Vertigo refers to hallucination of movement. It is defined as an abnormal perception of movement of the environment or self, and occurs because of conflicting visual, proprioceptive and vestibular information about a person’s position in space. Vertigo commonly arises from imbalance of vestibular input and is within the experience of most people, since this is the ‘dizziness’ that occurs after someone has spun round vigorously and then stops.1
Vertigo is a cardinal symptom of vestibular disease.
Most patients with vertigo have acute vestibular failure, benign paroxysmal positional vertigo or Ménière’s disease.1
Frequently accompanied by nausea, postural unsteadiness, and gait ataxia; may be provoked or worsened by head movement.
Depending on the frequency and duration of attacks, vertigo can be classified into 3 clinical types:
- Prolonged Spontaneous Attacks of Vertigo
This occurs when due to unilateral loss of vestibular function. The vertigo is acute in onset, may last for days and is aggravated by head movement. The patient prefers to sit upright with the head still or to lie with the intact side down. On movement the patient may fall towards the affected side. The vertigo is associated with nausea, vomiting and malaise. This type of vertigo may be peripheral or central. Common causes of this type of vertigo include acute labyrinthine/vestibular dysfunction due to infection, trauma or ischemia, brainstem or cerebellar infarction/hemorrhage, multiple sclerosis and brainstem tumors/vascular malformations.2
- Recurrent Spontaneous Attacks of Vertigo
The vertigo is sudden, temporary and reversible due to impairment of labyrinthine function. The vertigo of vascular origin like transient ischaemic attacks (TIA) lasts for minutes, whereas, that due to disease of the inner ear may last for hours. The common causes of recurrent spontaneous vertigo include Meniere’s disease, autoimmune inner ear disease, syphilitic labyrinthitis and vertebro-basilar TIA.2
- Recurrent Positional Vertigo
Positional vertigo is precipitated by the movement of the head either to the right or to the left from the recumbent position, triggering the vestibular pathway. The peripheral type of positional vertigo is more common than that of central origin.2
Benign Paroxysmal Positional Vertigo (BPPV)
BPPV is characterized by sudden onset of a peripheral vestibular syndrome with no auditory component. The vertigo occurs when the patient rolls to the side on lying down, or while gazing upwards, or bending forwards. The episode lasts for 10 to 20 seconds. BPPV occurs in bouts lasting for a few days or weeks and may recur after several weeks or months. BPPV can be caused by head injury, stapes surgery, otitis media, labyrinthine ischemia and viral infection of the ear. Occasionally, the cause is not obvious. The diagnosis is confirmed by standard positional testing test (Dix-Hallpike test).2 and 3
TYPES OF VERTIGO
Usually severe, accompanied by nausea and emesis. Tinnitus, a feeling of ear fullness, or hearing loss may occur. A characteristic jerk nystagmus is almost always present. The nystagmus does not change direction with a change in direction of gaze; it is usually horizontal with a torsional component and has its fast phase away from the side of the lesion. It is inhibited by visual fixation. The patient senses spinning motion away from the lesion and tends to have difficulty walking, with falls toward the side of the lesion, particularly in the darkness or with eyes closed. No other neurologic abnormalities are present.2and 3
Identified by associated brainstem or cerebellar signs such as dysarthria, diplopia, dysphagia, hiccups, other cranial nerve abnormalities, weakness, or limb ataxia; depending on the cause, headache may be present. The nystagmus can take almost any form (i.e., vertical or multi directional) but is often purely horizontal without atorsional component and changes direction with different directions of gaze. Central nystagmus is not inhibited by fixation. Central vertigo may be chronic, mild, and is usually not accompanied by tinnitus or hearing loss. It may be due to vascular, demyelinating, neurodegenerative, or neoplastic disease. Vertigo may be a manifestation of migraine or, rarely, of temporal lobe epilepsy.2and3
The vertigo develops gradually, increasing with associated anxiety and terminates abruptly. Organic vertigo occurs
Abruptly and disappears gradually. Psychogenic vertigo is sometimes called phobic postural vertigo, associated with panic attacks or agoraphobia (fear of large open spaces or crowds).The vertigo is not associated with nystagmus or vomiting. Most patients adapt to being ‘house-bound’, whereas inorganic vertigo patients attempt to function in spite of theincapacity.2and3
VERTIGO MAY BE DUE TO PHYSIOLOGICAL OR PATHOLOGICAL CAUSES2
Physiological vertigo is seen in normal individuals with unfamiliar head movements, unusual head and neck position or following spinning.2
Pathological vertigo results from lesions of the visual, somatosensory or vestibular system. Visual vertigo is caused by incorrect eye-glasses, and extra-ocular muscle paresis. Somatosensory vertigo is due to myelopathy or peripheral neuropathy and is rarely seen in isolation.2
The most common cause of pathological vertigo is vestibular dysfunction. If may involve the end organ (labyrinth), the nerve or central connections. Vertigo is associated with jerk nystagmus frequently accompanied by nausea, postural unsteadiness and gait ataxia.2
APPROACH TO THE PATIENT
Vestibular dysfunction is demonstrated by a simple ‘headshaking nystagmus test’. The patient is asked to close his eyes and bend his head down 30°. The head is oscillated horizontally 20 times. Elicitation of nystagmus after the manoeuvre suggests vestibular imbalance. Further evaluation of vestibular dysfunction is essential to determine the side of the lesion, the type of lesion and to distinguish central from peripheral lesions. The standard tests include head thrust test, Dix-Hallpike test and electro-nystamography. If a central aetiology is suspected, MRT is mandatory.2
MANAGEMENT OF VERTIGO
Treatment of acute vertigo consists of bed rest for 1 to 2days and use of anti-vertiginous drugs. These drugs give
Symptomatic relief in acute vestibulopathy (Meniere’s syndrome, vestibular neuritis), acute brain-stem lesions near the vestibular nuclei and prevent motion sickness. These are also used in frequent attacks of vertigo, vomiting and severe BPPV. Surgical procedures like labyrinthectomy, and section of 8th nerve are used in selected patients. In chronic and recurrent vertigo, exercises which provoke vertigo may be tried in order to habituate the patient. Patients who are refractory to conventional therapy may benefit from a formal rehabilitation programme, habituation customized programme and use of instruments, like tilt tables.2
SCOPE OF HOMEOPATHY
Homeopathic literature has a great deal of data which covers symptoms of vertigo and can play an important role in management of vertigo. Oral Homeopathic medicines aid to resolve the symptoms of vertigo. There are medicines especially targeting the labyrinth inflammation. Finding the correct cause is an important aspect of vertigo management. Response to homeopathic medicines is usually very fast and relief is long lasting.
MEDICINES FOR VERTIGO4
Vertigo and headache in forehead and occiput, both worse on bending forward, vertigo, particularly on raising the head, or else on riding from a recumbent position, on stooping or moving the head, and often with the sensation of intoxication, or reeling in the head, loss of consciousness, dimness of the eyes, nausea and qualmishness at the pit of the stomach; while rising up from lying in a warm room; functional heart disease; fainting after emotional.
Strong sunshine causes momentary vertigo, attacks of vertigo, with staggering gait and imperfect vision, even of near objects, only removable by thinking of quite different things; vertigo from mental exertion and high living; tendency of falling forward; partial amaurotic blindness.
Vertigo in cases of debility arising from protracted illness, loss of fluids, defective nutrition; vertigo from mental overexertion, with general debility; excessive nausea with giddiness; frequent attacks of fainting with dizziness.
A feeling of vertigo seizes him when he walks across flowing water or beside a canal; he fears he shall fall in; vertigo proceeding from occiput.
Morning dizziness, with headache; complete but transitory blindness, nausea and confusion of the senses, buzzing in the ears, and general debility of the limbs, as after fatigue, and trembling; dizziness before falling asleep; weakness of memory; dullness of senses; sensation of expansion.
Vertigo on going up-stairs, not on going downstairs, and less felt on level ground.
MENIERE’S DISEASE; vertigo, especially in old people, when stopping as if turning in a circle, goes off when rising; as if drunk, when walking in open air; feels as if he would fall to the left; must lie down and even then it returns for sometimes on the slightest motion. Congestion of sexual organs or sexual organs or spinal cord.
Anxiety on sudden downward motion; sickness from riding; especially on the back seat,(?); attacks of dizziness, with loss of presence of mind; vertigo and fullness of the head early in the morning; vertigo and fullness of head of going uphill or up stairs; vertigo as if pushed from right to left and sometimes forward.
Vanishing of the senses; loss of consciousness; when walking he staggers to and fro; vertigo with heaviness of the head; which inclines backward; sudden and complete prostration of the vital forces, with great coldness of the external surface; great cardiac weakness.
Vertigo, with flushed, hot face and head; confused feeling in the head after eating and drinking; vertigo increased by sitting up in bed, or by the motion of a carriage; vertigo as from intoxication, with nausea and falling down without consciousness; hysterical dizziness and headache, aggravated by noise, walking, smoking or drinking coffee; whirling vertigo with nausea when sitting up in bed, forcing the resumption of recumbent position, accompanied by a peculiar dullness in forehead, as if there were a board in front of head; during the attack speech difficult, followed by difficulty in reading or thinking.
Giddiness of the head; vertigo and blackness before the eyes when stooping.
Vertigo as if he were turning in a circle, when rising from his seat; confused vision and giddiness as soon as he stops to keep his sight fixed on an object (agoraphoby), complete loss of muscular power throughout the body; vertigo on looking around as if he would fall to one side; vertigo on lying down, when turning over in bed, when going down stairs; continued stupefaction with constant inclination to sleep; (<) at night.
Vertigo in the occiput, followed by pain in vertex; vertigo with shaking the head or throwing it back; intoxicated feeling and vertigo when stooping; vertigo in the fresh air; as if were on a vessel or riding backward in a carriage; vertigo, fainting, with violent throbbing of the temporal arteries.
- Epley maneuver and Brandt Daroff exercise are good recommended exercises but shall be done under guidance of trained physiotherapist to do the right technique and get benefit.
- Avoiding alcohol
- Adding Vitamin D in diet
- Adequate amount of sleep
- Daily Yoga
- Stress management
- 1. Ralston S.H., Penman I.D., Strachan M.W.J., Hobson R.P. Davidson’s, Principles and Practice of Medicine. 23rd ed. Edinburgh; Churchill Livingstone/Elsevier; 2018. 1417p.
- API Textbook of Medicine. 9threv.ed. Mumbai: The Association of Physicians of India, Jaypee Brothers Medical Publishers (P) Ltd; 2012. 2066p.
- Kasper D.L., Fauci A.S., Hauser S.L., Longo D.L., Jameson J.L., Loscalzo J. Harrison’s Manual of Medicine. 19th rev. ed.United States: McGraw Hill; 2016. 1222p.
- Lilienthal, S. Homoeopathic therapeutics. Philadelphia: Boericke& Tafel; 1907