Season 2 | Episode 1
>> Narrator: Vertigo, a feeling of dizziness. A swimming in the head, figuratively. A state in which all things seem to be in a whirlpool of terror.
>> Joe: Welcome to the Merck Manuals Medical Myths podcast where we set the record straight on today’s most talked about medical topics and questions. I’m your host, Joe McIntyre, and on this episode we welcome Dr. David Kaylie Dr. Kaylie is an ear, nose, and throat doctor, head and neck surgeon, neurotologist, and otologist. He comes to us from Duke University Medical Center and is also the author of a number of sections in the Merck Manual. Dr. Kaylie, thanks for coming on the show.
>> Dr. Kaylie: Thank you for having me.
>> Joe: Today we’re going to talk to Dr. Kaylie about a topic that I think a lot of people find truly fascinating: the feeling of vertigo. What is it? How does it work? And why do we feel it sometimes? Now there may be many people out there who may think that they’ve never experienced vertigo, but Dr. Kaylie we talked about a week or so ago and you say that’s probably not the case. Many of us have probably had this experience when we were kids, care to explain a little bit?
>> Dr. Kaylie: Yes, most of us have experienced what true vertigo is, and by that I mean a rotational sensation like the world is spinning around, and people experience that when they’re kids because most of us have spun around in a circle and then stopped until we felt dizzy, and that truly is the sensation of vertigo where you feel like the world around you is spinning in a rotation. Like you’re on a merry-go-round or the world is on a merry-go-round revolving around you.
>> Joe: So what’s the difference between simple dizziness and vertigo?
>> Dr. Kaylie: Dizziness is a term that can really mean anything. It really doesn’t have a medical meaning. It could be true vertigo like rotational spinning or it could be a sensation off balance. It could be a feeling of off balance from light blood pressure, or it doesn’t really have a medical meaning, whereas the term “vertigo” really refers to an abnormal sensation of motion to a normal stimulus, or even if there is no stimulus, having a sensation of motion. So it really requires there to be an abnormal sensation of motion and it doesn’t have to be a rotational motion, it can be a dizzy equilibrium like a rocking sensation or an unsteadiness, but it’s abnormal sensation of motion.
>> Joe: So I know a lot of us when we were kids did a little spinning, or we spun around in an office chair just to see what that sensation is like. Does this cause vertigo later in life if you do this as a kid?
>> Dr. Kaylie: No, not at all. There’s no risk for that at all, that does not change anything in the brain or put you at risk for developing dizziness problems later in life.
>> Joe: There’s other aspects of vertigo besides just spinning around as a kid or spinning around in an office chair. What about when you’re, let’s say in a parked car, and you see a car beside you start moving and you feel a little woozy or you feel a little dizzy. Is that vertigo, or what’s the difference between that vertigo or spinning vertigo? Is there any difference?
>> Dr. Kaylie: So that’s actually a sensation that most of us experience at some point where you’re in a parked car and you look out the window and the car next to you moves and you have that very strong sensation that you’re moving, or it could happen on a train or a bus. But most of us experience something like that, and it can really be a powerful sensation that you’re moving or falling and you have to grab on to something or slam on the breaks, so it can be quite distressing. And that is caused by a mismatch in the input your brain uses to maintain balance. So balance isn’t just your inner ear telling your brain where it is in space, your brain is also taking information from your eyes. Your eyes are telling your brain where you are in space and your muscles and skin and joints are telling you where your body is in space. So your brain takes information from all three of those sources and combines it to give you that sensation of balance. So when you’re in a parked car and the car next to you moves, your eyes are telling your brain you’re moving, but your inner ears and your muscles are telling you you’re not, and that mismatch gives you vertigo.
>> Joe: So one other myth that we hear is this idea that when you go to pick something up, for example you bring your head down to the ground and then you come up really quickly, you may have some dizziness or you may feel light headed. Is that vertigo?
>> Dr. Kaylie: No. That’s a totally different feeling, and that’s real important to differentiate when you’re talking to patients because that, that’s caused by a totally different thing, not caused by the inner ear or the balance system. When you’re bent over and your head is below your heart, the heart can sense that it doesn’t have to pump very hard to get blood to your brain, because just blood will get into your head by gravity, that if you stand up real quickly, now all of a sudden the heart has to pump harder to get blood up to your brain against gravity and you can have a brief moment where you have a little bit of insufficient blood to the brain which give you that lightheaded, near-passing out feeling. So most people have experienced that also. That can happen to anybody, you can stand up real quickly and you can have that head-rush or lightheaded feeling. But that can also happen to people whose blood pressure is too low, if you’re anemic, meaning your blood counts are too low, or you’re dehydrated. All those things can cause that, but it’s not vertigo and that’s not caused by the inner ear.
>> Joe: So we talked in the beginning how pretty much everybody who’s listening to this podcast has experience vertigo in one shape or the other. How common is vertigo later in life? Is it something that affects older people more than younger people, or sicker people more than healthier people? How does it come up later in life?
>> Dr. Kaylie: Well it’s actually one of the most common reasons people visit primary care offices in the U.S. and as you get older, the likelihood of having an episode of dizziness that you seek medical attention for goes up. So by age eighty, sixty-percent of people will have seen a doctor at some point in their life for dizziness. So it is a very very common healthcare issue and reason for visiting the doctor and it ends up being a very costly symptom, because there’s missed work and doctor’s visits and medical costs associated.
>> Joe: And I’m sure that when a lot of people hear the word “vertigo,” they think of the Alfred Hitchcock movie Vertigo--
>> Dr. Kaylie: Yes.
>> Joe: -- starring Jimmy Stewart. And I believe in the movie he more so experiences a fear of heights, and there is a difference between vertigo and a fear of heights, is there not? And are they somehow related?
>> Dr. Kaylie: Yeah, that is true, and I mean the phobia of heights, or some people have agoraphobia, so they have fear of going outside, and that fear can be very intense and that causes an intense anxiety and that can give you a dizzy feeling, but it truly is not vertigo. Now there are anxious conditions that are triggered by a true vertigo event that leads to anxiety and fear of heights or fear of falling or of going outside and there truly was a vertigo even that led to it, but anxiety is really a different diagnosis than vertigo.
>> Joe: So Dr. Kaylie, can you explain the difference between vertigo as a symptom of another health issue or vertigo as a medical condition. Is vertigo essentially the issue or is vertigo essentially the side effect of a more serious or potentially more serious medical condition?
>> Dr. Kaylie: Yeah vertigo is a symptom, it’s not really a diagnosis. So a lot of times I’ll see patients who had a vertigo event and they went to the emergency room and they tell me there “Well the doctor said I have vertigo.” It’s like yes, of course, you had vertigo, that’s obvious, but that isn’t the diagnosis. That’s not what the underlying problem is. It’s sort of like having a cough. You can have a cough because you have a cold or you could have a cough because you have lung cancer. Cough is just the symptom, so you need to find out what the underlying disease is that’s causing the vertigo. So, that’s the important thing, understand that there is a symptom of vertigo but knowing what the characteristics of that vertigo is, like how long did it last, what other symptoms have you had with it like did you have any senses or hearing or ringing in your ears or did you have a migraine associated with it or weakness in the side of your body or facial paralysis or hearing — other things related to it. So isolated vertigo without any other symptoms doesn’t happen, there’s always something else that goes along with it that really helps you come along to a true diagnosis of what the cause is.
>> Joe: And you mentioned something just a few seconds ago that I think is something people suffer from a decent amount, is the idea that migraines, sometimes they can cause pain, sometimes they can cause sensitivity to light, and then sometimes they can cause vertigo. How do you go about diagnosing migraines and what role does vertigo play in that?
>> Dr. Kaylie: Yeah that’s actually hugely important because the association between migraines and vertigo is very very high. And surprisingly is wasn’t really put together, the two weren’t associated for a really long time, even though the earliest medical reports on migraines discuss the frequency of vertigo was not really understood as a symptom of migraines until quite recently. And so there are diseases that can happen where you might have one disease and you might have another disease, and you just happen to have two diseases by random chance, but the incidence of having vertigo and migraines is actually three times higher than random chance. So there clearly is a fairly high correlation between migraines and vertigo. In fact, some reports that up to fifty percent of patients who have migraines have vertigo at some point. So it’s really really important that when someone has new symptoms of vertigo to actually find out about migraine history, and a lot of times the migraines might be fairly minor and there are a lot of misconceptions about what migraines are. People think of them as these absolutely crippling headaches, where you’re in a dark room, nauseated and miserable, and a lot of times the headaches can be quite mild and actually the other symptoms can be much more pronounced. So it’s really important to think of a migraine as a constellation of neurological symptoms and vertigo as one of them.
>> Joe: Now sticking on the topic of migraines just for a second, is there anything that brings about migraines in people or is it just some people are just, you know, afflicted with this condition and there’s really no rhyme or reason or it’s a little more of a complex issue than that?
>> Dr. Kaylie: Well yes to all those.
>> Dr. Kaylie: Migraines are really complicated. There are certain things, like they run in families, they’re very common for multiple people in the family to have migraines, so there’s clearly a genetic component. Women get migraines up to six times more frequently than men do, so there’s gender triggers for it. It could be hormonal. There are environmental triggers, people get migraines triggered by smells or lights or foods. So there are lots of foods that are very common migraine triggers that people don’t even think about that would be very shocking that they’re actually migraine triggers like bananas and avocados are really high incidents of triggering migraines in patients who are susceptible to migraines. Something that’s really important to do in someone who has a new diagnosis of migraines is to look at a migraine diet and eliminate a lot of these common foods that can trigger migraines. Most people know about red wine and chocolate and cured meats like salami are pretty well-known triggers for migraines, but there are a lot of other foods like potatoes, like who would think a potato could be for—
>> Joe: Right!
>> Dr. Kaylie: --could really trigger migraines, but it’s really important if you do have migraines, if you do have vertigo, to really try and look at diet as a non-medicine treatment, and a lot of people get tremendous relief just from diet modifications.
>> Joe: Thanks Dr. Kaylie. More right after this.
>> Joe: The Merck Manuals website offers a variety of video, audio, and interactive content. With so many choices, it’s easy to access information as the first place to go for free, understandable medical content.
>> Joe: Now let’s stick to the issue of heads real quick. Is there any correlation between head injuries and vertigo? And I ask this because one of my colleagues actually recently got into a skiing accident, hit his head on the ground and went to the doctor and wasn’t, you know, experiencing any symptoms of vertigo, but then the doctor put his head over the back of a chair and tilted it back a little bit and he experienced some vertigo. How does that relate to each other and what is the connection there?
>> Dr. Kaylie: Well that’s a specific type of vertigo called benign paroxysmal positional vertigo, or BPPV, and it commonly occurs after a minor head injury, and basically what happens is crystals that are in one part of the inner ear, where they’re supposed to be, can shaken loose by a head injury and it floats to another part of the inner ear and it causes a very specific type of vertigo. It causes a really intense spinning dizziness that happens when you lean your head back and tilt it to one side or the other. And it generally only lasts thirty to ninety seconds and no other symptoms associated with it, like you don’t have hearing loss, you don’t have a ringing in your ear, it can make you very nauseated but really that that’s it and that that’s really specific. And that’s fixable by a maneuver called the Epley maneuver, or more technically it’s called the canalith repositioning maneuver, those are a couple ways of fixing it, and this is fixable. Those maneuvers will eliminate it in ninety-five percent of people after one or two tries. So that’s certainly one type of vertigo that can happen after a head injury. But another thing we really learned a lot about is the effects of concussions and traumatic brain injury and its effect on migraines and vertigo. We see so many professional athletes who have multiple concussions who develop traumatic brain injuries and who have chronic headache and dizziness. We see it a lot in the soldiers who’ve have a lot of explosions from IEDs have traumatic brain injury, concussions, and have tremendous amount of problems with vertigo and migraines. So head injury and traumatic brain injury can cause tremendous amount of problems for various reasons, and that specific one you mentioned is just one. It just happens to be one that’s quite easily fixed. The vertigo you get from a traumatic brain injury or even multiple concussions is even more complicated and severe and difficult to treat.
>> Joe: Dr. Kaylie, you mentioned something pretty interesting there. This idea that we have crystals in our ears. Can you explain more about what these crystals are, how big they are, can we actually see them? Can we take them out of our heads and actually see them with the naked eye?
>> Dr. Kaylie: Well you won’t ever see them, fortunately. If you did, you’d have a problem.
>> Dr. KAYLIE: They’re inside the inner ear, so they’re pretty isolated. They’re in a part of the inner rear that helps you detect motion when you’re going up and down, like when you’re in an elevator you know you’re going up or down because of those crystals in the inner ear. They help stimulate that part of the inner ear to detect that kind of motion. So you don’t have to look around you to see you’re moving in an elevator, you can just sense it. And so the crystals are very very important for that part of the inner ear to work, but there’s other parts of the inner ear that detect head motion rotation, so like shaking your head no or shaking your head yes, those motions are detected by a different part of the inner ear and if the crystals break loose and float into one of those areas, it’ll cause that specific type of dizziness.
>> Joe: Is there a correlation between hearing loss and vertigo? Are there instances where someone experiences vertigo with hearing loss and it’s a sign of a different or more serious condition?
>> Dr. Kaylie: There’s a lot of different type of vertigo that can be associated with hearing loss, and that is really important when someone does have vertigo and hearing loss to get evaluated. So if someone has an episode of vertigo and they feel like they lost hearing in one ear, that really requires medical attention cause it can be caused by several things. There’s a condition called Meniere’s disease, which is episodes of vertigo that can be really intense that last for twenty minutes to hours and it’s associated with hearing loss, mostly just one ear, that can be pretty severe and they also get very loud noise in their ear, tinnitus is the term, but it’s a very loud noise that’s often described as a roaring or jet engine noise, so it’s very loud, and it’s pressure in your ear, so it’s a feeling that you have to pop your ear or you can’t clear your ear. And so the vertigo, the hearing loss, the pressure and the ringing are the four symptoms of Meniere’s disease and they all come in a wave, or an attack, and they last for hours. So that’s really important, but there can also be benign growths on the hearing imbalance nerves that can mimic that can cause you to have a sudden drop in hearing and dizziness. And so anyone who has that constellation symptoms with vertigo and hearing loss needs to get and MRI to look at the hearing imbalance to make sure they don’t have one of these benign, non-cancer growths.
>> Joe: So Dr. Kaylie, over the past few minutes we’ve talked about this idea that vertigo is typically a symptom of another medical condition. So let’s say someone experiences vertigo quite often— who should they go about calling when they have this issue? Is it a physical therapist, is it 911, is it their primary care physician, or is it you? Who should they call?
>> Dr. Kaylie: There’s no right answer for that. Any one of those would be appropriate. If someone is very concerned and they feel that something dangerous is happening, certainly they should go to the emergency department to be evaluated. Most of the time an acute vertigo event is not a sign of anything really dangerous, so it’s not something that often needs that level of care, but certainly I would never tell anyone don’t go to the ED if they are concerned. But that being said, the treatment for vertigo is often physical therapy, that’s often a very helpful treatment. Physical therapy often retrains the brain to accept the input it’s getting as normal. So, if somebody has an injury to the inner ear or surgery where it knocks out some of the inner ear functions, or they have a condition like Meniere’s disease where they can deteriorate your balance function, then physical therapy can be very helpful. The problem is if someone’s having frequent episodes of vertigo and their function in the inner ear is changing day to day, physical therapy will actually make you feel a lot worse and won’t help you. It has to be something that happens once and is stable and the brain just needs help recovering from it and accepting the new normal. When someone’s having migraines and the ears cause vertigo, that means that inner ear function is fluctuating every time they have a Meniere’s attack or migraine and physical therapy won’t help with that. So really the best treatment for vertigo in that case is treating the underlying cause, so migraine medications or diet and with Meniere’s there are multiple medications, sometimes even surgeries that can be helpful. So if somebody’s having multiple episodes of vertigo, then they really do need to be evaluated, and generally that’s something that’s best treated by a specialist, either a neurotologist, E and T doctor like myself, or a neurologist. E and T doctors are specifically trained in vertigo, so that’s something that we often see, so we’re a really good source for treatment of vertigo, but there are neurologists who also are quite good with diagnosing and treating vertigo, especially if it’s a migraine that’s the cause of it.
>> Joe: Now let’s say that someone is experiencing vertigo but doesn’t think there’s necessarily a reason to go to the emergency room or to call their E and T doctor. Are there natural ways an individual can help remedy this feeling of vertigo, or is it an instance where if you experience it you should probably call your doctor?
>> Dr. Kaylie: Well, it really depends on the nature of the vertigo. So, sometimes people can have a one-time event of BPPV, it just happens once and then the crystal floats out and then it never happens again and if you feel fine and it only happens once then it probably would not be necessary to see a doctor. But if someone’s having vertigo over and over again, particularly if their hearing is going down or if they’re having other symptoms, then they really should be evaluated. So you would really have to use your judgment. There are some people who one episode of vertigo is so distressing they want to make sure there isn’t anything else going on and that’s perfectly reasonable. Other people have a much higher threshold for when they would go to a doctor and sometimes that leads to people putting off things that should have been addressed a long time ago. So, it’s one of those things where people have to use their own judgement and do what’s comfortable for them, but I would not recommend putting off getting treated or seen for vertigo that’s happening over and over again.
>> Joe: Okay so Dr. Kaylie, thank you so much for joining us. I think it’s been an incredibly, incredibly insightful conversation. If someone has any questions about their experiences with vertigo, what it’s like, what is it, are there places people can go online for answers to their questions?
>> Dr. Kaylie: Absolutely, I would recommend that people look at Merck Manuals. There’s great information there on vertigo. That can be very helpful. Another resource people can go to online is MSD Manuals dot com. There’s another association called the Vestibular Disorders Association, or VeDA, that’s got lots of information. It’s got links to articles and links to physicians who treat disorder and their website is vestibular.org. So that’s a really good resource as well.
>> Joe: And for our listeners who may not be in the United States of Canada, we invite you to visit MSD Manuals doc com for more information as well. Okay Dr. Kaylie, thank you so much again for joining us. Like I said, it’s been seriously entertaining I think, to learn more about vertigo and also super educational as well. So as we say at the Merck Manuals—
>> Dr. Kaylie: Medical knowledge is power. Pass it on.
>> Joe: Thank you so much.