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Vertigo: Getting the Right Diagnosis

by Health After 50

Have you ever turned your head and then had the world suddenly start to spin around you? This dizzying sensation can be both disconcerting and potentially dangerous. Losing your equilibrium could cause you to fall and fracture a bone.

If you’re an older adult, one likely reason for your dizziness is an inner-ear condition called benign paroxysmal positional vertigo (BPPV). The condition affects up to 10 percent of adults by the time they turn 80, according to researchers at the University of Connecticut Health Center in a review published in the Journal of the American Geriatrics Society. BPPV is responsible for about half the cases of dizziness in older adults.

As common as BPPV is, some primary care doctors may not immediately recognize the condition in older patients, and diagnosis may be delayed or missed, report the study’s authors. One reason is that dizziness can be caused by any number of conditions ranging from arrhythmia and heart disease to allergies and infections as well as other types of balance disorders, including those brought on by medication. Because of the wide range of possible causes, patients may go through a multitude of tests before a diagnosis is reached, thus delaying referral to a specialist. Some doctors may chalk up dizziness to aging or take a “wait-and-see” approach when vertigo occurs only occasionally and for short periods. Indeed, in some people vertigo may go away on its own. But many others with BPPV don’t get the treatment they need to relieve their symptoms, putting them at risk for a debilitating fall.

What is BPPV?

BPPV is a sensation that comes on suddenly with the feeling that you’re spinning even though you’re not actually turning. The word positional in its name refers to the fact that certain head positions can trigger the dizziness. Typically, the dizziness will come in episodes, triggered by movements like getting out of bed or turning your head. Each vertigo episode is quick, lasting a minute or less, but you might have several dizzy spells over a period of about two weeks. You might also have nausea along with vertigo. Symptoms can be a little different in people over 70, who tend to feel unsteady or off-balance rather than dizzy, which can also contribute to a delay in diagnosis.

Although BPPV isn’t life threatening, it can be life altering and profoundly affect one’s quality of life. The spinning sensation could potentially lead to loss of balance and falls, and since older adults are already more vulnerable to bone fractures, the risk of a fall might make a person fearful of going out and doing things. BPPV has also been associated with depression in older adults.

A crystal-clear cause?

BPPV stems from your vestibular system—structures inside your ear that help orient you and keep you balanced. This system includes three fluid-filled, semicircular canals lined with sensory hair cells that continually detect your head’s position. Sacs within this system contain calcium carbonate crystals called otoliths, which are embedded in a gel-like substance. These crystals help sense your body’s orientation to gravity as you move.

Age, injury, or other factors can dislodge the otoliths and cause them to float freely in the canals. In this setting, after you move your head, the momentum of the crystals in the canal may make them bump against the tiny hairs lining the canals. This creates a false sense of movement even after you have stopped turning your head. This combination gives you the sensation that you’re spinning.

Avoid a Vertigo-Related Fall

Having benign paroxysmal positional vertigo puts you at greater risk of falling. Follow these tips to prevent injury.

BPPV doesn’t always have a clear cause in people over 50. Most likely, age-related degeneration wears down and loosens the crystals. Women are more susceptible than men to BPPV. This type of vertigo has also been associated with long periods of bed rest during illness or after surgery. Conditions like Ménière’s disease and inner-ear infections (vestibular neuritis, herpes zoster oticus) can trigger BPPV. Or it can occur as a complication of sinus or ear surgery.

Diagnosis maneuvers

If your doctor suspects you have BPPV, he or she may try to set off your vertigo by performing a test called the Dix-Hallpike maneuver. Your doctor will turn your head, then have you lie on your side. He or she will look for rapid, involuntary back-and-forth eye movements—a condition called nystagmus—which are a sign of BPPV.

The Vestibular Disorders Association suggests that you have a better chance of getting an early diagnosis for the cause of your vertigo if you follow these recommendations when you visit your doctor:

  • Share as much medical information as you can with your doctor. Bring a list of all the prescription and over-the-counter drugs and supplements you take. Be prepared to provide your family’s medical history as well as your own. Note when your symptoms occur and what may make them improve or worsen, so you can accurately describe episodes to your doctor.
  • Ask questions. Speak up if you don’t understand something the doctor tells you. Ask the reasons for any tests. If your doctor chooses to watch and wait before making a diagnosis, ask why he or she has chosen this approach, especially if you’re experiencing bouts of dizziness that are troublesome and may make you lose your balance.
  • Seek a second opinion. Consider consulting a specialist in balance disorders, such as an otolaryngologist, a neurologist, an otologist, or a neuro-otologist.

Treating vertigo: the Epley maneuver

First-line treatment for BPPV is a repositioning maneuver involving a series of head movements that shift the crystals out of the semicircular canals into an open area where they can dissolve. The most effective repositioning procedure is the Epley maneuver, similar to the Dix-Hallpike maneuver used to diagnose BPPV. The Epley maneuver involves the following steps:

  1. Your doctor turns your head to the side while you’re seated on a table.
  2. He or she then quickly guides you to a lying position on your back with your neck extended off the table and your head still turned at 45 degrees. Moving to this position, in which you’ll remain for about 30 seconds, intentionally triggers vertigo and nystagmus.
  3. Your doctor then rotates your head in the opposite direction. You’ll stay in that position for another 30 seconds.
  4. The doctor rolls you onto your side with your head pointed to the ground at a 45-degree angle.
  5. After 30 seconds, you’ll sit up again.

Your doctor will repeat this sequence as many as five or six times until you no longer experience nystagmus. The Epley maneuver is safe and effective for most patients, but it can trigger temporary nausea, vomiting, and fainting. In about 6 to 7 percent of cases, the crystals may shift to the opposite ear canal.

People who are very frail or who have a neck or spinal injury or condition, certain vascular disorders, or a detached retina may not be good candidates for the procedure. If you’re unable to undergo the maneuver, your doctor may prescribe medications such as antihistamines, anticholinergics, and benzodiazepines. However, older adults need to be cautious about taking these drugs because of the risk for serious side effects like confusion and falls. Surgery is rarely used for BPPV, but it’s an option if other treatments haven’t worked. One procedure places bony plugs to block the part of your ears that’s causing vertigo.

Up to 37 percent of people with BPPV experience some mild residual dizziness for two to three weeks after undergoing the Epley maneuver. You’ll need to follow up with your doctor about one month after the procedure. If you’re still experiencing vertigo, your doctor may perform additional tests to look for another cause, since other central nervous system disorders may mimic BPPV. You should also call your doctor if you experience any hearing loss, vertigo not triggered by movement, changes in gait, nausea, or vomiting after BPPV symptoms have subsided.

The risk of BPPV recurring is about 15 percent. Your doctor may show you how to perform maneuvers on your own at home to help manage any future episodes.

When to Seek Emergency Help for Vertigo

Call 911 or visit the emergency room if you have any of these symptoms along with vertigo, which could signal a more serious problem.

This article was adapted from HealthAfter50.