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. 

Read more: Vertigo, headaches and palpitations

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).