Ending Vertigo Today

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.

Muffled hearing and ringing in the ears

“I woke up with extreme nausea, the room was spinning, my eyes were extremely sensitive to light. I didn’t think much of it at the time, I had thought maybe I was coming down with a virus or that I was extremely dehydrated. A couple days after that I started to get migraines severe enough to end up in the ER… My symptoms were vertigo, dizziness, rapid heart rate, nausea, ringing in the ears and muffled hearing at times…I had also… (traveled) and once the plane was airborne the ringing started in my right ear again.”

Ringing in just one ear, a feeling of muffled hearing in one ear, and room-spinning vertigo are all classic symptoms of Meniere’s disease. It is easy to diagnose once it has become severe because there will be permanent hearing loss in the affected ear on audiogram and balance function in that ear may show a decline in responses to caloric (warm and cold water) testing. However, it is much harder to be certain of the diagnosis in early cases.

In the early years during a spell, your hearing will be decreased. The simplest way to test this is to rub your fingers next to each ear; the hearing will be muffled on the bad side. Or put an earbud up to each ear in sequence and listen for a change in tone or muffling of the sound.

If the hearing loss during a spell is noticeable you will likely also be able to hear a low rumbling or roaring sound, like the sound you hear when holding a conch seashell over your ear. This can get quite loud, meaning the hearing loss is worsening. It can also be faint in the early stages. The hearing loss and the tinnitus are two sides of the same coin.

At first there is no permanent hearing loss, so if you have an audiogram it may look normal. During a spell, though, there will be hearing loss, usually in the low tones. After the spell resolves the hearing may return to normal. Because of the vertigo, it may be hard to get in for testing while having a spell. Talk to a local audiologist about getting permission to come in quickly when a spell happens and have someone else drive you.

Barometric pressure changes, like what happens when flying, can change pressure in the inner ear and set off a spell. A barometer can be helpful in warning of an impending attack. Very low pressure (like a storm) followed by high pressure can be a trigger.

Headaches, especially migraines, frequently accompany Meniere’s disease. There are several underlying conditions that cause migraine, so a workup by a neurologist is best. The combination of headache and Meniere’s disease is frequently caused by an anatomic abnormality in the ear (endolymphatic hydrops) along with sleep apnea or any other cause of increased stroke or heart attack risks. These include smoking of any kind, high blood pressure, autoimmune diseases and diseases of the vascular system.

The cornerstone of diagnosis is to see a neurotologist (ENT specializing in the inner ear) and have a complete workup including VNG, audiogram, and any other tests they may recommend.

Subjective vs. Objective Vertigo

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?

“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.