Ending Vertigo Today

Aural vertigo comes in two flavors

By far the most common cause of inner-ear-related vertigo is BPPV, with brief spins brought on by lying down or rolling over in bed. However, there are many other causes of vertigo, and it can be very confusing to figure out which one is the problem if you have something more complicated than BPPV. One way to narrow this down is by looking at two very broad categories of vertigo, so that you can decide which of these you have. This quickly helps you narrow down the diseases that may be affecting you.

Your brain creates the sensation of turning every time you move your head. When you are not moving, each ear generates a low but steady flow of electrical signals that is received continuously by the brain. This symmetric flow lets your brain know that your head is completely still. If you move your head, the flow of signals changes instantly. If you turn your head to the right, your right ear “turns on” and increases the flow of signals, while the left “turns off”, and shows a decrease. Your brain interprets this change in the symmetry of the signals as a turn—a right turn if the right ear is increased and the left ear is off, and a left turn if the left ear is increased while the right ear signals decline. That’s what happens with normal head turns.

Vertigo—the feeling of spinning when you are not turning—happens when the symmetry of the two ears is broken even though you are not moving, for example if one ear becomes turned on while the other is not. This means there are two flavors of vertigo. The first flavor is vertigo brought on by an ear that suddenly gets turned on, increasing its signals. If you are not turning, both ears should be sending the same low flow of signals, so if one suddenly starts firing more, this asymmetry will be felt as a turn toward the abnormal side. If your right ear suddenly increases its firing, you’ll feel spinning to the right.

The second flavor of vertigo is spinning brought on by a sudden decrease in one ear’s signals—the ear turns off. Again, the brain feels spinning any time there is asymmetry between the ears. So, an ear that turns off makes the other ear’s signals look too fast, and you feel a spinning toward that normal ear. A left ear that shuts off will cause a spinning feeling to the right for this reason. Notice that a spin to the right can come from EITHER the right ear being turned on or the left ear being turned off. How can you tell whether it is due to an ear being stimulated vs. inhibited?

One way to determine this is to look at the speed of the feeling of spinning. The key is that both ears have a fairly low flow of signals when you are not moving. If you inhibit or turn off one of the ears, the other unaffected side does not increase—the flow is still fairly low from the good ear. When your head is still, this will give you a constant, steady, unvarying feeling of spinning. The room spins in a smooth fashion, not very fast. You can usually still see things around you when having this vertigo, even though they will shift constantly. Rather boring—the plain vanilla kind of vertigo. You will be able to make this spinning increase by moving your eyes to one side, which is an important clue that you have one ear that is not working. It will also worsen when you make a sudden head turn.

The situation is very different if you have one ear that becomes “too turned on”. The natural sensor of the ear can sense extremely high rates of acceleration, so there’s no upper limit to the speed of the spinning you will feel. Fortunately, stimulatory vertigo is usually very short. This is the flavor of vertigo caused by BPPV, when you directly stimulate one spinning sensor in your ear. It’s not boring at all. It’s thrilling (but not in a good way). Not the sort of thing you can sleep through. The world spins and it feels like you’re going to rocket off the bed. How you move your eyes has no impact on this kind of vertigo.

Here are some diseases that cause each flavor of vertigo:

Stimulatory vertigo—ear too turned on: BPPV, semicircular canal dehiscence, fistula

Inhibitory vertigo—ear turned off: vestibular neuritis & viral infections, labyrinthitis, Meniere’s disease, autoimmune diseases, tumors such as acoustic neuroma, any loss of blood flow or trauma to the inner ear

It’s ironic that the most common cause of vertigo, BPPV, is stimulatory and so is more severe than the many other causes in the inhibitory category. Mercifully, BPPV is short and easy to fix with maneuvers.

BPPV treatment: Turning 45 degrees?

A positional vertigo patient struggles to understand how to do the maneuver for the right ear:

TURN HEAD TOWARDS ELBOW? Which part of head, the chin or the back of the head? Picture shows back of head towards rt elbow. I don’t see any 45 degree angle; the head looks almost in same plane as back in the picture. R U saying 45 degrees relative to the plane of the back so the chin points slanted down towards the floor?

The handouts are in our book and at the bottom of the blog webpage, and our videos can help too, but it’s always disorienting to figure out what that means when your head is upside down! The best way to understand how to correctly move your head is to first practice the head turn when you are upright.

If the right ear is the problem ear, sit in a chair and turn your chin toward your right shoulder, stopping when you are halfway there. A 45 degree angle is the halfway point to looking fully over your right shoulder. If you turned all the way, your chin would be almost touching your right shoulder, so you don’t want to go that far. You will do this same halfway-to-the-shoulder move when you are upside down.

An easy way to know you are doing this properly when upside down on your hands and knees is to turn until you are looking straight at your right elbow . This places your head near the correct 45 degree angle. Your head should be completely upside down, so the chin is not tilted much up or down, although tucking your chin under slightly can help move some deeper particles.

If your problem is in the left ear, you will want to turn your chin toward your left shoulder and to look at your left elbow when upside down.

Ask the Doctor: Brief vertigo

For about 3-4 years now, I will occasionally get VERY strong episodes of vertigo where it feels like I am being very strongly pulled in a weird direction. Sometimes it feels like my head is shaking back and forth. These episodes usually last anywhere from 20 seconds to sometimes 5-7 minutes. They NEVER happen when standing or moving. They only happen when lying down or sitting down, completely still. … I don’t have migraines, I DO sometimes get spinning sensations… I’m struggling to find conditions that cause vertigo that are not brought on by head movements. I used to get these episodes once every 3 or so weeks maybe, but over the past 3 months, I get them now daily, sometimes multiple times a day. The only good thing is that I can get myself out of any episode by moving, slightly aggressively. All I have to do is stand up and walk around and the sensation will subside until I sit or lay again completely still.

Your description gives some important clues. These are spontaneous, non-positional vertigo spells that last for minutes. They are fairly mild because you don’t see the world spinning when they occur, although you mentioned some spinning sensations. The pulling sensation you describe can be coming from the spinning sensors if the spinning is very brief. With brief vertigo there will be a sense of tugging of the head along with a short rotation as if just starting to flip forward or back and toward one side. Very brief spells of vertigo don’t allow you to see the room spin because the sensation is not long enough to cause nystagmus (the rhythmic jerking of the eyes when vertigo is prolonged). Brief vertigo spells can progress to longer spells over time and might eventually cause you to see the room spinning if the condition is progressive. One condition that can cause these type of brief spells is superior semicircular canal dehiscence (SSCD). Sometimes a slight squealing sound can be heard if you turn your eyes strongly to the side in this condition, and loud noises, sneezing or coughing may set off a momentary feeling of tilting or spinning.

Pulling sensations can also be due to gravity sensor malfunctions. If the spells are brief and you are upright, you will see the floor appear to tilt momentarily. This type of vertigo strongly affects balance, but since yours have been while sitting or lying down, that hasn’t affected you yet. Gravity sensor vertigo can be brought on when lying down, but unlike BPPV it does not have a curving or spinning quality. It feels like you are rocketing in a straight line, often backward or up- or downward, as if in an elevator.

The most common cause of spontaneous vertigo lasting minutes is a form of migraine. While you deny headaches, it is possible to have this kind of vertigo even with fairly mild headaches. Headaches on one side of the head that are low grade can still be migraines. Sometime migraine presents with flashing lights in the eyes or seeing a rippling zig-zag or rainbow-like illusion. There is another important condition that causes migraine-like vertigo, however: sleep apnea. This is associated with snoring or pauses in breathing while asleep and frequent nighttime awakenings. If you have these symptoms, you should inquire about having a sleep study. The treatment, a CPAP machine, often resolves all the vertigo.

Pay attention to your hearing. When an ear has a progressive disorder, hearing can often decline. Rubbing your fingers next to each ear can allow to notice small differences in hearing–both ears should normally hear the same intensity and sound quality. Any ringing in the ear is also an important clue. Ringing is often thought of as a high pitched sound, but low sounds like the roar of a vacuum cleaner can also indicate a disease. A formal hearing test is much more sensitive and should be done in anyone with vertigo.

Your best bet is to have a full inner ear workup by an otolaryngologist. This should include a hearing test, videonystagmography (VNG), vestibular evoked myogenic potentials (VEMP), and a sleep study if you have any of the sleep apnea symptoms above. These tests will show if there is any permanent damage to hearing or balance or any evidence for SSCD. If every test comes back perfectly normal, be prepared to re-test in 6 months as progressive inner ear disorders sometimes take time to develop signs of damage.