Dr. Kevin Most: Vertigo
When you hear the word “vertigo” do you think of the great Hitchcock movie or the medical condition. If you have ever had vertigo you know it is one of the worst feelings in the world. Spinning rooms, loss of balance, lightheaded and nausea are the most common symptoms. For many, the first time they feel like this can be quite concerning as well, are they having a stroke, are they dehydrated, is something wrong in their brain or is it an eye problem? It is not uncommon to have these symptoms and seek medical care which is a great thing to do. For many patients it is a benign condition and a good exam simple treatment, reassurance and education is all that is needed, for others it may be a sign of a more concerning condition and further testing is needed.
So first let’s do a quick lesson on our balance. When you think about it the body is amazing, think of the positions we can put ourselves in and still maintain our balance, think about a trip and near fall where you quickly right yourself before hitting the ground. Or think of the moves on “Dancing with the Stars” that Mary likes so much. We all enjoy the 1 year old learning to walk and balance. We take all of this for granted as it just happens without us thinking. However when it doesn’t work like we expect it to, it grabs our attention and rightly so.
Our balance system is quite complex and fortunately it has some redundancy. The simple set up is that the brain receives input and that input is then used to make the body move and muscle react. Think about that for a second, think about a time you almost fell but you caught yourself, all of this occurring in under a second. How does it work? The brain relies on input from a few areas. First our vision, the eyes send a message to the brain and tell the brain, we are coming up to a curb, or we are entering uneven terrain, the brain sends message to the body and our balance is maintained. But it is not that simple, if it were, how could we walk at night? How could a blind person walk? The body has built in redundancies that allow us to keep our balance.
We have receptors on the soles of our feet as well as our hands that send messages to the brain about our position. This allows us to walk in the dark and for some people the talent needed to walk on their hands. More importantly we have receptors in our inner ear that sends messages to the brain as well that supports our balance. These receptors are called semicircular canals and they have very fine hair cells in them. As the body moves even subtly, messages are sent to the brain informing it of the bodies position and movement.
So when the system is working well and all parts are firing appropriately we do great, we can run on uneven surfaces, we can jump from one level to another, we can run in the dark, the list goes on. The brain is able to take all of the information and send commands to the body, we run into problems when the systems are not all working appropriately. When this occurs the brain is forced to make decisions with incomplete or incorrect information. Sometimes this is gradual and the body starts to adjust, think of the individual with worsening vision, or the diabetic with nerve issues in their feet, these changes are slow and can occur over a few years. In those cases the body is not as quick to respond and can result in falls or slips. For these conditions we start to work with patients as it occurs, making changes in the environment, glasses, walking aids or clothing, all to protect the patient and keep them safe.
However what happens with this happens quickly? This is a much bigger problem, a concerning issue and potentially a safety issue for the individual. It can occur in many situations. Strokes can bring this on, brain tumors can as well. Fortunately these are much less common than a condition called Benign Positional Vertigo or another called Viral Vertigo.
For the basics, in these conditions what is happening is essentially sensory overload or sensory confusion. It is almost always associated with the inner ear portion of our balance system. The inner ear has some inflammation of irritation of the semicircular bones and the hair in them. What happens next is the brain receives signals from the feet and the eyes, these 2 are in line. It then also receives input from the inner ear that is incorrect and thus the brain cannot figure out what is right and dizziness occurs. Often this signal from the inner ear is noted in a specific position or after a rapid head movement and it settles down when the movement is halted and the head is held still. At that point the inner ear can send the correct message and the dizziness resolves, but any movement can cause the problem to occur again.
What is often happening is that there are small crystals in our ear and sometimes these are free and end up in the semicircular ear canals, inflammation or debris that pushes against these fine hairs and causes the confused message to the brain. The vast majority of the time there is no cause identified, it just happens. In some cases the individual may have had an upper respiratory infection that causes some inflammation in the inner ear and causing the symptoms. Since the cause is the free crystals , unknown or viral you can imagine there is not a lot we can do as individuals to prevent it from occurring.
One thing people will notice is that the vertigo resolves as long as you are holding your head steady, which makes sense as the message from the ear to the brain would be a steady position. Move your head quickly and the symptoms will return, stop and they often resolve. This occurs because the tiny crystals stop moving and stop the brain from getting an incorrect positioning message.
As far as treating this condition, it too can be frustrating. Medications often will not work well and the side effects from the anti histamines can make one very drowsy. There is a treatment call the Epley Maneuver that a physician can do in their office and then teach you how to do it at home. This maneuver is designed to move the crystals back out of the canals and in place where they belong. It is a series of movements you do with your head while lying down. Often this can cure the problem immediately, for others it may take a few treatments. Once it is resolved your doctor may tell you it is a good idea to sleep with your head propped up for a few nights. Again this maneuver only works in some cases. If you have the condition, Google Epley Maneuver and there are many videos showing you how to do it at home.
It is great when this is a benign condition, frustrating but not dangerous or life threatening. Getting it checked by your doctor is a good idea, the symptoms can mimic a stroke or in some cases a brain tumor, so a good exam is key to your health. Your physician may order a CT scan or an MRI, do not be upset with them if the test is normal. I am still amazed everyday by individuals who are upset that a test was normal, as doctors we need to balance the clinical picture we see with the tests we need and the possible diagnosis we could be dealing with. This balance is not easy, the next time your doctor orders a test, as him what his concern is and if the test will eliminate that concern. This should make both of you sleep easier. Hopefully patients realize that doctors do not get paid to do more tests, they do not do these to run up a bill, they do them to give them an answer and to diagnose a condition early.