Ending Vertigo Today

Rocking vertigo and PMDD

A reader writes: I have a general sensation that I am on a boat. It is the worst in the morning and I am finding that I have difficulty walking straight and really have to concentrate on keeping my balance during the first hour of the day.

Rocking vertigo is a feeling of continuous up-and-down, boat-like rocking. Usually this sensation is inside your head and there is no visual appearance of motion. It can occur spontaneously or can arise immediately after travel in a boat or airplane.

Most people with this sensation have experienced migraine headaches or auras in the past, suggesting that it may be a form of migraine-associated vestibulopathy. Usually vestibular testing is normal, although some people show a low-grade positional nystagmus. The disorder does not worsen over time, causes no permanent damage to the ears, and tends to spontaneously disappear.

It is common to experience a rocking sensation for a few hours after returning to land from a boat trip. This sensation tends to increase when lying down with the eyes closed and can cause nausea similar to seasickness. A French term, Mal De Debarquement, is often used to refer to this normal sensation.

In some people the symptom can drag on for weeks, months or even years after travel, and is relieved by going back on a boat. This has been named Persistent Mal De Debarquement, or PMDD. It is also sometimes called Disembarkation Syndrome. The cause of this disorder is not known. The vestibular system is able to adapt to the rocking motion of the boat, part of the process that reduces motion sickness as one acquires “sea legs” on a voyage. PMDD likely results from a difficulty in shutting off this adaptation when returning to land. This sensation can also occur after turbulent airplane flights or other long-term exposure to rhythmic motion.

Part of this syndrome is is that you may become permanently programmed to the rocking feeling. This programming can be helpful in some ways; if you travel by boat often, you will adapt more quickly to the motion than most people do. Even after your symptoms resolve you might go into a room that triggers the memory months later, causing the rocking to instantly reappear.

There is a connection between OCD (obsessive compulsive disorder) and rocking vertigo. Once the rocking subsides, it is best to stop checking in your head for little signs of the feeling. It is better to distract yourself with other movement and not to pay close attention to it. Treatment with Paroxetine, a medication that affects serotonin in the brain, is one of the more effective drugs for this condition. Typically a remission develops gradually, with a day free of symptoms followed by a recurrence of the rocking, with more and more normal days over the next few weeks until the condition disappears. Activities that involve a great deal of head motion are also helpful, but rhythmic vertical movement should be avoided (tennis is a better choice, for example, than jogging). Vestibular rehabilitation is often useful when combined with medication. Since the rocking feeling is a vertical motion, you can counteract this by rotating your head side to side in the same rhythm as the rocking you feel. This helps override the programming.

Is my vertigo Meniere’s?

(My doctor) says I have beginning of Meniere’s but I truly don’t believe so. I only have one symptom, vertigo, no loss of hearing or ringing at time of the episode. My vertigo comes on when my left ear is plugged and feels full of fluid due to allergies, (which I always have). Usually it hits when that ear is plugged and if I turn my head to the right or sleep on my right side, (ear that is usually affected) when I get up I feel a little off, then suddenly I get the spinning sensation even if eyes closed. Usually lasts for a few seconds but better lying down.

It can be hard to decide which vertigo problem a patient has when they first see a physician. Often they have trouble describing the vertigo. They might say, “I just feel dizzy” and then when I ask them to describe the dizziness in more detail, they add “it’s really bad”. It’s not easy thinking of other words to describe what is felt inside unless very specific questions are asked.

One of the most confusing decisions to make is whether the patient has Meniere’s disease, which is a serious condition that results in the gradual destruction of an ear, or another repeated kind of vertigo that isn’t nearly as dangerous, like BPPV (“bed spins”) for example.

Meniere’s has four basic symptoms: hearing loss, ringing in the ear (tinnitus), fullness in the ear, and vertigo. This very simple list overlaps with a lot of other conditions. For example, an older person might have age-related hearing loss, with tinnitus from that hearing loss, allergies causing stuffy feelings, and positional vertigo. Even though they have everything on the list, they do not have Meniere’s disease . It is the subtle details that determine whether Meniere’s is the problem.

In Meniere’s, the hearing loss, feeling of fullness, and tinnitus are all connected together. In fact they are all different facets of hearing loss. If you abruptly lose hearing in one ear, you will usually also hear a ringing sound in that ear. The pitch of the ringing will match the tones that are impaired. In Meniere’s, the hearing loss during a spell is in the low tones, so the “ringing” is more of a roaring sound, or the sound you hear when you hold a large coiled seashell to your ear. It can sound like a jet engine or a vacuum cleaner. People often say that the sound is so loud that it drowns out their hearing, but this is an illusion. It is the hearing loss that results in the sound. This can last for hours at a time, but when the sound eventually fades, the hearing also returns. After many such spells, a different and more permanent hearing loss slowly develops, and there may be a different pitch to the accompanying more constant tinnitus.

The feeling of fullness in the ear is also a part of the hearing loss. If you suddenly lose hearing, you will feel a flattened, cottony feeling in your ear. It’s rather like the feeling of getting water in your ear while swimming. If your Eustachian tube gets blocked while flying, you can get a similar stuffy feeling and that also mildly affects hearing. Unlike a blocked ear, however, you cannot “pop” your ear and get rid of the Meniere’s stuffiness. It just gradually goes away as the spell ends.

The vertigo of Meniere’s disease is unpleasant and nauseating, but the spinning is not as fast as in some other disorders like BPPV. The spinning sensors of the ear shut off, and this results in a constant, quite steady spinning. You can often see the environment spinning or shifting. This is worse if you hold your gaze in one direction, and better if you look in the opposite direction. Since the vertigo is very long lasting, often for hours, it is typical to become nauseated. Turning the head quickly when upright makes the vertigo worse.

Other conditions don’t have these more detailed symptoms. Sudden damage to an ear causes hearing loss, fullness and tinnitus with vertigo, but these symptoms are constant for days to weeks. All but the hearing loss usually decline over time. BPPV causes short spells of vertigo brought on by lying with the affected ear down, and worsened when trying to arise. If you also happen to have constant hearing loss and ringing from age, this still won’t mean you have Meniere’s disease. In Meniere’s, those symptoms mostly occur at the same time as the vertigo and last for long periods (up to hours). Short bursts of vertigo when arising are almost always BPPV, and being able to stop the vertigo by doing maneuvers proves it is not Meniere’s disease.

Of course, no diagnosis is as easy as a few paragraphs can imply. I have seen people start with BPPV, only to develop a destructive disorder of the inner ear as time goes by. This means that having a hearing test periodically is a good idea if symptoms of hearing loss, ringing in the ear or repeated vertigo continue to occur.

Drop Attacks in Vertigo Patients

If you have vertigo, you will have noticed that your balance can be so impaired that you may fall. There are lots of other reasons for falls (fainting, for example), but if the fall is due to the inner ear there is one important characteristic: you don’t lose consciousness before the fall. In fact, unless you hit your head during the fall and get knocked out, you will be able to remember everything that happened before and during the fall. This helps to signal that it was due to the inner ear. The inner ear can make you fall in more than one way, so the treatment depends on the type of problem you have.

The most common reason for a fall is the vertigo itself. If you have BPPV, for example, you might see the room spinning violently when you tip your head upward or arise from your bed. If the room is dark, or you have nothing nearby to hold onto, this can make you fall. When a spinning sensor in your ear turns ON suddenly, your body reacts by counter-balancing because it feels like you are spinning. This is just an illusion, so all the reflexes to counter-balance instead throw you off to one side. Once you have had several spells, you become less likely to fall because you learn to use touch to correct for these inappropriate reflexes.

If your inner ear is destroyed by a virus or an injury, it is hard to walk at first because the environment will be spinning for the first few days. Usually by touching a wall or other support surface you can remain upright. However, even once the nystagmus and vertigo have declined, you may still fall if you close your eyes or enter a dark room. When the gravity sensors of one ear are destroyed, the horizon will not seem level and will look a bit tilted. You may feel as if you are being pulled to one side. Vision helps keep this feeling of tilt under control. In darkness, however, you can’t use vision, and the inner tilting feeling becomes more intense. Even a week after such an injury, closing your eyes can cause you to fall to the ground like a log, although to you it will feel like the ground came up and slapped you. As the amount of tilt you see gradually declines over a few weeks, so will the tendency to fall over.

Drop attacks are a late-stage effect of Meniere’s disease, which can gradually destroy all balance sensors, including the gravity sensors. These attacks are very sudden. It will feel like the ground came up and hit you, with very little feeling of falling. This probably happens due to a mechanical deformation of the gravity sensor, causing it to suddenly generate a feeling of extreme tilting. The world will appear to tip up sideways, and your attempt to stay upright will cause you to overcorrect and fall. These attacks are so sudden and violent that you can be injured. The treatment is to see an otologist to consider ablative surgery (destroying the balance function of the ear) so that no more attacks can occur.