Sometimes when discussing vertigo with a patient, providers try to decide if the vertigo the patient is experiencing is subjective or objective. What does this mean, and what are the implications for treatment?
Read more: Subjective vs. Objective Vertigo“Subjective” means an internal feeling that only you experience and that is not visible to others. When referring to vertigo, it means a feeling of motion when you are otherwise still, usually a spinning sensation that you feel only in your head. The environment does not look like it is spinning or shifting.
“Objective” vertigo is not only feeling motion but also actually seeing the environment move. You might have to close your eyes because the visual illusion of spinning is so strong. If you can see the environment spinning, often an outside observer can see this too because you will have nystagmus. When your eyes are observed closely, they will be seen to move in a rhythmic jerking motion, as if panning and resetting over and over.
The problem with these two terms is that vertigo falls along a spectrum of severity. Subjective vertigo symptoms can simply mean shorter or milder vertigo, while objective vertigo is a more prolonged, more intense vertigo. As your vertigo disorder worsens, you can transition from subjective to objective.
The reason for this is that your eyes have the ability to focus away a lot of the spinning that you feel inside. Vision suppresses vertigo. If your vertigo is low-grade, staring at one spot or focusing strongly on an object that is not moving can make the vertigo slow down or stop. This means that if you are examined when feeling low-grade vertigo, the observer may not see any abnormal eye movements if they are looking at you in the light. If you are examined during testing in darkness you may have a low-grade nystagmus, since in the dark you will be unable to use vision to stop this drifting.
From a practical standpoint, then, the difference between subjective and objective vertigo is not all that helpful. They are merely either end of the same spectrum of vertigo. You can transition back and forth between them. For example, when I treat people with BPPV, they will often have very violent nystagmus when the first maneuver is being performed and will see the room spin crazily. After a couple of treatments this may improve to the point where I no longer see nystagmus and they don’t see the room spin, but they still might feel a mild spin inside. They’ve gone from objective to subjective vertigo. This just means that the remaining vertigo has become much milder but is not completely gone. I will do another maneuver in this situation.
Meniere’s disease also shows transitions like this. It can start with a mild spell felt only as a low, constant spin in the head. Later spells, though, can be quite much more intense, with the room spinning and nystagmus that is easily seen by others. Because subjective vertigo can transition to the more severe objective vertigo, it should be worked up with hearing and balance testing, rather than waiting to see if there is a visible progression.
Read more: Subjective vs. Objective Vertigo
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