Vertigo is a false sensation that the self, the surroundings, or both are moving or spinning, usually accompanied by nausea and loss of balance.

• Vertigo results from disorders that affect the inner ear or parts of the brain involved in balance.
• In addition to a sense of spinning, people may have nausea, loss of balance, hearing or vision problems, and headaches.
• Doctors can often diagnose the cause based on the person's description of the problem and results of a physical examination, but other tests are sometimes needed.
• Sometimes taking simple precautions, based on what triggers vertigo, or a drug can prevent vertigo.
• Drugs, such as the scopolamineSome Trade Names
  TRANSDERM SCOP
  patch, can help relieve the vertigo and nausea.

Vertigo, a type of dizziness, resembles the feeling produced by the childhood game of spinning round and round, then suddenly stopping and watching the surroundings spin. Most cases of dizziness are not vertigo.

Causes

Vertigo can be caused by disorders of body parts that are involved in maintaining balance:

• Inner ear (see Biology of the Ears, Nose, and Throat: Inner Ear)
• Brain stem and cerebellum
• Nerve tracts connecting the brain stem and cerebellum or within the brain stem

The inner ear contains structures (the semicircular canals, saccule, and utricle) that enable the body to sense position and motion. Information from these structures is sent to the brain through the vestibulocochlear nerve (8th cranial nerve, which is also involved in hearing). This information is processed in the brain stem, which adjusts posture, and the cerebellum, which coordinates movements, to provide a sense of balance.

Inner Ear Disorders: Most commonly, vertigo results from motion sickness. Motion sickness may develop in people whose inner ear is sensitive to particular motions, such as swaying or sudden stopping and starting.

Another common cause of vertigo is an abnormal collection of calcium particles in one semicircular canal of the inner ear. The resulting disorder, called benign paroxysmal positional vertigo, or BPPV, is especially common among older people. It occurs when the head is moved in certain ways.

Meniere's disease produces attacks of vertigo. The cause of Meniere's disease is thought to involve excess fluid in the inner ear (hydrops). What triggers this is unknown, but it may result from an autoimmune reaction, an allergy, an imbalance in the autonomic nervous system, a blockage to certain structures in the ear, or a viral infection.

Disorders of the vestibulocochlear nerve can cause vertigo, a hearing disorder, or both.

Other disorders that may cause vertigo by affecting the inner ear or its nerve connections include the following:

• Bacterial or viral infections, such as vestibular neuritis, herpes zoster, and mastoiditis
• Paget's disease
• Tumors, such as an auditory nerve tumor
• Inflammation of nerves

The inner ear may also be damaged by drugs, such as aminoglycoside antibiotics, aspirinSome Trade Names
BAYER
, the chemotherapy drug cisplatinSome Trade Names
PLATINOL
, the sedative phenobarbitalSome Trade Names
LUMINAL
, the anticonvulsant phenytoinSome Trade Names
DILANTIN
, the antipsychotic chlorpromazine, and certain diuretics including furosemideSome Trade Names
LASIX
. Excessive use of alcohol can cause temporary vertigo.

Disorders That Affect the Brain: A decrease in the blood supply through arteries to the brain stem, cerebellum, and back of the brain can cause vertigo. This decrease is called vertebrobasilar insufficiency because the arteries affected include the vertebral and basilar arteries. If the decreased blood supply causes temporary symptoms, a transient ischemic attack (TIA) is diagnosed. If permanent damage results, a stroke is diagnosed.

Less common disorders that cause vertigo by affecting the brain stem or cerebellum include multiple sclerosis, fractures at the base of the skull, head injuries, seizures, infections, and tumors growing in or near the base of the brain. Vertigo can sometimes be part of a migraine attack and occasionally occur without the headache.

Occasionally, vertigo is caused by disorders that suddenly increase pressure within the skull, putting pressure on the brain. These disorders include benign intracranial hypertension, brain tumors, and bleeding (hemorrhage) within the skull.

Did You Know... In many instances, not taking drugs to relieve vertigo is better than taking them.

Symptoms

People with vertigo have an unusual and uncomfortable sense that they, their environment, or both are spinning around. Occasionally, the person feels simply pulled to one side. The resulting loss of balance makes walking and driving difficult. Vertigo is often accompanied by the following:

• Nystagmus (the rapid jerking movement of the eyes in one direction alternating with a slower drift back to the original position), which occurs repeatedly during an episode of vertigo
• Nausea, sometimes with vomiting

Vertigo may last for only a few moments or may continue for hours or even days. People who have vertigo sometimes feel better when lying down or sitting still. However, vertigo may continue even when they are not moving at all. Symptoms from an inner ear cause (for example, BPPV, Meniere's disease, or vestibular neuritis) typically improve over days to weeks, whereas symptoms caused by a disorder of the central nervous system (for example, stroke or multiple sclerosis) require weeks to months to improve.

People with Meniere's disease may have sudden, episodic attacks of vertigo. Other symptoms include the following:

• Noise in the ears (tinnitus)
• Progressive hearing loss (usually low frequency or bass sounds)
• A sense of fullness or pressure in the affected ear
• Often, severe nausea and vomiting

Episodes usually last from several minutes to several hours. At first, hearing returns to normal, but as the disease continues, hearing loss persists and worsens.

In people with a viral infection of the inner ear (vestibular neuritis), vertigo usually begins suddenly and worsens over several hours. Nausea may be intense. People with this disorder may sit very still because moving the head or eyes may trigger vomiting. Vestibular neuritis begins to subside over a period of days, but it may last weeks or even months.

Vertigo due to a brain disorder, including vertebrobasilar insufficiency, may be accompanied by the following:

• Headaches
• Slurred speech
• Double vision
• Weakness of an arm or a leg
• Uncoordinated movements
• Loss of consciousness

Vertigo due to a disorder that suddenly increases pressure within the skull may be accompanied by the following:

• Headache
• Temporary blurring of vision
• Unsteadiness when walking

Diagnosis

Doctors ask the person to describe the nature and circumstances of the sensations felt. Balance and hearing are tested.

Physical Examination: The eyes are checked for abnormal movements, such as nystagmus. Abnormal eye movements suggest a disorder affecting the inner ear or various nerve connections in the brain stem. Doctors deliberately try to induce nystagmus because the direction in which the eyes move helps doctors make the diagnosis. They can observe the direction in several ways. During an ophthalmoscopic examination, the doctor focuses on the optic disk and then covers the other eye. If the optic disk jiggles, nystagmus is present. Alternatively, the person may be given special glasses called Frenzel lenses to wear. Doctors can easily see the person's eyes through the lenses, but the person sees only a blur and cannot visually fixate on anything (visual fixation suppresses nystagmus). Sometimes eye movements are recorded using electrodes (sensors that stick to the skin) placed around each eye (electronystagmography) or using a video camera attached to the Frenzel lenses.

Other maneuvers to induce nystagmus include putting ice-cold water into the ear canal (caloric testing), rapidly shaking the person's head from side to side for 20 seconds (head shaking test), and stimulating the posterior semicircular canal by rapidly changing the position of the person's head (Dix-Hallpike maneuver). The Dix-Hallpike maneuver, which is used in the diagnosis of BPPV, is identical to the first part of the Epley maneuver (see Dizziness and Vertigo: The Epley Maneuver: A Simple Cure for a Common Cause of Vertigo).

Testing: For many people, additional testing is not needed. When it is, computed tomography (CT) or magnetic resonance imaging (MRI) of the head can detect some of the disorders that can cause vertigo. CT can show abnormalities in bone, such as an infection of the bone behind the ear (mastoiditis), fractures at the base of the skull, erosion of bone by tumors, and abnormal bone formation as occurs in Paget's disease. MRI produces better images of the brain stem and cranial nerves than CT.

If an ear infection is suspected, doctors may take a sample of pus or fluid from the ear with a needle or swab.

If a brain infection is suspected, a spinal tap (lumbar puncture) may be done to obtain a sample of cerebrospinal fluid from the spine.

If multiple sclerosis is suspected, an MRI may be done.

If doctors suspect that the blood supply to the brain is inadequate, Doppler ultrasonography, CT angiography, magnetic resonance angiography (MRA), or catheter angiography (which uses x-rays) may be done.

Prevention and Treatment

Vertigo due to certain disorders can be prevented. For example, if vertigo is due to motion sickness, situations that cause it (such as a rocking boat) can be avoided, and fixing the eyes on an unmoving object in the distance (visual fixation) can help avert an attack or stop one that has started. A scopolamineSome Trade Names
TRANSDERM SCOP
patch can help prevent as well as treat vertigo due to motion sickness.

Drugs that may relieve vertigo and the accompanying nausea include cyclizineSome Trade Names
MAREZINE
, dimenhydrinate, diphenhydramineSome Trade Names
BENADRYL
, hydroxyzineSome Trade Names
VISTARIL
, meclizineSome Trade Names
ANTIVERT
, and promethazine. These drugs can be taken by mouth. ScopolamineSome Trade Names
TRANSDERM SCOP
, taken through a skin patch (often worn behind the ear), may be used instead. It is effective for several days and may be preferred if nausea is present.

If the vertigo is severe or causes anxiety, sedatives may be useful. Most often, benzodiazepines are used. Particularly for older people, the benzodiazepines alprazolamSome Trade Names
XANAX
and lorazepamSome Trade Names
ATIVAN
are preferred because their effects do not last as long as those of other benzodiazepines.

All of these drugs may have side effects, especially in older people. Older people should avoid taking them whenever possible, but when vertigo is severe and persistent, taking a drug may be necessary but should be supervised by a doctor. ScopolamineSome Trade Names
TRANSDERM SCOP
given through a patch tends to have the fewest side effects. More often than not, vertigo is caused by BPPV in older people and can be relieved without drugs. Drugs used in the treatment of vertigo may cause agitation in infants and very young children and should not be given to them except as directed by a doctor.

Last full review/revision October 2007 by Michael Jacewicz, MD