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Dizziness and balance problems
A guide for patients and carers
What diseases can cause dizziness?
Many diseases can give rise to dizziness or off-balance sensations, e.g. blood disorders such as anaemia or certain heart conditions, but if you have been referred to a neurologist or otologist such general conditions will usually have been excluded in advance. You should also be aware that a number of medications can cause dizziness as an unwanted side effect. Being tense or irritable can also provoke dizziness or a sense of imbalance, and this can be a vicious circle, as being dizzy can also make you feel anxious or depressed.
In this section we will describe some of the specific conditions that can lead to dizziness. The treatments given for any of the specific diseases that cause dizziness will also be described. Dizziness as a symptom - independently of what has caused it - can also be treated, but we will deal with that later, in the section What treatments are available? Most cases of dizziness, vertigo or other off-balance sensations are due to one of the seven following conditions:
1. Viral labyrinthitis
2. Benign paroxysmal positional vertigo
3. Ménière’s disease
4. Vertigo of vascular origin
5. Post-traumatic vertigo
6. Peripheral vestibular disorder
7. “Central” or neurological causes.
Viral labyrinthitis
As the name indicates, this is a viral infection of the labyrinth, or inner ear. Other names frequently used for this condition are “vestibular neuronitis” (as some doctors think that the problem lies in the nerve cells or neurons connected to the inner ear) or “epidemic vertigo”, because small epidemics of this condition can sometimes occur. With this condition there is rather sudden onset of a spinning vertigo, accompanied by nausea or sickness and unsteadiness. These symptoms frequently develop a few days or weeks after a bad cold or ’flu.
People with this condition often prefer to stay in bed because any movement makes the vertigo worse, which may just last for a few days or may persist for two or three weeks. Some people remain a little unsteady afterwards, but most make a full recovery. Only a minority of patients with viral labyrinthitis will experience persistent, troublesome dizziness or will suffer recurrences of the condition - either spontaneously or associated with later bouts of the common cold or ’flu.
Viral labyrinthitis does not cause any hearing problems, but the initial dizziness is intense and distressing. The minority of people who experience prolonged or recurrent problems do not suffer from intense symptoms, but they are nevertheless a nuisance and limit them in their everyday working or social lives. Treatment in the initial stages of viral labyrinthitis includes anti-vertiginous drugs, which are medicines that are identical or similar to those used for car or sea sickness.
Benign Paroxysmal Positional Vertigo (BPPV)
The dizziness experienced in this condition is intense and also has a rotational or spinning character. It is, however very short-lived, lasting a minute or less, and is typically brought on by certain head movements. Examples are the movements associated with turning over in bed or looking up to hang clothes on the washing line. Most people with this form of vertigo know exactly what type of movements can induce the symptoms and so learn to avoid them. It is now pretty well established that the cause of this vertigo is the accumulation of certain particles or crystals within one of the “tubes” of the balance organs, the posterior semi-circular canal. The diagnosis can only be established by the positional test described earlier on.
Due to the intricate connections between the balance organs of the ears and the eye muscles, BPPV often causes a highly specific nystagmus (jerky movements of the eyes) which is unique to the condition. Recent developments have allowed new treatments to be devised to clear out the particles trapped in the semi-circular canal. These include the so-called particle repositioning procedures, the more commonly used of which are the Epley manoeuvre and the Semont manoeuvre. These can be performed in the doctor’s or physiotherapist’s room and consist of a series of movements of the head guided by the doctor or physiotherapist, without the need for any specialised instruments. These procedures offer a non-invasive and effective form of treatment but are fairly new, and not all doctors are yet familiar with them.
Ménière’s disease
People with Ménière’s disease suffer from repetitive attacks of intense, spinning vertigo. Each attack typically lasts for two, up to 24 hours and affected people are frequently sick. People usually experience noticeable changes in their hearing either before or during the vertigo attacks, including both tinnitus and a loss of hearing. There is usually a tenderness or pressure in one of the ears either before or during these attacks of vertigo. In between attacks the person may have fairly good balance and experience no dizziness, but they will experience various degrees of hearing loss. This hearing loss is initially fluctuating - that is, it improves after attacks but there is a tendency for it to get worse over time and become permanent. Approximately one third of people with Ménière’s disease have symptoms in both ears. Usually there is no warning that one of these vertigo attacks is going to occur, and this leads to anxiety that they may happen in public places. This is largely because patients are worried that people might think they are drunk because they are “all over the place and sick”.
The actual cause of Ménière’s disease is not known, but each episode or attack is due to a build-up of pressure in the inner ear - a phenomenon called endolymphatic hydrops. That is why one of the main treatments for this condition is a strict low-salt diet and a diuretic - “water tablets”- which help get rid of excess salt and fluid in the body. In this way the risk of a build-up of salt, fluid and pressure in the ear is reduced. This form of treatment can be of benefit in reducing the frequency and intensity of each vertigo attack, but will not necessarily slow down the progression of the deafness. Antivertiginous drugs can help some people if taken as soon as the first symptoms develop, but they may be brought up when they are sick, making them useless. Some anti-vertiginous drugs come as suppositories and they can reduce the intensity of the vertigo attacks.
Vertigo of vascular origin
The term vascular is given to describe conditions that are caused by a reduced supply of blood reaching a particular organ. In the case of dizziness, the organs in question are the labyrinth and the lowermost part of the brain which contains the balance centres. The blood vessels that supply both the labyrinth and the balance organs of the brain are shared, and therefore vascular dizziness can come from a combination of “peripheral” (inner ear) and “central” (brain) dysfunction. The symptoms can include double vision, slurred speech, blurred vision and numbness in the face or limbs. Unless the deficit in blood supply has caused a stroke, the dizziness and accompanying symptoms are likely to come and go.
There are essentially two types of vascular dizziness. With the first type, the symptoms appear during certain types of migraine, generally in younger people (less than 50 years of age). These people may benefit rom anti-migraine treatment. In older people, the symptoms are usually an indication of general vascular disease and relate to the so-called vascular risk factors such as high blood pressure, smoking, high levels of blood cholesterol, obesity or a family history of vascular disease (high blood pressure, heart attacks, and strokes). Treatment here is aimed at reducing the vascular risks, and most doctors will also prescribe a small aspirin a day to thin the blood as long as there are no reasons why aspirin should be avoided (such as stomach ulcers).
Post-traumatic vertigo
Dizziness commonly occurs after moderate to serious head injuries and frequently occurs after only minor head injuries. The actual mechanism that makes people feel dizzy can again be a combination of peripheral (inner ear) and central (brain) disorders. Patients may have additional symptoms, limb fractures or worries related to the head injury and the treatment will have to take all of these issues into consideration.
Peripheral vestibular disorder
In many cases doctors are only able to diagnose that the cause of the
dizziness is a peripheral vestibular disorder - that is, the problem is in the ear, not the brain - without being able to establish the exact underlying disease. Strictly speaking, viral labyrinthitis, BPPV and Ménière’s disease are all peripheral vestibular disorders, but we reserve the term here for conditions that cannot be properly classified into any of the well-defined groups. In some cases, abnormalities may show up in the specialised balance tests, but in others even these tests will be normal. There may be relatively minor permanent symptoms (but disabling nevertheless) or recurrent episodes of vertigo, which may or may not be triggered by certain factors, such as head movements, tiredness, stress, menstrual periods or viral infections. Don’t worry if your doctor cannot be 100 per cent sure of the cause of your balance disorder because it has been shown that in the long term, the majority of people in this group improve with time. Recovery can be helped by rehabilitation procedures (see What reatments are available?).
Central of neurological causes of dizziness
A minority of people complaining of dizziness have a neurological disease. The part of the brain that organises balance is the lowermost part of the brain and includes what is called the brain stem and the cerebellum. This part of the brain also deals with the organisation of movement, posture and speech, which can therefore also be affected. Strokes or demyelination (for instance, multiple sclerosis), inflammation or tumours in this area and bony deformities of the back of the head and the upper spine can all cause dizziness and balance disorders. Any of these problems can be picked up in the neurological examination carried out by the doctor and from brain scans.
1. Viral labyrinthitis
2. Benign paroxysmal positional vertigo
3. Ménière’s disease
4. Vertigo of vascular origin
5. Post-traumatic vertigo
6. Peripheral vestibular disorder
7. “Central” or neurological causes.
Viral labyrinthitis
As the name indicates, this is a viral infection of the labyrinth, or inner ear. Other names frequently used for this condition are “vestibular neuronitis” (as some doctors think that the problem lies in the nerve cells or neurons connected to the inner ear) or “epidemic vertigo”, because small epidemics of this condition can sometimes occur. With this condition there is rather sudden onset of a spinning vertigo, accompanied by nausea or sickness and unsteadiness. These symptoms frequently develop a few days or weeks after a bad cold or ’flu.
People with this condition often prefer to stay in bed because any movement makes the vertigo worse, which may just last for a few days or may persist for two or three weeks. Some people remain a little unsteady afterwards, but most make a full recovery. Only a minority of patients with viral labyrinthitis will experience persistent, troublesome dizziness or will suffer recurrences of the condition - either spontaneously or associated with later bouts of the common cold or ’flu.
Viral labyrinthitis does not cause any hearing problems, but the initial dizziness is intense and distressing. The minority of people who experience prolonged or recurrent problems do not suffer from intense symptoms, but they are nevertheless a nuisance and limit them in their everyday working or social lives. Treatment in the initial stages of viral labyrinthitis includes anti-vertiginous drugs, which are medicines that are identical or similar to those used for car or sea sickness.
Benign Paroxysmal Positional Vertigo (BPPV)
The dizziness experienced in this condition is intense and also has a rotational or spinning character. It is, however very short-lived, lasting a minute or less, and is typically brought on by certain head movements. Examples are the movements associated with turning over in bed or looking up to hang clothes on the washing line. Most people with this form of vertigo know exactly what type of movements can induce the symptoms and so learn to avoid them. It is now pretty well established that the cause of this vertigo is the accumulation of certain particles or crystals within one of the “tubes” of the balance organs, the posterior semi-circular canal. The diagnosis can only be established by the positional test described earlier on.
Due to the intricate connections between the balance organs of the ears and the eye muscles, BPPV often causes a highly specific nystagmus (jerky movements of the eyes) which is unique to the condition. Recent developments have allowed new treatments to be devised to clear out the particles trapped in the semi-circular canal. These include the so-called particle repositioning procedures, the more commonly used of which are the Epley manoeuvre and the Semont manoeuvre. These can be performed in the doctor’s or physiotherapist’s room and consist of a series of movements of the head guided by the doctor or physiotherapist, without the need for any specialised instruments. These procedures offer a non-invasive and effective form of treatment but are fairly new, and not all doctors are yet familiar with them.
Ménière’s disease
People with Ménière’s disease suffer from repetitive attacks of intense, spinning vertigo. Each attack typically lasts for two, up to 24 hours and affected people are frequently sick. People usually experience noticeable changes in their hearing either before or during the vertigo attacks, including both tinnitus and a loss of hearing. There is usually a tenderness or pressure in one of the ears either before or during these attacks of vertigo. In between attacks the person may have fairly good balance and experience no dizziness, but they will experience various degrees of hearing loss. This hearing loss is initially fluctuating - that is, it improves after attacks but there is a tendency for it to get worse over time and become permanent. Approximately one third of people with Ménière’s disease have symptoms in both ears. Usually there is no warning that one of these vertigo attacks is going to occur, and this leads to anxiety that they may happen in public places. This is largely because patients are worried that people might think they are drunk because they are “all over the place and sick”.
The actual cause of Ménière’s disease is not known, but each episode or attack is due to a build-up of pressure in the inner ear - a phenomenon called endolymphatic hydrops. That is why one of the main treatments for this condition is a strict low-salt diet and a diuretic - “water tablets”- which help get rid of excess salt and fluid in the body. In this way the risk of a build-up of salt, fluid and pressure in the ear is reduced. This form of treatment can be of benefit in reducing the frequency and intensity of each vertigo attack, but will not necessarily slow down the progression of the deafness. Antivertiginous drugs can help some people if taken as soon as the first symptoms develop, but they may be brought up when they are sick, making them useless. Some anti-vertiginous drugs come as suppositories and they can reduce the intensity of the vertigo attacks.
Vertigo of vascular origin
The term vascular is given to describe conditions that are caused by a reduced supply of blood reaching a particular organ. In the case of dizziness, the organs in question are the labyrinth and the lowermost part of the brain which contains the balance centres. The blood vessels that supply both the labyrinth and the balance organs of the brain are shared, and therefore vascular dizziness can come from a combination of “peripheral” (inner ear) and “central” (brain) dysfunction. The symptoms can include double vision, slurred speech, blurred vision and numbness in the face or limbs. Unless the deficit in blood supply has caused a stroke, the dizziness and accompanying symptoms are likely to come and go.
There are essentially two types of vascular dizziness. With the first type, the symptoms appear during certain types of migraine, generally in younger people (less than 50 years of age). These people may benefit rom anti-migraine treatment. In older people, the symptoms are usually an indication of general vascular disease and relate to the so-called vascular risk factors such as high blood pressure, smoking, high levels of blood cholesterol, obesity or a family history of vascular disease (high blood pressure, heart attacks, and strokes). Treatment here is aimed at reducing the vascular risks, and most doctors will also prescribe a small aspirin a day to thin the blood as long as there are no reasons why aspirin should be avoided (such as stomach ulcers).
Post-traumatic vertigo
Dizziness commonly occurs after moderate to serious head injuries and frequently occurs after only minor head injuries. The actual mechanism that makes people feel dizzy can again be a combination of peripheral (inner ear) and central (brain) disorders. Patients may have additional symptoms, limb fractures or worries related to the head injury and the treatment will have to take all of these issues into consideration.
Peripheral vestibular disorder
In many cases doctors are only able to diagnose that the cause of the
dizziness is a peripheral vestibular disorder - that is, the problem is in the ear, not the brain - without being able to establish the exact underlying disease. Strictly speaking, viral labyrinthitis, BPPV and Ménière’s disease are all peripheral vestibular disorders, but we reserve the term here for conditions that cannot be properly classified into any of the well-defined groups. In some cases, abnormalities may show up in the specialised balance tests, but in others even these tests will be normal. There may be relatively minor permanent symptoms (but disabling nevertheless) or recurrent episodes of vertigo, which may or may not be triggered by certain factors, such as head movements, tiredness, stress, menstrual periods or viral infections. Don’t worry if your doctor cannot be 100 per cent sure of the cause of your balance disorder because it has been shown that in the long term, the majority of people in this group improve with time. Recovery can be helped by rehabilitation procedures (see What reatments are available?).
Central of neurological causes of dizziness
A minority of people complaining of dizziness have a neurological disease. The part of the brain that organises balance is the lowermost part of the brain and includes what is called the brain stem and the cerebellum. This part of the brain also deals with the organisation of movement, posture and speech, which can therefore also be affected. Strokes or demyelination (for instance, multiple sclerosis), inflammation or tumours in this area and bony deformities of the back of the head and the upper spine can all cause dizziness and balance disorders. Any of these problems can be picked up in the neurological examination carried out by the doctor and from brain scans.
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