Vertigo & Balance Disorders
Evaluation of dizziness, spinning sensations and balance problems to identify and treat the underlying cause
What is vertigo & balance disorders?
Vertigo is the false sense that you or the room is moving, usually spinning. It is distinct from light-headedness, from the feeling of being about to faint, and from general unsteadiness on the feet, and separating those four is the first thing anyone assessing you will try to do, because they lead to entirely different causes.
Balance is built from three inputs: the balance organs of the inner ear, your eyes, and position sensors in the joints and feet. The brain compares them continuously. When one input suddenly disagrees with the other two, you get vertigo. When several are quietly weak, as happens with age, you get unsteadiness without any spinning.
How long a typical attack lasts is the most useful single fact about it. Seconds to a minute, set off by rolling over in bed or tipping the head back, points one way. Minutes to hours with hearing changes points another. Days of continuous severe spinning with vomiting points somewhere else again, and constant daily unsteadiness that never comes in discrete attacks points somewhere different from all three. Timing an attack before you come to the appointment is worth doing.
What you might notice
- Dizzy spells or near-blackouts
- Walking that has become unsteady
- Ringing in the ears
How it is diagnosed
The history does most of the work. Your doctor will ask how long an attack lasts, what position or movement sets it off, whether your hearing has changed or your ear feels full, whether there is ringing, whether headache comes with it, and what medicines you take, since several cause dizziness on their own.
The examination then separates the inner ear from the brain. Your doctor watches your eyes for the flicking movement called nystagmus and tests how your eyes hold a target while your head is moved, checks eye movements, facial sensation and power, speech, swallowing and coordination, and watches you stand and walk. They may lie you back quickly with your head turned to one side and watch your eyes for thirty seconds, a bedside test that reproduces one very common cause and confirms it on the spot. They will look in both ears and take your blood pressure lying and then standing.
Most causes are settled on the history and examination alone. Hearing tests are arranged where hearing is involved, and a scan is reserved for when the examination points to the brain instead of the ear, when hearing loss on one side needs explaining, or when the pattern does not fit anything familiar.
Recovery
It depends entirely on the cause and the range is very wide. The commonest cause, in which loose crystals have moved into the wrong part of the inner ear and set off seconds of violent spinning whenever you move your head a particular way, is treated in the clinic with a sequence of head positions and settles in most people after one or two visits. It can return months or years later, and the same treatment works again.
Inflammation of the balance nerve is the opposite: several days of constant severe vertigo and vomiting, with the worst over in two or three days, followed by two to six weeks of unsteadiness that fades as the brain recalibrates. Anti-sickness medicine is used only for the first few days, because continuing it holds up exactly the adjustment you are waiting for. Getting up and moving, even while it feels awful, speeds it.
Where dizziness has been present for months, the treatment is a daily exercise programme taught by a physiotherapist, which deliberately provokes mild symptoms so the brain learns to ignore the faulty signal. It takes six to twelve weeks, it feels worse before it feels better, and it works for most people who see it through.
If it is left untreated
Some causes settle on their own. The crystal-related type often resolves within weeks without anyone touching it, though it can be cleared in a few minutes in clinic, so waiting has little to recommend it.
The real cost of leaving dizziness unassessed is falling. In anyone over sixty-five a fall carries a genuine risk of a hip or wrist fracture and of the loss of independence that follows one. There is a second effect that builds quietly: people who are dizzy stop going out and stop moving, the legs weaken, and the balance that was already poor gets poorer, so the loss of confidence becomes a cause in its own right.
Where hearing loss in one ear comes with the vertigo, the cause needs identifying promptly, since some causes damage hearing permanently and are treatable in the first days. Sudden hearing loss in one ear is an emergency measured in days.
Vertigo arriving with double vision, slurred speech, weakness or numbness down one side, a severe new headache, or unsteadiness so bad you cannot walk, needs emergency assessment the same day, because a stroke at the back of the brain can present as dizziness and very little else.
Questions about vertigo & balance disorders
Is my dizziness coming from my ear or my brain?
The examination answers this far more often than a scan does. Vertigo from the inner ear typically comes in identifiable attacks, is made worse by head movement, often comes with nausea, hearing change or a full feeling in one ear, and leaves everything else about you completely normal. Vertigo from the brain is more often accompanied by double vision, slurred speech, numbness or weakness on one side, difficulty swallowing, or unsteadiness so severe that walking is impossible even between attacks. Your doctor has bedside tests of eye movement that distinguish the two reliably in a couple of minutes. If any of the second group applies to you, that needs emergency assessment the same day.
Can I drive while I am getting attacks?
Not while attacks are happening without warning. An attack of true spinning while driving is dangerous to you and to everybody else, and this applies whatever the cause turns out to be. Stop driving until the cause is identified and the attacks are either predictable, controlled or gone, and ask your doctor directly at the appointment when it is safe to restart, since the answer differs a great deal by cause. Check the terms of your driving licence and your insurance too, because some conditions have specific notification requirements. Once the cause is treated most people drive normally again, and for the commonest cause that can be within a week.
Will the spinning come back once it has been treated?
For the commonest cause, in which loose crystals have moved into the wrong part of the inner ear, one or two clinic sessions of head positioning clear it in the great majority of people, and a share do have it return months or years later. That is not a failure of the first treatment and the same manoeuvre works again, so go back instead of living with it. Other causes behave differently: inflammation of the balance nerve usually happens once and does not return, while some inner ear conditions run in clusters of attacks over years and are managed with medication and diet. Ask which of these you have, because the answer changes what to expect.
Other neurology treatments
Diagnosis and treatment of recurring headaches with features such as throbbing pain, nausea or sensitivity to light and sound
Day CareLong-term management of recurrent seizures with treatment tailored to seizure type and individual needs
Day CareTalk to a care coordinator about vertigo & balance disorders
Leave a number and a care coordinator calls you back with what the treatment involves and which hospital it would be at. They book a consult only if you want one