Vertigo is a condition in which a person has the sensation that they are moving, or that objects around them are moving, when that is not the case.[1] Often it feels like a spinning or swaying movement.[1][2] It may be associated withnausea,vomiting,perspiration, or difficulties walking.[2] It is typically worse when the head is moved.[2] Vertigo is the most common type ofdizziness.[2]
Benign paroxysmal positional vertigo is more likely in someone who gets repeated episodes of vertigo with movement and is otherwise normal between these episodes.[9] Benign vertigo episodes generally last less than one minute.[2] TheDix-Hallpike test typically produces a period of rapid eye movements known asnystagmus in this condition.[1] In Ménière's disease there is oftenringing in the ears,hearing loss, and the attacks of vertigo last more than twenty minutes.[9] In vestibular neuritis the onset of vertigo is sudden, and the nystagmus occurs even when the person has not been moving.[9] In this condition vertigo can last for days.[2] More severe causes should also be considered,[9] especially if other problems such as weakness, headache,double vision, or numbness occur.[2]
Dizziness affects approximately 20–40% of people at some point in time, while about 7.5–10% have vertigo.[3] About 5% have vertigo in a given year.[10] It becomes more common with age and affects women two to three times more often than men.[10] Vertigo accounts for about 2–3% of emergency department visits in thedeveloped world.[10]
Vertigo is classified into either peripheral or central depending on the location of the dysfunction of thevestibular pathway,[11] although it can also be caused by psychological factors.[12]
Vertigo can also be classified into objective, subjective, and pseudovertigo. Objective vertigo describes when the person has the sensation that stationary objects in the environment are moving.[13] Subjective vertigo refers to when the person feels as if they are moving.[13] The third type is known as pseudovertigo, an intensive sensation of rotation inside the person's head. While this classification appears in textbooks, it is unclear what relation it has to thepathophysiology or treatment of vertigo.[14]
People with peripheral vertigo typically present with mild to moderateimbalance,nausea,vomiting,hearing loss,tinnitus, fullness, and pain in the ear.[16] In addition,lesions of the internal auditory canal may be associated with facial weakness on the same side.[16] Due to a rapid compensation[clarification needed] process, acute vertigo as a result of a peripheral lesion tends to improve in a short period of time (days to weeks).[16]
Vertigo that arises from injury to the balance centers of thecentral nervous system (CNS), often from a lesion in thebrainstem orcerebellum,[9][15][19] is called "central" vertigo and is generally associated with less prominent movement illusion andnausea than vertigo of peripheral origin.[20] Central vertigo may have accompanyingneurologic deficits (such asslurred speech anddouble vision), andpathologic nystagmus (which is pure vertical/torsional).[16][20] Central pathology can causedisequilibrium, which is the sensation of being off balance. Thebalance disorder associated with central lesions causing vertigo is often so severe that many people are unable to stand or walk.[16]
Vertigo is a sensation of spinning while stationary.[22] It is commonly associated withnausea orvomiting,[21]unsteadiness (postural instability),[19] falls,[23] changes to a person's thoughts, and difficulties in walking.[24] Recurrent episodes in those with vertigo are common and frequently impair thequality of life.[10]Blurred vision, difficulty in speaking, a lowered level ofconsciousness, and hearing loss may also occur. The signs and symptoms of vertigo can present as a persistent (insidious) onset or an episodic (sudden) onset.[25]
Persistent onset vertigo is characterized by symptoms lasting for longer than one day[25] and is caused by degenerative changes that affect balance as people age. Nerve conduction slows with aging, and a decreased vibratory sensation is common as a result.[26] Additionally, there is a degeneration of theampulla andotolith organs with an increase in age.[27] Persistent onset is commonly paired with central vertigo signs and symptoms.[25]
The characteristics of an episodic onset vertigo are indicated by symptoms lasting for a smaller, more memorable amount of time, typically lasting for only seconds to minutes.[25]
A large meta-analysis of genome-wide association study (GWAS) associated six genes with vertigo and implicated the proteins they encode in the biology of the inner ear.[28]
The neurochemistry of vertigo includes six primaryneurotransmitters that have been identified between the three-neuron arc[29] that drives thevestibulo-ocular reflex (VOR). Glutamate maintains the resting discharge of the central vestibular neurons and may modulatesynaptic transmission in all three neurons of the VOR arc. Acetylcholine appears to function as an excitatory neurotransmitter in both the peripheral and central synapses.Gamma-Aminobutyric acid (GABA) is thought to be inhibitory for the commissures of themedial vestibular nucleus, the connections among the cerebellarPurkinje cells, thelateral vestibular nucleus, and the vertical VOR.
Three other neurotransmitters work centrally.Dopamine may accelerate vestibular compensation.Norepinephrine modulates the intensity of central reactions to vestibular stimulation and facilitates compensation.Histamine is present only centrally, but its role is unclear. Dopamine, histamine,serotonin, and acetylcholine are neurotransmitters thought to produce vomiting.[9] It is known that centrally acting antihistamines modulate the symptoms of acute symptomatic vertigo.[30]
The HINTS test, which is a combination of three physical examination tests that may be performed by physicians at the bedside, has been deemed helpful in differentiating between central and peripheral causes of vertigo.[33] The HINTS test involves the horizontal head impulse test, observation of nystagmus on primary gaze, and the test of skew.[34]CT scans orMRIs are sometimes used by physicians when diagnosing vertigo.[21]
A number of specific conditions can cause vertigo. In the elderly, however, the condition is often multifactorial.[10]
A recent history ofunderwater diving can indicate a possibility of barotrauma or decompression sickness involvement, but does not exclude all other possibilities. The dive profile (which is frequently recorded bydive computer) can be useful to assess a probability for decompression sickness, which can be confirmed bytherapeutic recompression.[35]
Benign paroxysmal positional vertigo (BPPV) is the most common vestibular disorder[3] and occurs when loosecalcium carbonate debris has broken off of the otoconial membrane and enters a semicircular canal thereby creating the sensation of motion.[1][9] People with BPPV may experience brief periods of vertigo, usually under a minute,[9] which occur with change in the position.[36]
This is the most common cause of vertigo.[10] It occurs in 0.6% of the population yearly with 10% having an attack during their lifetime.[10] It is believed to be due to a mechanical malfunction of the inner ear.[10] BPPV may be diagnosed with theDix–Hallpike test and can be effectively treated with repositioning movements such as theEpley maneuver.[10][36][37][38]
Ménière's disease is an inner ear disorder of unknown origin, but is thought to be caused by an increase in the amount ofendolymphatic fluid present in the inner ear (endolymphatic hydrops).[1] However, this idea has not been directly confirmed withhistopathologic studies, butelectrophysiologic studies have been suggestive of this mechanism.[39] Ménière's disease frequently presents with recurrent, spontaneous attacks of severe vertigo in combination with ringing in the ears (tinnitus), a feeling of pressure or fullness in the ear (aural fullness), severe nausea or vomiting, imbalance, and hearing loss.[9][25][39] As the disease worsens, hearing loss will progress.
Vestibular neuritis presents with severe vertigo[10] with associated nausea, vomiting, and generalized imbalance and is believed to be caused by a viral infection of the inner ear, although several theories have been put forward and the cause remains uncertain.[9][40] Individuals with vestibular neuritis do not typically have auditory symptoms, but may experience a sensation of aural fullness or tinnitus.[40] Persisting balance problems may remain in 30% of people affected.[10]
Vestibular migraine is the association of vertigo andmigraines and is one of the most common causes of recurrent, spontaneous episodes of vertigo.[3][10] The cause of vestibular migraines is currently unclear;[3][41] however, one hypothesized cause is that the stimulation of thetrigeminal nerve leads tonystagmus in individuals with migraines.[1] Approximately 40% of all migraine patients will have an accompanying vestibular syndrome, such as vertigo, dizziness, or disruption of the balance system.[41]
Other suggested causes of vestibular migraines include the following: unilateral neuronal instability of the vestibular nerve, idiopathic asymmetric activation of the vestibular nuclei in the brainstem, andvasospasm of the blood vessels supplying the labyrinth or central vestibular pathways resulting inischemia to these structures.[21] Vestibular migraines are estimated to affect 1–3% of the general population[1][10] and may affect 10% of people with migraine .[1] Additionally, vestibular migraines tend to occur more often in women and rarely affect individuals after the sixth decade of life.[3]
Motion sickness is common and is related to vestibular migraine. It is nausea and vomiting in response to motion and is typically worse if the journey is on a winding road or involves many stops and starts, or if the person is reading in a moving car. It is caused by a mismatch between visual input and vestibular sensation. For example, the person is reading a book that is stationary in relation to the body, but the vestibular system senses that the car, and thus the body, is moving.
Alternobaric vertigo is caused by a pressure difference between the middle ear cavities, usually due to blockage or partial blockage of one eustachian tube, usually when flying or diving underwater. It is most pronounced when the diver is in the vertical position; the spinning is toward the ear with the higher pressure and tends to develop when the pressures differ by 60 cm of water or more.[42][43]
Vertigo is recorded as a symptom of decompression sickness in 5.3% of cases by the U.S. Navy as reported by Powell, 2008[42] including isobaric decompression sickness.
Decompression sickness can also be caused at a constant ambient pressure when switching between gas mixtures containing different proportions of different inert gases. This is known asisobaric counterdiffusion, and presents a problem for very deep dives.[44] For example, after using a very helium-richtrimix at the deepest part of the dive, a diver will switch to mixtures containing progressively less helium and more oxygen and nitrogen during the ascent. Nitrogen diffuses into tissues 2.65 times slower than helium, but is about 4.5 times more soluble. Switching between gas mixtures that have very different fractions of nitrogen and helium can result in "fast" tissues (those tissues that have a good blood supply) increasing their total inert gas loading. This is often found to provoke inner ear decompression sickness, as the ear seems particularly sensitive to this effect.[45]
A stroke (either ischemic or hemorrhagic) involving theposterior fossa is a cause of central vertigo.[34] Risk factors for a stroke as a cause of vertigo include increasing age and known vascular risk factors. Presentation may more often involve headache or neck pain, additionally, those who have had multiple episodes of dizziness in the months leading up to presentation are suggestive of stroke with prodromalTIAs.[34] The HINTS exam as well as imaging studies of the brain (CT, CTangiogram,MRI) are helpful in diagnosis of posterior fossa stroke.[34]
Vertebrobasilar insufficiency, notably Bow Hunter's syndrome, is a rare cause of positional vertigo, especially when vertigo is triggered by rotation of the head.[46][47]
Definitive treatment depends on the underlying cause of vertigo.[9] People with Ménière's disease have a variety of treatment options to consider when receiving treatment for vertigo and tinnitus, including a low-salt diet and intratympanic injections of the antibioticgentamicin or surgical measures such as a shunt or ablation of thelabyrinth in refractory cases.[48]Common drug treatment options for vertigo may include the following:[49]
All cases of decompression sickness should be treated initially with 100% oxygen untilhyperbaric oxygen therapy (100% oxygen delivered in a high-pressure chamber) can be provided.[51] Several treatments may be necessary, and treatment will generally be repeated until either all symptoms resolve, or no further improvement is apparent.
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