Ending Vertigo Today

Vertigo, headaches and palpitations

A reader writes in with a group of puzzling symptoms: After a lifetime of excellent balance, she experienced slight dizziness and instability that gradually worsened over a few weeks. There was also a low, deeply vibratory sound in the right ear. This was followed by severe vertigo for which weeks were spent in bed. She felt a constant internal spinning sensation even without any head movement, although she did not see the room spinning.

She also noticed pulsing vertigo in the right ear and increased sound sensitivity in that ear. Hearing felt “under water” and the ear felt full on and off. She could sometimes have brief vertigo when rolling over in bed.

She was diagnosed with a few different dizziness disorders including BPPV and Meniere’s disease. She was also diagnosed with migraine-associated dizziness since she had had migraines for many years. Then more new symptoms arose: irregular heartbeats and blood pressure spikes. A workup found an AV fistula on the right side of the brain inside the skull, although no connection was made with her Meniere problem.

This reader has the classic triad of Meniere’s disease with a low-pitched tinnitus, vertigo, and hearing loss in the right ear. Hearing tests usually remain normal at first except during flareups, but over time a permanent hearing loss will develop in the affected ear. Balance function also gradually declines over time, often immediately after a bad spell. BPPV (positional vertigo caused by rolling over in bed) often complicates the picture and this more minor symptom can be controlled with maneuvers.

Meniere’s has long been connected to endolymphatic hydrops, a dilation of the inner ear with build-up of fluid. In my articles I have shown that this condition by itself is not enough to cause the symptoms of Meniere’s disease . A second hit is needed. That second problem is vascular disease. The inner ear has a sensitive system to keep blood flowing smoothly called autoregulation, and this is lost in people who have hydrops. This means that any additional fluctuations in blood flow near the ear can result in sluggish perfusion of the inner ear itself. Low perfusion can shut off or impair hearing and balance in the ear during spells and eventually destroys the ear.

The most common vascular disease in Meniere patients is sleep apnea. This causes snoring or gasping during sleep, frequent awakenings, elevated blood pressure and palpitations. Migraines are also associated with sleep apnea. Migraine itself is known to cause vasospasm—constrictions in blood vessels that can slow blood flow. Because sleep apnea is so prevalent in Meniere’s patients, every person with this disorder should have a formal sleep study. If sleep apnea is the main vascular problem, using a CPAP machine can greatly slow the progression of the disease.

There is another potential problem here, an AV (arteriovenous) fistula. Normally arteries and veins are separated by a capillary bed, where cells receive oxygen and nutrients before passing on the depleted blood to veins. Arteries have high pressure blood flow, while veins are low pressure, allowing the blood for easily flow “downhill” from a pressure standpoint. A fistula exposes the veins to pressure that is too high and slows blood flow. These can cause headaches and pulsing tinnitus, just as she describes.

If a fistula is located in the skull near an inner ear, the pressure that is too high in the veins can lead to back pressure in the ear itself. If there is also hydrops in the ear, the loss of autoregulation combined with back pressure is enough to cause Meniere’s disease. We don’t have information about where the fistula is in this case. If the fistula is near the ear it may increase the blood flow problem in the ear. These leaks can be blocked by embolization, a type of surgery that is done from inside the vessels. Some fistulas can also be resolved from outside the head by a focused beam of radiation (radiosurgery).

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.