Vertigo

Vertigo is a widespread neurological complaint that can arise for a variety of reasons. In the foreground of vertigo are complaints such as spatial coordination disorders and balance problems. In many cases, other symptoms such as nausea and vomiting, increased sweating, an accelerated pulse and a feeling of weakness are also present. Dizziness can be divided into different types. Basically, an acute, short-lasting dizziness attack can be distinguished from constant dizziness. Around 25% of people suffer from a dizziness attack at least once in their lifetime. Dizziness occurs more frequently, especially in older people.

The inner ear contains the so-called vestibular organ (organ of equilibrium), which is responsible for the sense of balance, for the orientation of the body in space, as well as for the perception of linear and rotational acceleration. The vestibular organ is composed of bony and softer structures. Basically, the vestibular organ consists of three arcuate ducts (arcuates), two outpouchings (sacculus, utriculus) and one duct (ductus endolymphaticus). All these structures are in communication with each other and are filled with the inner ear fluid (endolymph). When the position of the head or the whole body changes, the endolymph moves in relation to the inner ear because of its inertia and excites the sensory cells of the vestibular organ. These transmit the excitation by means of nerves to the brain, where further processing takes place.

In addition to the vestibular organ, the eyes and receptors in the joints and muscles also provide information about the position of the body in space and are therefore also responsible for spatial orientation. If one of these sensory organs provides incorrect sensory stimuli, dizziness can occur.

Possible causes of dizziness can be diseases of the vestibular organ, foreign sensory stimuli, such as during travel on the high seas, as well as diseases of the cardiovascular system. There is also a form of vertigo that can be caused by psychological changes.

Vestibular vertigo:

Darunter versteht man einen Schwindel, der durch Erkrankungen des Gleichgewichtsorgans verursacht wird. Der vestibuläre Schwindel kann in einen peripheren und zentralen Schwindel unterteilt werden. Bei Erkrankungen des Vestibularorgans oder des ableitenden Nervs bezeichnet man den Schwindel als peripher vestibulär. Sind jedoch Veränderungen des Gehirns beziehungsweise des Kleinhirns für den Schwindel verantwortlich, handelt es sich um einen zentralen vestibulären Schwindel. Meistens empfinden die Betroffenen beim vestibulären Schwindel einen Drehschwindel.

Benign paroxysmal positional vertigo:

Diese Erkrankung ist für den Großteil der Schwindelbeschwerden verantwortlich. Hierbei kommt es zur Lösung von kleinsten Kristallen des Vestibularorgans, die sich in weiterer Folge in einem der Bogengänge ablagern und dort die Sinneszellen reizen. Bei Veränderung der Kopf- oder Körperhaltung werden die Kristalle bewegt und führen dadurch zu Schwindelattacken.

Neuritis vestibularis:

This is an inflammation of the nerve that carries information from the inner ear to the brain. Although this is the second most common cause of vertigo and therefore of clinical relevance, it has not yet been possible to clarify how the inflammation occurs. Those affected suffer from violent spinning vertigo and usually feel very ill. The symptoms can last up to four weeks, but usually disappear completely.

Vestibulopathy:

This refers to damage to the organ of balance. In addition to dizziness, sufferers report that objects in the environment move up and down when they walk (oscillopsia), appear blurred and can therefore no longer be easily recognised. The vertigo can be both a swinging and a spinning vertigo that can last from a few hours to over several days. Vestibulopathies can develop as a result of taking certain medications (for example, aminoglycosides, which belong to the group of antibiotics), but also as a result of meningitis. In some cases, no cause for the disease can be found.

Vestibular paroxysmia:

This disorder is characterized by short-lasting, recurrent attacks of vertigo. It usually involves a spinning or swaying vertigo that lasts for a few minutes. It is also typical that the dizziness is caused by certain head postures. The cause of this disease has also not yet been clarified, but it is assumed that the dizziness is caused by an incorrect wiring of the nerve pathways.

Meniére's disease:

In Meniére's disease, excessive accumulation of endolymph in the inner ear occurs for reasons that are not fully understood, resulting in so-called Meniére's seizures, which are characterized by sudden reduction in hearing, severe tinnitus, and spinning vertigo.

Basilaris migraine:

This is a special type of migraine in which there are recurrent migraine attacks characterized by dizziness, vision problems, difficulty walking and standing, and severe headaches.

Stroke and TIA:

In the context of a circulatory disturbance of the cerebellum, symptoms such as dizziness, nausea and vomiting, as well as coordination difficulties with gait and standing unsteadiness, sensory disturbances and speech difficulties may come.

Acoustic neuroma:

This is a benign tumor of the eighth cranial nerve, which transmits sensory information from the auditory and vestibular apparatus to the brain. The tumor arises from altered Schwann's cells, which are responsible for insulating the nerves.

Fracture of the petrous bone:

Accidents or falls can cause fractures of the petrous bone, a bone of the skull that surrounds and protects the vestibular organ. As part of the fractures, the inner ear can be injured, which can lead to vertigo.

Vestibular epilepsy:

This refers to a particular form of epilepsy in which there are seizures as well as dizziness and involuntary, jerky eye movements. Usually the dizziness occurs before the epileptic seizures.

Kinetosis- motion sickness:

Unaccustomed movements during ship travel, rapid car rides, or airplane turbulence can cause excessive irritation of the vestibular organ. Since no fixed points in the environment can be fixed with the eyes when reading in a car, on the high seas, or in an airplane, the brain cannot properly process the stimuli from the vestibular organ, resulting in the complaints of vertigo, as well as nausea and vomiting.

Non-vestibular vertigo:

This form of vertigo is not caused by diseases of the vestibular organ or neurological processing. For example, diseases of the cardiovascular system, such as severe changes in blood pressure (hypertension, hypotension), as well as cardiac arrhythmias, can lead to attacks of vertigo. Other causes of dizziness can be the intake of medicines, drug abuse or metabolic disorders. Common triggers of non-vestibular vertigo include low blood sugar (hypoglycemia) or accelerated breathing (hyperventilation).

Somatoform vertigo:

This is a form of vertigo in which no physical illness is detectable. In most cases, the affected person reports a variety of other complaints in addition to the dizziness, such as shortness of breath or constant fatigue. In most cases, a psychological change in the affected person is the cause of the symptoms. For example, depression or anxiety disorders can cause these symptoms without the affected person even recognizing the mental illness. It is also very typical that those affected visit a number of doctors without ever experiencing any real success in treatment.

Phobic vertigo:

This is the most common somatoform vertigo disorder. People between the ages of 30 and 50 are most likely to suffer from phobic vertigo. Patients report severe staggering vertigo, unsteadiness in walking and standing, often feel dizzy and have a constant fear of falling. The vertigo attacks are mainly triggered by psychological strain and stress, whereby even walking on bridges or even climbing stairs can be causative situations.

To clarify the vertigo, sometimes the examination by different specialists may be necessary, since different organs and thus specialties are responsible for the symptoms. The examination is best carried out in specialised centres or dizziness outpatient clinics. In the case of very severe symptoms, admission to hospital may be necessary.

An important role in the clarification of vertigo is played by the patient interview. Often a suspected diagnosis can be made by a detailed questioning of the complaints and the course of the illness. This is usually followed by a physical examination and an ECG to rule out other physical causes.

Furthermore, attention is paid to specific neurological symptoms:

• Nystagmus: These are involuntary, jerky, rhythmic eye movements that, under normal circumstances, serve to keep objects in focus automatically in focus on the retina even when the head is moved. In people who suffer from vertigo, nystagmus can often be observed even at rest by means of the so-called Frenzel glasses. Furthermore, nystagmus can be triggered by caloric stimulation or by repeated rotation on a swivel chair.
• Balance testing: A wide variety of tests are suitable for this purpose in order to check the balance system for proper functioning.
• Coordination test: In the finger-nose test, for example, the patient has to move the index finger in a large arc with closed eyes to the tip of the nose. If changes are detected by this examination, complementary examination methods may be performed. For example, a test of hearing (audiometry), imaging techniques such as CT or MRI may be used to clarify the vertigo. In some cases, an examination using an ultrasound device or an EEG (electroencephalogram) may also prove helpful.

Dizziness can become a life-threatening burden, as consequences such as the risk of falling or psychological consequences are possible. If the episodes of dizziness recur, a visit to a specialist is significant, in order to be able to exclude underlying diseases such as a sleep attack or different tumors. Especially in case of accompanying severe headaches or coordination problems or if the dizziness lasts for a longer period of time, a visit to the doctor is recommended.

Depending on the cause, the dizziness can then be treated. Depending on the type of attack (acute or chronic) and the presence of accompanying symptoms such as visual disturbance, different therapies are offered for the treatment of vertigo (physical or psychosomatic measures).

Medications:

Antivertiginosa are used to improve symptoms of the vertigo attack (not the underlying disease). These are used especially for acute and severe vertigo. For acute attacks and motion sickness, antihistamines may also be used. During the seizure-free period, betahistine (promotes blood flow in the inner ear and brain) may be used in Meniere's disease (i.e., disease of the inner ear) to positively affect the frequency and severity of seizures. In this regard, the medications prescribed for vertigo attacks vary depending on the type of attack or accompanying symptoms such as nausea and vomiting.

Physical exercise:

Since physical exercise can generally have a positive effect on vertigo attacks, physiotherapy treatments can also be used. In this case, the organ of equilibrium is stressed by certain movements that cause gait insecurities of the affected person in order to promote natural corrective movements. Especially in cases of permanent vertigo and benign positional vertigo, physical exercises such as positional training or freeing maneuvers according to Epley or Sémont are used in therapy to accelerate the healing time. In the liberation maneuver, the positional vertigo-provoking otoconia (i.e., "stones" in the vestibular organ that mediate balance) are moved back to their point of origin.

Psychotherapy:

Psychotherapeutic methods such as behavioral therapy can be used to treat psychologically induced vertigo. Medicines may be used as supportive treatment in severe cases.

Surgery:

Only in particularly severe cases, such as Meniere's patients with highly repetitive vertigo or vertigo that occurs over a very long period of time with significantly limited hearing functions, can doctors consider surgery. In this case, the affected organ of equilibrium is rendered non-functional, for example, by injecting it with medication (e.g. gentamicin). Nowadays, however, such treatments are several times the exception.