Vertigo, the Disease
For up to 10 percent of the population—and close to half of people over the age of 40—vertigo is more than just an Alfred Hitchcock movie. A leading Westchester authority, Dr. Stephen Marks, attending neurologist at Westchester Medical Center/New York Medical College in Valhalla, discusses how to distinguish it from other types of dizziness, what causes the sensation, and why hands-on therapy is superior to drug treatment.
What is vertigo?
As distinct from lightheadedness or motion sickness, “vertigo usually involves the sensation of movement—tilting or leaning, rocking or spinning,” Dr. Marks says. “When I roll over in bed, the room spins” is the classic complaint among his vertigo patients.
What causes vertigo?
One GPS might suffice for our car, but the human body relies on three mechanisms to orient us in space: our vision, a joint-positioning system, and a vestibular system of balance, controlled centrally in the brain with ancillary equipment in the inner ear. “The vestibular system helps us find the appropriate response when the head moves or gravity’s relation to us changes,” Dr. Marks says. When something in this system goes awry, we experience vertigo. And, except in rare cases, vertigo has nothing to do with hearing.
“Evolution has coupled two very different systems in our inner ear—vestibular and hearing,” Dr. Marks explains. Each uses hair cells called cilia to process sounds or detect motion. The labyrinth translates head movements (front-to-back, side-to-side) into neural impulses for the brain to interpret. Those impulses enter the brain and “head upstairs” to the temporal lobe to help orient us in space, Dr. Marks explains. Most vertigo sufferers’ problems stem from malfunctions within this ear-to-brain connection.
The most common cause of vertigo—especially common among older patients, though not necessarily those with hearing deficits—are dislodged calcium crystals knocked off from their host cells into the fluid of the inner ear due to sudden head movements, head injury, viral infections, or nerve inflammation. After being dislodged in a head at rest, the labyrinth causes a barren input that the brain interprets as vertigo. A less common culprit, called Meniere’s disease, is due to a buildup of fluid in the inner-ear membrane that leads to hearing loss and vertigo. “Those canals and pouches in the inner ear are very vulnerable,” Dr. Marks says. “They’re tiny chambers packed with fluid and cells, so they’re easily affected by many differing insults.” Both benign positional vertigo and Meniere’s disease are instances of “peripheral” cases of vertigo, involving the inner-ear apparatus of the vestibular system. Vertigo that arises from the brain’s vestibular functions—such as constricted blood flow due to atherosclerosis, tumors, or trauma—are known as “central cases” of vertigo, which Dr. Marks says are far less symptomatic.
How can my vertigo be diagnosed and treated?
Your primary-care provider will likely refer you to a neurologist or otolaryngologist (ear, nose, and throat doctor). Like his colleagues, Dr. Marks employs a series of “provocative maneuvers” known collectively as the Dix-Hallpike test—the definitive diagnostic tool for vertigo: twisting and flipping the head to re-create dizziness and induce jerky eye movements called nystagmus. “If my patient says, ‘Doc, I’m dizzy,’ and you see his eyes jerk in all different directions, you know there’s a vestibular problem,” Dr. Marks says.
Right now, vertigo treatment is completing a paradigm shift away from drug treatment toward a more hands-on approach—literally. For years, Dr. Marks says, doctors would prescribe pills called Antivert (or, generically, meclizine), an antihistamine that blunts vestibular sensation. “We now know that just putting your inner ear to sleep is not the proper treatment; it delays quick recovery,” he says. “So we’re weaning patients off of Antivert and onto a new tactic to rehabilitate the inner ear—aggressively, if necessary.” That rehab involves doctors vigorously turning, rotating, and maneuvering a patient’s head to jostle those calcium crystals back into place. “The patient’s head is like a snow-globe,” Dr. Marks says. “If we tilt it one way, the crystal ‘snowflakes’ tumble into their rightful place in the ear.” Known as canalith repositioning maneuvers (“canalith” is another term for the calcium particles), they are performed in one office visit and reinforced at home—curing close to 90 percent of patients with benign positional vertigo. “It’s not quackery but legitimate science—and very gratifying,” Dr. Marks says.