Vertigo & Balance

BPPV typically presents with a very classic history. Patients will report 10-15 seconds of room-spinning vertigo, specifically after a positional change to one direction, commonly rolling over in bed. This is due to small ‘crystals’ in the inner ear that are dislodged and have moved to the wrong part of the semicircular canals. This causes your vestibular system to think you are rotating even when you are not. The diagnosis and treatment can be easily done within just a few minutes in the office. This is achieved with a test called a Dix-Hallpike and can be then resolved with an Epley maneuver.

Vestibular neuritis or a very similar disorder called labyrinthitis, is an infection of the vestibular nerve which causes a severe sensation of room spinning vertigo. Patients may often lie on the ground with extreme nausea and end up going to the ER due to the severity of the vertigo. This room-spinning episode can last for many hours. Afterwards, for up to a few months, individuals can feel dizzy and off-balance, but no longer will have the room-spinning vertigo. Eventually this will improve over many months, but can be improved much quicker with a type of physical therapy called vestibular therapy.

Vestibular migraines, sometimes called migraine associated vertigo (MAV), are a unique manifestation of migraines. Some patient’s migraines will present mostly or even entirely as dizziness and unsteadiness. The best evidence suggests that avoiding common migraine triggers can help, and additionally, there are medications that can be used and often offer significant benefit. Nortriptyline is technically in a class of anti-depressants called TCA’s but is used ‘off-label’ for many things such as nerve pain and vestibular migraines. Nortriptyline is used in very low doses taken at night to successfully treat vestibular migraines.

Sometimes our blood pressure can play a role in our dizziness. Our blood pressure, by design, is meant to temporarily increase as we get up from a sitting or lying position. When this happens, blood vessels constricted increasing blood pressure. As we age, the blood vessel walls are less compliant, and do not squeeze as forcefully. This can mean that blood pressure will take longer to increase after we stand up. This can be confounded if we’re also on blood pressure medications. The combination of this can cause our brain to not get enough blood when we stand up causing us to be dizzy and feeling like we are going to pass out. Sometimes treatment can include reducing our blood pressure medications or dosages as we get older. We can also increase our blood pressure with our diet by including more sodium in our meals. Most importantly, we can focus on sitting on the edge of the bed for a few minutes before we stand up to allow our body time to get enough blood to perfuse the brain.

Overall, there are many causes of dizziness, much more than described above. These can be cardiovascular, neurologic, otologic, or even related to a combination of too many medications, called polypharmacy. There are only a few causes related to the ear, nose, and throat but is important to be seen to be fully evaluated to rule out these etiologies. For some patient’s they will take a combination of their primary care, ENT, cardiologist, and neurologist, to slowly rule in or rule out various contributing factors. It is important to be an advocate for yourself and ensure you have received a complete and thorough workup. We are here at Alpharetta ENT specialists to help guide you in your care.