the executive control system of the mind...

, and hearing loss may also occur. Central nervous system
Central nervous system
The central nervous system is the part of the nervous system that integrates the information that it receives from, and coordinates the activity of, all parts of the bodies of bilaterian animals—that is, all multicellular animals except sponges and radially symmetric animals such as jellyfish...

 disorders may lead to permanent symptoms.

Differential diagnosis

A number of specific conditions can cause vertigo. In the elderly however the condition is often multifactorial.

Benign paroxysmal positional vertigo

Benign paroxysmal positional vertigo
Benign paroxysmal positional vertigo
Benign paroxysmal positional vertigo is a disorder caused by problems in the inner ear. Its symptoms are repeated episodes of positional vertigo, that is, of a spinning sensation caused by changes in the position of the head.-Classification:...

 (BPPV) is brief periods of vertigo ( less than one minute ) which occur with change in position. It is the most common cause of vertigo. It occurs in 0.6% of the population yearly with 10% having an attack during their lifetime. It is believed to be due to a mechanical malfunction of the inner ear. BPPV can be effectively treated with repositioning movements.

Vestibular migraine

Vestibular migraine is the association of vertigo and migraine
Migraine
Migraine is a chronic neurological disorder characterized by moderate to severe headaches, and nausea...

s. It is the second most frequent cause of recurrent vertigo with a lifetime occurrence rate of about 1%.

Ménière's disease

Ménière's disease
Ménière's disease
Ménière's disease is a disorder of the inner ear that can affect hearing and balance to a varying degree. It is characterized by episodes of vertigo and tinnitus and progressive hearing loss, usually in one ear. It is named after the French physician Prosper Ménière, who, in an article published...

 frequently presents with vertigo in combination with ringing in the ears, a feeling of pressure or fullness, severe nausea or vomiting, and hearing loss. As the disease worsens, hearing loss will progress.

Vestibular neuritis

Vestibular neuritis presents with severe vertigo. It is believed to be caused by a viral infection of the inner ear. Persisting balance problems may remain in 30% of people affected.

Motion sickness

Motion sickness is one of the biggest symptoms of vertigo and it develops most often in persons with inner ear problems. The feeling of dizziness and lightheadedness is often accompanied by nystagmus
Nystagmus
Nystagmus is a condition of involuntary eye movement, acquired in infancy or later in life, that may result in reduced or limited vision.There are two key forms of Nystagmus: pathological and physiological, with variations within each type. Nystagmus may be caused by congenital disorders,...

. This is when the eyes rapidly jerk to one side and then slowly find their way back to the original position. During a single episode of vertigo, this action will occur repeatedly. Symptoms can fade while sitting still with the eyes closed.

Pathophysiology

The neurochemistry of vertigo includes 6 primary neurotransmitter
Neurotransmitter
Neurotransmitters are endogenous chemicals that transmit signals from a neuron to a target cell across a synapse. Neurotransmitters are packaged into synaptic vesicles clustered beneath the membrane on the presynaptic side of a synapse, and are released into the synaptic cleft, where they bind to...

s that have been identified between the 3-neuron arc that drives the vestibulo-ocular reflex
Vestibulo-ocular reflex
The vestibulo-ocular reflex is a reflex eye movement that stabilizes images on the retina during head movement by producing an eye movement in the direction opposite to head movement, thus preserving the image on the center of the visual field. For example, when the head moves to the right, the...

 (VOR). Many others play more minor roles.

Three neurotransmitters that work peripherally and centrally include glutamate, acetylcholine
Acetylcholine
The chemical compound acetylcholine is a neurotransmitter in both the peripheral nervous system and central nervous system in many organisms including humans...

, and GABA
Gabâ
Gabâ or gabaa, for the people in many parts of the Philippines), is the concept of a non-human and non-divine, imminent retribution. A sort of negative karma, it is generally seen as an evil effect on a person because of their wrongdoings or transgressions...

.

Glutamate maintains the resting discharge of the central vestibular neurons, and may modulate synaptic transmission
Chemical synapse
Chemical synapses are specialized junctions through which neurons signal to each other and to non-neuronal cells such as those in muscles or glands. Chemical synapses allow neurons to form circuits within the central nervous system. They are crucial to the biological computations that underlie...

 in all 3 neurons of the VOR arc. Acetylcholine appears to function as an excitatory neurotransmitter in both the peripheral and central synapses. GABA is thought to be inhibitory for the commissures of the medial vestibular nucleus, the connections between the cerebellar Purkinje cells and the lateral vestibular nucleus, and the vertical VOR.

Three other neurotransmitters work centrally. Dopamine
Dopamine
Dopamine is a catecholamine neurotransmitter present in a wide variety of animals, including both vertebrates and invertebrates. In the brain, this substituted phenethylamine functions as a neurotransmitter, activating the five known types of dopamine receptors—D1, D2, D3, D4, and D5—and their...

 may accelerate vestibular compensation. Norepinephrine
Norepinephrine
Norepinephrine is the US name for noradrenaline , a catecholamine with multiple roles including as a hormone and a neurotransmitter...

 modulates the intensity of central reactions to vestibular stimulation and facilitates compensation. Histamine
Histamine
Histamine is an organic nitrogen compound involved in local immune responses as well as regulating physiological function in the gut and acting as a neurotransmitter. Histamine triggers the inflammatory response. As part of an immune response to foreign pathogens, histamine is produced by...

 is present only centrally, but its role is unclear. It is known that centrally acting antihistamines modulate the symptoms of motion sickness.

The neurochemistry of emesis overlaps with the neurochemistry of motion sickness and vertigo. Acetylcholine, histamine, and dopamine are excitatory neurotransmitters, working centrally on the control of emesis. GABA inhibits central emesis reflexes. Serotonin
Serotonin
Serotonin or 5-hydroxytryptamine is a monoamine neurotransmitter. Biochemically derived from tryptophan, serotonin is primarily found in the gastrointestinal tract, platelets, and in the central nervous system of animals including humans...

 is involved in central and peripheral control of emesis but has little influence on vertigo and motion sickness
Motion sickness
Motion sickness or kinetosis, also known as travel sickness, is a condition in which a disagreement exists between visually perceived movement and the vestibular system's sense of movement...

.

Diagnostic approach

BPPV is normally diagnosed with the Dix-Hallpike test
Dix-Hallpike test
The Dix–Hallpike test or Nylen-Barany test is a diagnostic maneuver used to identify benign paroxysmal positional vertigo .-Process:...



. Tests of vestibular system
Vestibular system
The vestibular system, which contributes to balance in most mammals and to the sense of spatial orientation, is the sensory system that provides the leading contribution about movement and sense of balance. Together with the cochlea, a part of the auditory system, it constitutes the labyrinth of...

 (balance) function include electronystagmography
Electronystagmography
Electronystagmography is a diagnostic test to record involuntary movements of the eye caused by a condition known as nystagmus. It can also be used to diagnose the cause of vertigo, dizziness or balance dysfunction by testing the vestibular system....

 (ENG), rotation tests, caloric reflex test
Caloric reflex test
In medicine, the caloric reflex test is a test of the vestibulo-ocular reflex that involves irrigating cold or warm water or air into the external auditory canal.-Utility:...

, and computerized dynamic posturography
Posturography
Posturography is a general term that covers all the techniques used to quantify postural control in upright stance in either static or dynamic conditions...

 (CDP).

Tests of auditory system
Auditory system
The auditory system is the sensory system for the sense of hearing.- Outer ear :The folds of cartilage surrounding the ear canal are called the pinna...

 (hearing) function include pure-tone audiometry, speech audiometry, acoustic-reflex, electrocochleography (ECoG), otoacoustic emissions (OAE), and auditory brainstem response test
Auditory Brainstem Response
The auditory brainstem response is an auditory evoked potential extracted from ongoing electrical activity in the brain and recorded via electrodes placed on the scalp. The resulting recording is a series of vertex positive waves of which I through V are evaluated...

 (ABR; also known as BER, BSER, or BAER).

Other diagnostic tests include magnetic resonance imaging
Magnetic resonance imaging
Magnetic resonance imaging , nuclear magnetic resonance imaging , or magnetic resonance tomography is a medical imaging technique used in radiology to visualize detailed internal structures...

 (MRI) and computerized axial tomography (CAT or CT).

Treatment

Definitive treatment depends on the underlying cause of the vertigo.
  • benign paroxysmal positional vertigo
    Benign paroxysmal positional vertigo
    Benign paroxysmal positional vertigo is a disorder caused by problems in the inner ear. Its symptoms are repeated episodes of positional vertigo, that is, of a spinning sensation caused by changes in the position of the head.-Classification:...

     (BPPV) is treated with repositioning maneuvers designed to move the otoconia (crystals) back into the utricle where they belong. The most common maneuver is the Epley maneuver
    Epley maneuver
    The Epley maneuver is a maneuver used to treat benign paroxysmal positional vertigo . It is often performed by a doctor, chiropractor, or a physical therapist, after confirmation of a diagnosis of BPPV using the Dix-Hallpike . This maneuver was developed by Dr. John Epley and first described in 1980...

     (performed by a doctor, audiologist, physical therapist, or with a BPPV maneuver at home
    DizzyFIX
    The DizzyFIX is an FDA cleared home medical device available to assist in the treatment of Benign Paroxysmal Positional Vertigo and its associated vertigo. The device itself is a head-worn representation of semi-circular canals. The device is filled with fluid and a particle representing the...

    ). See its Treatment descriptions.
  • anticholinergics
  • antihistamines

Epidemiology

Vertigo is a frequent symptom in the general population with a 12-month prevalence of 5% and an incidence of 1.4% in adults. Its prevalence rises with age and is about two to three times higher in women than in men. It accounts for about 2-3 % of emergency department visits.
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