Dizziness causes forms treatment and prognosis

Dizziness is not a disease entity, but a symptom behind which many different diseases can be hidden. As an alarm sign of the brain, vertigo is an indication of a disturbance in the vestibular system, which can be harmless but also threatening.

The dizziness is caused by a disturbed interaction of sensory organs, which are responsible for spatial orientation and balance. The safety resp. stability of one's body in space is impaired, there is a feeling of insecurity and balance problems. 1

dizziness causes forms treatment and prognosis

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Since the causes of dizziness are very different, it may be possible to take some time until the correct diagnosis is made. If dizziness occurs very suddenly, frequently or persists for a long time, a specialist should clarify the possible cause.

How dizziness develops?

In organic diseases, dizziness always occurs when contradictory information from sensory organs reaches the vestibular center in the brainstem or cerebellum.

The information comes from the vestibular organ in the inner ear, the eye or from sensors in joints, tendons and muscles. The brain then tries to reconcile the conflicting information and process it correctly. If this is not successful, the feeling of dizziness develops.

Origin of the vertigo

However, a feeling of dizziness can also occur, When the brain itself can no longer do its job as "coordinator" of balance due to damage. For example, in the case of a stroke in the area of the brain stem or cerebellum.

Duration as a distinguishing criterion

The different forms of vertigo differ in the temporal duration of the syndromes: 4

Acute vertigo syndromes, that last for days to weeks. Episodic vertigo syndromes, lasting from seconds to days. Chronic dizziness syndromes, that lasts for months to years.

Acute vertigo syndromes

Acute onset vertigo is the most common complaint in the emergency care setting. Most sufferers are diagnosed with a benign cause. In about 25 percent, it is a threatening condition such as a transient ischemic attack (TIA) or a stroke caused by a cerebral infarction or cerebral hemorrhage. 4

A neurological examination is performed to help define the location of the damage: Does the dizziness originate from the Organ of balance in the inner ear (peripheral-vestibular) or the Brain centers (central-vestibular) from? So it is distinguished between a Peripheral vertigo and a Central vertigo differentiated. 4

Central vertigo originates from damage (lesions) in the brain. 7 It is usually accompanied by speech or balance problems or double vision. A circulatory disturbance in the area of the brain stem or cerebellum is usually responsible.

The exact location of brain damage cannot be deduced from the type (spinning or swaying), duration and intensity of the dizziness.

What are the forms of vertigo?

The classification of vertigo can be done in different ways.

Classification according to the patient's description:

Staggering vertigoPatients have the feeling that the ground under them is swaying, like on a ship. spinning vertigo: The affected person feels as if he is on a merry-go-round, he himself or the environment is spinning in circles. 1 Elevator dizzinessThe feeling of being pulled up or down as if in an elevator. Dizziness vertigo: This is not an actual vertigo in the neurological sense, rather patients can describe this feeling only with difficulty. You feel "strange", "as if drunk", "as if walking on absorbent cotton or clouds", "as if in a fog" or "stupid in the head".

Spinning, vertigo and elevation vertigo are also referred to as systematic vertigo referred to as sensation due to directional movement in space.

Dizzy vertigo, on the other hand, is also called unsystematic vertigo called.

However, it is completely normal if, for example, after a long boat trip, the land under your feet seems to continue to sway, although you have solid ground under your feet again. Or when after a carousel ride the environment seems to continue spinning for some time.

Classification according to anatomical criteria, i.e. according to the place of origin:

Peripheral vertigo due to disorders of the vestibular organ in the inner ear: examples are benign positional vertigo, Meniere's disease, neuritis vestibularis, vestibular migraine; rare: Vestibular paroxysmia Central vertigo by disturbances in the cerebellum and/or brain stem, caused by cerebral infarctions, cerebral hemorrhages, inflammatory causes, tumors 7

Peripheral vertigo is much more common than central vertigo. However, central vertigo is more often a medical emergency.

The "cerebellar vertigo" or "cerebellar vertigo" is a great challenge in the differential diagnostic differentiation from peripheral forms of vertigo. There may be persistent vertigo, attacks of vertigo, or both. Diagnostically crucial is the examination of eye movements. 1

For understanding: The structure of the inner ear

The so-called peripheral organ of equilibrium is located in the inner ear. It consists of three arcades as well as the sacculus (lat.: sac). The utriculus (lat.: small tube).: sac) and the utriculus (lat.: small tube).

The fluid-filled arcuate ducts, which are perpendicular to each other in the three different planes of space, respond to rotational movements. Sacculus and utriculus, which are also arranged perpendicular to each other, register linear movements, i.e. movements that occur horizontally (right – left) or vertically (up – down).

vertigo causes forms treatment and prognosis

Structure of the inner ear

Sensory cells, which carry fine hairs on their surface, are located in the area where the different components are spatially connected. During movements, these hairs are moved back and forth in the fluid and transmit their information via the vestibular nerve to the brainstem, cerebellum, and spinal cord. The vestibular nerve runs together with the auditory nerve, therefore some forms of vertigo may also cause hearing disorders.

Most common acute peripheral and central vestibular vertigo syndromes

These forms of vertigo usually occur only once, i.e. not recurrently.

Acute unilateral vestibulopathy (also called "neuritis, neuronitis, or neuropathia vestibularis")

– a sudden onset of spinning vertigo lasting at least 24 hours – tendency to fall, nausea and vomiting – eye movement disorders (oscillopsia and spontaneous nystagmus) – no acute hearing disorder – no accompanying neurological disorder indicating a central cause

The cause is thought to be an inflammation (neuritis) caused by a virus. Reactivation of a latent herpes simplex virus (HSV)-1 infection is suspected. 4

Therapeutic help In addition to physiotherapy with balance exercises, the corticosteroid methyl prednisolone, especially if administered in the first 5 days. 4

The course is benign. Most patients do not complain of any further complaints or limitations after twelve weeks at the latest.

Acute vestibular stroke

Circulatory disturbances in the area of the "centers of equilibrium" brainstem and cerebellum are not easy to detect, especially when they manifest as a transient ischemic attack (TIA). 4

Since TIA can be a harbinger of stroke, any acute onset of vertigo must be subjected to a thorough neurological examination, even in younger people.

The diagnosis of an acute vestibular stroke is considered certain if

– neurological and ophthalmological examination reveals evidence of eye movement disorders indicating a central cause, – in addition to the vertigo, neurological disorders such as speech disorders (dysarthria), drooping of one corner of the mouth (central facial paresis), double vision, hemiparesis (ataxia), muscle weakness (paresis) or sensory disorders u.a. occur. – magnetic resonance imaging (MRI) shows a brainstem or cerebellar infarction. 4

Therapeutically, it is decided on a case-by-case basis whether intravenous lysis therapy should be initiated in addition to intensive treatment of the stroke on a stroke unit. 4

The course or. depending on the location and size of the cerebral infarction, the prognosis is often very favorable with regard to the regression of neurological impairments and symptoms.

Episodic vertigo syndromes

Benign positional vertigo (benign paroxysmal positional vertigo, BPLS)

It is the second most common form of vertigo after "functional vertigo" (see below) in a special outpatient clinic for vertigo syndromes at the Neurological Clinic of the Ludwig Maximilian University in Munich in 34 860 patients (1998 – 2019). 5

Although it is described as benign, and it is, it can be very threatening for the affected person when it first occurs. 1 Typical is a severe spinning vertigo, for example in the morning after getting out of bed, usually accompanied by nausea or vomiting.

Orientation in the room is lost. When getting up, a massive unsteadiness of stance and gait is noticeable and there is a risk of falling. After lying down again and in a stable position, the rotary vertigo calms down after a short time. Characteristically, the vertigo is triggered or provoked by changes in the position of the head. 5

The diagnostic criteria are: 4

– Repeated attacks of rotational vertigo triggered by a change in the position of the head. – duration of the attacks less than 1 minute. – eye movement disorder ("positional nystagmus") detectable by the physician during the spinning vertigo. – Exclusion of another disorder.

The cause is amed to be the detachment of fine limestone particles (otoliths) in an arcade. 4

The most effective therapy, which should be applied as soon as possible, are positioning maneuvers according to a fixed scheme, which is given by a doctor. 4

These maneuvers can also be performed at home according to instructions, three times each in the morning, at noon and in the evening until the patient is free of complaints regarding the rotary vertigo. 4

Usually the vertigo disappears after a few days. 4 However, this is followed by a fluctuating vertigo lasting for several days until the system is "back in balance" again. 4

Recurrence of positional vertigo occurs in ca. 50 percent of patients when the posterior arch is affected, usually within a year. 4 It is not uncommon to find vitamin D deficiency or osteoporosis in these patients and should be treated accordingly. 4

Meniere's disease or. Menièr's disease

Typical is the repeated (recurrent) occurrence of attacks of rotary vertigo and a hearing disorder, usually a one-sided hearing loss or tinnitus. 4

Out of complete comfort, without a triggering event or prior movement, there are violent attacks of spinning vertigo with severe balance disturbances, risk of falling, nausea and vomiting, hearing loss or hearing loss in one ear and/or a ringing in the ears (tinnitus).

Symptoms last between 1 and 6 hours, rarely up to 24 hours. Since in the further course of months or years such attacks can occur again and again, there is often an increasing deterioration of the hearing in the affected ear. 1

The cause is an excess of fluid in the inner ear, although the reason for this is ultimately not yet conclusively clarified. 4, 5

The diagnosis is made by an otorhinolaryngologist with the help of hearing and balance tests. Imaging of the head is recommended (computed tomography and/or magnetic resonance imaging) to avoid overlooking a tumor on the vestibular and auditory nerves.

The diagnosis is considered confirmed,

– two or more sudden attacks of vertigo lasting from 20 minutes to 12 hours, – hearing loss in the low frequency range or in the middle frequency range. the low and medium frequency range is detectable, – if alternating ear symptoms such as tinnitus, ear prere or hearing loss occur, and – if the symptoms cannot be explained by any other disorder. 4, 5

Therapeutic administration of a cortisone drug into the tympanic cavity of the middle ear or long-term drug treatment with high-dose betahistine may be tried. 4

Vestibular migraine

Typical is an attack-like occurring spinning vertigo With nausea and vomiting lasting from minutes to an hour, followed by an often hemiplegic headache. 4 Also includes symptoms typical of migraine, such as sensitivity to light and noise, irritability, fatigue, or the desire to retreat to a quiet, dark room. 5

Occasionally, vertigo may persist during headaches. In some cases, the headache may be absent (30% of cases), which can make it difficult to distinguish it from other forms of vertigo of the inner ear. Often migraine is known as a pre-existing condition or family members suffer from migraine.

The diagnosis is considered confirmed,

– when there are at least 5 episodes of vertigo lasting from 5 minutes to 72 hours, – when migraine with or without aura is confirmed according to medical criteria, – when several migraine symptoms such as unilateral pulsating headache, light and noise aversion u.a. and – if no other explanation can be found – a functional (somatoform, psychogenic) disorder. 4

The therapy is carried out according to the guidelines for migraine therapy. 4, 5

Chronic vertigo syndromes

If a dizziness persists for several weeks or months, there is either a bilateral dysfunction of the vestibular organs in the inner ear, a malprocessing of signals from the vestibular organs in the cerebellum or, most frequently, a so-called functional (somatoform, psychogenic) disorder. 4 The latter is more common in the age group of people between 20 and 60 years old. The others concern older age. 4

Bilateral vestibulopathy

Typical is a motion-dependent staggering vertigo with unsteadiness of stance and gait, which intensifies in the dark or when walking on uneven ground. 4 Then there is an increased risk of falling.

head movements a "wobbling" of the environment can be triggered by rapid, involuntary eye movements (oscillopsias). 4

The most important diagnostic criteria are: 4

– Motion-dependent staggering vertigo with unsteadiness of stance and gait. – oscillopsia during rapid head movements or while walking. – Increased unsteadiness of gait in the dark or on uneven ground. – Abnormal findings on testing of the vestibular organs.

The cause can occur at approx. 75 percent of patients are not clarified. 4

The therapy consists mainly in physiotherapy, as balance training and gait training. 4

Cerebellar vertigo ( cerebellar vertigo)

Balance disorders and dizziness can occur in different, also genetically determined diseases of the cerebellum. 4

Eye movement disturbances are diagnostic, which can typically be traced back to a disturbed cerebellar function. 4

Again, physiotherapy with gait training is most important. 4

Functional vertigo syndromes

They are the most common form of vertigo. 5

If no organic cause of the vertigo is found, a changeable permanent vertigo or dizziness is classified as functional vertigo.

Diagnostic criteria are: 5, 4

– Subjectively perceived insecurity of stance and gait with fear of falling without organically justifiable disorder. – Feeling of dizziness or lightheadedness, varying in intensity. Complaints on most days. Longer than 3 months. 4 – Enhancement by upright body position, improvement by sport activities or moderate alcohol consumption. 4 – Previous organically justifiable dysfunction in the vestibular system, severe illness or severe mental stress. 4 – Often depressed or depressive mood. 4

Therapeutic In addition to physiotherapeutic measures, psychotherapy, preferably behavioral therapy, can be helpful. Medication: antidepressants are prescribed. 4

Other causes of dizziness vertigo

Causes are:

Blood prere fluctuations: Both too high and too low blood prere or also rapid fluctuation of the values. Cardiac arrhythmiaBoth too fast and too slow heartbeat 1 Blood sugar fluctuations: Both too high and too low blood sugar or rapid fluctuation of the values. MedicationSleep aids, sedatives, muscle relaxants, strong painkillers; a few drugs are "toxic" to the auditory nerve and can directly damage it. 1 Age: Due to decreased functioning of the sensory organs and decreased ability of the body to process the vertigo sensation. 1

What are the warning signs? When to seek medical help in any case?

Dizziness can have many and different causes, as explained above. It is not easy for the affected person to assess whether the dizziness is dangerous for him or whether there is a serious illness behind it.

In most cases If the vertigo is not based on a serious illness or health disorder, even if the patient feels severely restricted in his or her everyday life by the vertigo. The following symptoms that occur in addition to dizziness are warning signs and require prompt medical evaluation:

– Acute headache 9 – Acute severe neck pain – Gait unsteadiness without/with sudden falls 9 – Neurological symptoms: visual disturbances (especially double vision), difficulty speaking or swallowing, paralysis of arms and/or legs, hearing disturbances 1, 9 – Loss of consciousness 1

If any of these warning signs occur, severe physical impairment caused by the dizziness (z.B. with repeated vomiting) or continuous dizziness of more than one hour, medical help should be sought in any case. In the case of mild, brief attacks of dizziness that last less than a minute and do not cause any other symptoms, it is also possible to wait and see whether they recur. 1

Diagnosis of vertigo

A careful history is crucial for the initial classification of a possible cause of vertigo. 4

Here it is important as a patient to describe the dizziness as precisely as possible and to answer the doctor's specific questions precisely. In this case a description of the vertigo can be difficult. The doctor will ask about: 5

Type of dizziness: spinning dizziness, staggering dizziness, drowsiness, gait unsteadiness Duration: seconds, minutes, hours, days Additional symptoms: z.B. Nausea, vomiting, double vision, speech disorders, paralysis, hearing disorders, coordination disorders Triggering factors: z.B. when walking, head movements, after sitting up from lying down, physical exertion, stress, medication, readjusted glasses

This is followed by a Physical examination an. 5 Here, in addition to a neurological examination, an examination of the cardiovascular system will also take place. 1

If the general practitioner is the first point of contact for vertigo problems, he or she can then decide whether it is appropriate for the patient to see a specialist. 1

Neurologist: in the presence of neurological deficits ENT doctor: if an inner ear problem is suspected Cardiologist: in the case of underlying cardiac arrhythmias or circulatory disorders Psychotherapist / Psychiatrist: in case of psychogenic vertigo

Technical examinations

To clarify the cause of dizziness, technical examinations can be performed:

Computed tomography (CT) or magnetic resonance imaging (MRI) of the brainImaging is required if there are accompanying neurological abnormalities or if it is not possible to classify the vertigo at all. Imaging is not necessary for every occurrence of vertigo. 1 ECG / long-term ECG: if there is a suspicion that cardiac arrhythmia is the cause of the dizziness. 1 Hearing test and apparative function test of the equilibrium organ: these examinations are performed by the otolaryngologist and help to classify peripheral vertigo

Therapy of vertigo

The therapy depends very much on the cause of the dizziness. Therefore, it is very important to have a good medical evaluation at the beginning in case of persistent vertigo or severe physical impairment due to the vertigo. Only then can a good response to therapy be amed. To ame a rapid recovery of the patient.

Often a good explanation of the findings contributes to an improvement of the vertigo, even if no specific therapy is possible. The awareness alone that the dizziness is not caused by a serious illness can lead to a good recovery. 8

Benign paroxysmal positional vertigo (BPLS)

Therapy consists of performing body and head positioning exercises to help move the otoliths out of the arcades. These exercises are often perceived as very unpleasant, because several times a day you have to selectively take the position in which the dizziness occurs again.

However, avoiding the exercises causes a longer course of the disease, because the specific triggering of the vertigo also leads to a training effect for vertigo processing in the brain. BPLS is the most common form of inner ear vertigo. 1

Meniere's disease

Treatment is by taking betahistine 1 in high doses; in severe courses, it may be necessary to inject cortisone or antibiotics through the eardrum into the middle ear. 7 Special surgical techniques can promote drainage of the inner ear fluid. The therapy consists in the administration of medication against the nausea. vomiting as well as in the administration of cortisone in tablet form. 3 The healing process can be improved by rapid mobilization with targeted balance training. 3

Vestibular migraine

It is treated like any other migraine. 5, 4 In case of frequent occurrence or long-lasting attacks, drug prophylaxis can be discussed with a neurologist. 7 Regular physical exercise and stress reduction can also have a positive effect on the course of migraine.

Psychogenic vertigo

Psychotherapeutic treatment with a focus on behavioral therapy is advised here. 5, 4

Stroke

Both acute therapy and prevention of a recurrence depend on the cause of the stroke.

Dizziness after stroke

Dizziness after a stroke is a common symptom, which in most cases persists for several weeks after the stroke event and improves over time.

However, many people still complain of dizziness years after a stroke, which z.B. increase in situations involving physical activity or intense concentration.

Whether dizziness occurs after a stroke depends, among other things, on the region of the brain in which the stroke occurred. It does not matter whether it was a cerebral infarction or a cerebral hemorrhage. Especially strokes in the area of the cerebellum. Of the brain stem very often lead to dizziness. 2

In rare cases, dysregulation of blood prere with excessive depression can also lead to dizziness. Intensive drug lowering of blood prere in the acute phase of a stroke can also cause dizziness. 3 Particularly if high blood prere has not been well controlled for a long time, the body reacts to "normal" blood prere values with dizziness for some time until it has adapted to the blood prere values.

Important for the therapy of vertigo after stroke is a consistent rehabilitation treatment. This includes balance training as well as exercises for the correct handling of dizziness and the processing of this symptom in everyday life. 9

Prognosis of dizziness

Again: to give a reliable prognosis, it is essential to know the cause of dizziness. 3

At benign paroxysmal positional vertigo the symptoms have completely disappeared after days or weeks. 7 In 30 to 50 percent of patients, dizziness may recur within two years, and rarely much later. The complaints do not remain permanently. 7, 3

The course of the disease in Meniere's disease is very variable. In mild forms of the disease, only slight hearing impairments remain. 3 In severe cases and after many severe episodes, permanent loss of balance or complete deafness may occur. Often there is an accumulation of dizziness attacks over months, then several years without symptoms. In ca. 80 percent of the patients lose the vertigo attacks over the period of several years.

The neuritis vestibularis subsides completely after one to two weeks. While the dizziness improves within days, mild balance problems with unsteadiness of gait and a feeling of light-headedness, especially when walking, may still occur weeks or months afterwards.

However, the body is able to compensate for the damage to the vestibular organ to such an extent that the affected person does not retain any limitations in the long term. Recurrence of neuritis is very rare at about two percent. 3

Conclusion

Dizziness is a symptom that severely restricts the daily life of a person affected, even if the cause is very often "harmless". However, it is important not to overlook possible serious causes of vertigo and to recognize them in time. Not every form of dizziness can be quickly. Treat completely. Especially in old age, the treatment of chronic dizziness vertigo is very difficult or impossible.

Vertigo is a complaint that causes anxiety, conveying that one has lost control of one's body. Even the fear of the recurrence of dizziness alone can lead to significant impairment in everyday life and social life.

Therefore it can be necessary and meaningful to take up a psychotherapeutic co-treatment, in order to lose the anxiety. In the process, the body can learn to live with this dizziness. Regular physiotherapeutic exercise treatments with balance training also support compensatory mechanisms that the body can learn in order to no longer experience dizziness so intensely.

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dizziness causes forms treatment and prognosis

Author

Dr. med. Christina Ruckert is a specialist in neurology and geriatrics and worked for more than 10 years as a senior physician at the Oberschwabenklinik in Ravensburg, Germany. Her professional activities included deputy medical director of the central emergency room. Since July 2021, she and her husband – also a specialist in neurology – have had their own practice in Rothenburg ob der Tauber. One focus of her outpatient work is the follow-up care of patients after stroke.

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