Vertigo can be described as a kind of dizziness that makes it feel like everything is spinning around or moving. It can occur while standing, walking or lying down. Depending on what’s causing the dizziness, the length of an episode can vary greatly, and may be accompanied by drowsiness, nausea or other symptoms.
The most common cause of this type of vertigo is benign paroxysmal positional vertigo (BPPV). Here certain movements cause dizziness for a short time. BPPV is quite easy to diagnose and treat.
BPPV makes it feel like everything is spinning. Sudden movements of the head typically make you feel dizzy – for instance, when you
- turn or tilt your head down, to the side or backwards,
- lie down,
- turn over while lying down,
- sit up from a lying position, or
- bend over.
The dizziness usually only lasts a short while – for a few seconds to five minutes at the most.
You may feel nauseous during and after an episode of dizziness, and in rare cases it may cause vomiting.
Benign paroxysmal positional vertigo is probably caused by loose calcium deposits (crystals or “ear rocks”) in what are called the semicircular canals of the inner ear. This fluid-filled system of canals is part of the organ of balance (vestibular system). Special hair-like cells (“sensory hair cells”) in the three semicircular canals can sense whether your head is turning, and in which direction.
Structure of the ear and the vestibular system
In most cases, tiny crystals have collected in the posterior semicircular canal, although it is usually not clear why this happens. When you move your head, these crystals roll around the semicircular canal. This irritates the hair cells, which then transmit misleading information that doesn’t match up with the other sensory information. These contradictory signals lead to dizziness.
Structure of the vestibular system
Less common causes of BPPV include skull injuries, ear infections, circulation problems or being bedridden.
About 2 out of 100 people have BPPV at some point in their lives. It is twice as common in women as in men.
BPPV can lead to regular short attacks of vertigo. Over time, the tiny crystals settle inside the semicircular canals and are broken down inside the body. As a result, BPPV often goes away on its own after a while.
BPPV is usually easy to diagnose based on the symptoms and your recent medical history, and is easily differentiated from other types of vertigo. The doctor may ask about whether the dizziness is permanent, comes in episodes or is triggered by specific things.
The Dix-Hallpike test can be used to confirm that it is BPPV: The test involves moving your head and torso quickly in a specific order with the help of a doctor. This kind of “provocation” maneuver can trigger an episode of dizziness. The doctor watches closely to see whether you have involuntary eye movements (nystagmus), which occur during an episode of vertigo. You may have to wear special glasses (Frenzel goggles) during the test. This makes it easier for the doctor to see any eye movements during the test.
“Repositioning” procedures or maneuvers are commonly used to treat BPPV. They involve moving the patient into specific lying or sitting positions following a certain sequence, with specific positions of the head. The sequence of movements is designed to help move the tiny crystals out of the posterior semicircular canal and into areas of the vestibular system where they can no longer disturb the sensory hair cells.
The Epley maneuver and the Semont maneuver are two very simple and effective repositioning procedures for the treatment of BPPV caused by crystals in the posterior semicircular canal. These maneuvers are typically done several times with the help of a doctor. There are also slightly modified repositioning procedures that can be done at home in addition to the doctor-assisted maneuvers.
The crystals are only rarely found in either of the other semicircular canals. Then other repositioning maneuvers can be used.
Medication can help if the vertigo is causing nausea.
If the symptoms persist, surgery on the vestibular system may be considered. This involves destroying either the nerve fibers that are connected to the affected semicircular canal, or the semicircular canal itself. The hair cells can then no longer transmit misleading information – or any other information – to the brain. This means that the vestibular system in that ear is permanently affected by the surgery.
Sequence of movements in the Epley maneuver for deposits in the left ear:
- Sit upright.
- Lie on your back, tilt your head back slightly and move it about 45° to the side that the affected ear is on.
- After about 30 seconds, turn your head 90° to the other side, keeping your head tilted back slightly.
- After another 30 seconds, turn your body 90° so that you are lying on your side, keeping your head in line with your body.
- Sit upright again after another 30 seconds.
Deutsche Gesellschaft für Allgemeinmedizin und Familienmedizin (DEGAM). S3-Leitlinie: Akuter Schwindel in der Hausarztpraxis. AWMF-Registernr.: 053-018. February 14, 2017. (DEGAM-Leitlinien; Volume 17).
Hilton MP, Pinder DK. The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo. Cochrane Database Syst Rev 2014; (12): CD003162.
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McDonnell MN, Hillier SL. Vestibular rehabilitation for unilateral peripheral vestibular dysfunction. Cochrane Database Syst Rev 2015; (1): CD005397.
Von Brevern M, Radtke A, Lezius F, Feldmann M, Ziese T, Lempert T et al. Epidemiology of benign paroxysmal positional vertigo: a population based study. J Neurol Neurosurg Psychiatry 2007; 78(7): 710-715.
Zhang X, Qian X, Lu L, Chen J, Liu J, Lin C et al. Effects of Semont maneuver on benign paroxysmal positional vertigo: a meta-analysis. Acta Otolaryngol 2017; 137(1): 63-70.
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