Vertigo and dizziness

Vertigo and dizziness: a comprehensive guide to understanding and treating these symptoms

Vertigo and dizziness are very common symptoms that can significantly affect quality of life. Although they can be worrisome, the vast majority of cases are benign and respond very well to treatment. Vestibular physiotherapy has success rates of 80 to 95% for several conditions, including benign paroxysmal positional vertigo.

How can you tell the difference between vertigo and dizziness?

Vertigo and dizziness are two distinct symptoms that are often confused. Understanding the difference is important for identifying the cause of your symptoms.

Vertigo is a sensation where you feel as though you are spinning within your surroundings, known as internal vertigo, or when the environment around you seems to be spinning, known as external vertigo. A classic example of vertigo is when you feel as though the walls around you are spinning while you are standing still.

Dizziness is a more vague term that describes a feeling of discomfort in space, the feeling of not feeling well in the environment around you. The description can vary greatly from person to person. Typical sensations of dizziness include feeling disoriented, lightheaded, floating on a cloud, or unstable, as if you were drunk.

What is benign paroxysmal positional vertigo (BPPV)?

BPPV is the most common type of vertigo. It is a type of vertigo triggered by head movements. This condition is caused by the displacement of small crystals, called otoconia, in the inner ear, where our balance system is located.

When the head moves, these tiny crystals and other small debris shift and cause hyperstimulation of the balance system. This abnormal stimulation creates the sensation of vertigo, which can be very intense but fortunately is short-lived.

What are the symptoms of BPPV?

Vertigo is usually very intense but short-lived, generally lasting less than a minute. It is caused by a sudden change in head position. Typical triggering situations include getting up or lying down in bed, leaning forward or standing up, looking up, or turning over in bed.

Vertigo may be accompanied by other symptoms such as nausea or vomiting, loss of balance, and various complaints that vary from person to person. Often, sufferers completely avoid the positions or movements that caused the vertigo in order to prevent it from happening again. However, this avoidance strategy can prolong the problem.

What causes BPPV?

In 10 to 30% of cases, BPPD develops following trauma such as a concussion or any other injury to the head or neck. In 5 to 25% of cases, BPPD may be the result of migraine, labyrinthitis, neuronitis, or Ménière's disease. In 60 to 80% of cases, BPPD is idiopathic, meaning that the cause is unknown.

Some interesting facts about BPPV: there are three semicircular canals in the inner ear. Between 60 and 90% of BPPV cases are caused by damage to the posterior canal, 5 to 20% to the horizontal canal, and 1 to 10% to the anterior canal. One or more canals may be affected at the same time, and the signs and symptoms will differ depending on the canal affected. Trauma increases the risk of damage to multiple canals. Women are three times more likely than men to experience BPPV.

How is BPPV diagnosed?

The physical therapist diagnoses BPPV based on the history of symptoms and clinical examination. Specific maneuvers to provoke vertigo are used to identify the affected canal. An assessment of the oculomotor system, which examines eye coordination, and an assessment of the neck are also included in the clinical examination.

What are the treatments for BPPV?

When BPPV is diagnosed, maneuvers performed in the clinic with a physical therapist can be used to return the crystals to their normal position. The Epley maneuver is the best known and has a success rate of 80 to 92%. A series of specific exercises to be done at home completes the treatment and resolves the problem, often in just one or two sessions.

While waiting to see a physical therapist, simply avoid positions that cause dizziness if you find your symptoms too severe and unpleasant. However, completely avoiding these positions in the long term may prolong the problem.

What is cervicogenic dizziness?

Cervicogenic dizziness is dizziness caused by a problem related to the cervical spine. The neck contains many receptors that inform the brain of the position of the head in space. When these receptors are disrupted, they can send confusing signals that create a feeling of dizziness.

What are the symptoms of cervicogenic dizziness?

The sensation of dizziness is no different when it originates in the neck compared to other sources. Descriptions vary from person to person and may include feeling disoriented, lightheaded, floating on a cloud, or unstable.

In the specific case of cervicogenic dizziness, other signs and symptoms are often present. Neck pain or stiffness usually accompanies dizziness. Headaches are frequently associated with this condition. A decrease in neck mobility can be observed. Dizziness often occurs after prolonged neck postures, such as when working at a computer, driving, or reading.

What causes cervicogenic dizziness?

The exact cause is still poorly understood by researchers. One explanation could be that our brain misperceives the neck in space, which is known as poor neck proprioception.

Neck pain and headaches are also factors associated with dizziness. This type of dizziness can therefore occur following an episode of neck pain or whiplash, for example after a car accident.

How is cervicogenic dizziness diagnosed?

Your physical therapist will diagnose cervicogenic dizziness based on your symptom history and a comprehensive clinical examination. The clinical examination includes identifying the neck positions and postures that cause dizziness, assessing neck mobility, and performing specific tests.

A deficit in the oculomotor system, eye coordination, or vestibular system may also contribute to cervicogenic dizziness. An evaluation of these two systems is therefore also included to determine the cause.

There is no single definitive test for diagnosis. Medically speaking, it is often a diagnosis of exclusion, meaning that all other possible causes have been ruled out before concluding that the cause is cervical.

What are the treatments for cervicogenic dizziness?

Your physical therapist will evaluate several factors to develop a personalized treatment plan. The evaluation includes your joint mobility, nerve gliding, postural habits, quality of movement, strength and stability, oculomotor system, and vestibular system.

Based on the results of the assessment, the physical therapist will use joint mobilization and manipulation to treat your neck and nerves, reduce pain, and improve movement. Specific exercises to do at home will target the cause of the problem.

If the oculomotor or vestibular system is involved, your physical therapist will also include treatment for these two systems in your rehabilitation program. Physical therapy for neck pain offers comprehensive approaches for these conditions.

What are the warning signs that require urgent medical attention?

The presence of certain signs and symptoms should prompt you to seek immediate medical attention at the emergency room or from a doctor. These red flags are rare but important to recognize. Seek immediate medical attention if you experience loss of consciousness, dizziness during physical exertion, vertigo with severe headaches, hearing loss, significant balance problems such as falling when standing up, or projectile vomiting.

These symptoms do not necessarily indicate a serious problem, but they warrant prompt medical evaluation to rule out serious causes.

When should you see a physical therapist for dizziness or lightheadedness?

You should consult a physical therapist if you have symptoms as described above or if your doctor has already ruled out any other causes for your dizziness or lightheadedness. Physical therapy offers very effective treatments for these conditions.

For the treatment of BPPV, you should consult a physical therapist who has expertise and adequate training in vestibular physical therapy. This specialization allows for the proper assessment and treatment of various vestibular conditions.

You do not need to see a doctor before consulting a physical therapist. If your condition requires medical attention, the physical therapist will be able to advise you and refer you to the appropriate specialist.

Other causes of dizziness and lightheadedness

In addition to BPPV and cervicogenic dizziness, several other conditions can cause vertigo or dizziness. Vestibular disorders include vestibular neuritis, labyrinthitis, and Ménière's disease. Heart problems such as orthostatic hypotension or arrhythmias can also cause dizziness.

Psychiatric problems, particularly anxiety disorders and conversion disorders, can manifest as dizziness. Other rarer causes include brain tumors, multiple sclerosis, vestibular migraines, encephalopathy, Arnold-Chiari malformation, and drug or alcohol intoxication.

Central positional vertigo is very similar to BPPV, but rarer. Neurological symptoms such as headaches, significant weakness, and unsteadiness when walking are often reported with this type of vertigo.

What is the link between anxiety and vestibular problems?

Dizziness and lightheadedness are symptoms that often worry people who experience them. The experience is unpleasant and can create a feeling of loss of control. This concern can cause people to experience a great deal of anxiety and become hypervigilant, paying close attention to every symptom they feel.

In this state of hypervigilance, all bodily signals can become a potential threat to the anxious person. In some cases, anxiety can even become more problematic than the vestibular problem itself. The good news is that vestibular physical therapy helps break this cycle by reducing physical symptoms and restoring confidence in movement.

Conditions associated with dizziness and lightheadedness

Vertigo and dizziness can coexist with other conditions. Concussions are frequently associated with vestibular symptoms. Physical therapy for concussions often treats the vestibular component of these injuries.

Neck pain and dizziness are often related, especially after neck trauma. Headaches, especially migraines, can be accompanied by vestibular vertigo.

Get help for your dizziness or lightheadedness

If you suffer from vertigo or dizziness that affects your quality of life, our physiotherapists trained in vestibular rehabilitation can help. A comprehensive assessment will identify the cause of your symptoms and develop a personalized treatment plan.

The prognosis is generally excellent for most vestibular conditions treated with physical therapy. Schedule an appointment today to begin your journey toward relief.

Sources

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Bhattacharyya N, Baugh RF, Orvidas L, et al. Clinical practice guideline: benign paroxysmal positional vertigo. Otolaryngology Head Neck Surg. 2008;139(5 Suppl):S47-81.

Reiley AS, Vickory FM, Funderburg SE, Cesario RA, Clendaniel RA. How to diagnose cervicogenic dizziness. Archives of Physiotherapy. 2017;7(1):12.

Brandt T. Vertigo: its multisensory syndromes. Springer Science & Business Media; 2013.