Author: Dr. Chris Cheung
What is Vertigo?
Vertigo is a common symptom of conditions/traumas most often associated with the head or neck. It is recognizable by a sense of dizziness as if the room is spinning around you and may present with nausea and/or vomiting. It can be brought on by trauma (e.g. a blow to the head or whiplash), severe colds or a virus, minor strokes, degeneration of the inner ear associated with ageing or the use of certain medications (i.e. ototoxic drugs).
The most common cause, known as Benign Paroxysmal Positional Vertigo (BPPV), refers to a form of vertigo which is not due to malignancy, has a sudden onset with short duration (seconds to minutes) and can be triggered by a change in head position. Within the inner ear are collections of calcium carbonate crystals referred to as “otoconia” or “otoliths” which may become dislodged from their normal position and migrate into the semicircular canals of the inner ear. As gravity acts upon this displaced debris, the abnormal fluid displacement creates the dizziness symptoms. The vast majority of the time the otoliths will be dislodged into the posterior canal and less than 20% of time will be dislodged into the horizontal canal. Occasionally, otoliths will be stuck in the anterior canal but this is usually transitory as the crystals migrate into another canal during treatment.
Fig. 921 Anatomy of the Right Osseous Labyrinth. Henry Gray. Anatomy of the Human Body. 1918.
What Else Could Be Behind My Vertigo?
Some other causes of vertigo include:
- Meniere’s disease (disorder of inner ear with ringing in ears, feeling of fullness/pressure within ear, and fluctuating hearing loss)
- Neurological disorders e.g. Multiple Sclerosis
- Motion Sickness (lack of coordination between visual stimuli, inner ear balance and positional sense)
- Labyrinthitis (inflammation of the fluid-filled tubes and sacs within the inner ear; may also be associated with changes in hearing)
- Vestibular neuritis (inflammation of the nerves associated with transmission of sensory info from the inner ear; usually of viral origins)
How it can be treated/cured?
While certain medications have been prescribed for vertigo including Lorazepam, Diazepam, Flunarizine, and Meclizine (for motion sickness), there exists no evidence to support a recommendation of any medication in the routine treatment of BPPV. Clinical trials have demonstrated that repositioning techniques (listed below) are a superior option for management (Fife et al., 2008).
The Epley is a simple series of positional changes which can help to reposition the debris (otoliths) within the inner ear. The initial direction of movement is dependent on which side you experience worsening of the vertigo. The Epley will reduce the dizziness experienced after the full series is completed and may require several repeats. The following are instructions for the Epley’s maneuver of a right-sided BPPV:
- From a seated position on a bed turn the head 45 degrees to the right. Have a pillow behind the body so that the shoulders are supported in the laying down position
- Lie back quickly with shoulders on the pillow and the head on the bed. Wait 30 seconds
- Turn the head 90 degrees to the other side (left) without raising it and wait for 30 seconds.
- Turn the head another 90 degrees while moving the body onto the left side and wait 30 seconds.
- Finally, swing the legs off the side of the bed and sit up without changing the head position.
Perform the Epley’s Maneuver 3 times a day and repeat the routine daily until free from positional vertigo for a 24 hour period.
For directions for a left-sided BPPV please see the modified instructions available at the following link:
Similar to the previous maneuver, the Semont is a series of movements aimed at decreasing the symptoms of vertigo. It should be noted that the Semont is not as effective as the Epley with a significant difference between the two procedures with the Epley showing 95% efficacy vs the Semont showing 58% efficacy (Radtke et al. 2004) To perform the Semont have a partner who can assist with the positional changes. Follow the link for a description of how to perform the procedure:
The Foster half-somersault is another maneuver which places the head in a similar series of head positions to the Epley. The half-somersault requires a bit more in terms of upper body strength and flexibility and may be more helpful in cases of BPPV of the anterior canal. Detailed instructions for the half somersault for BPPV can be found here:
Brandt Daroff Exercise
The Brandt Daroff exercise is a way of treating BPPV at home when it is unclear which side intensifies the vertigo. It is less often used as the Epley Maneuver is significantly more effective. It is recommended the exercise be performed for 5 repetitions (approximately 10 minutes) done 3 times a day. Most people will experience relief of symptoms in 2 weeks if 3 exercise sessions done per day or in 3 weeks if 2 sessions done daily. For further details on how to perform the Brandt Daroff exercise follow the link here: http://www.ncuh.nhs.uk/our-services/brandt-daroff-excercises-quick-guide.pdf
If the exercises listed here have not made a change in your vertigo symptoms it is recommended you speak to a health practitioner to have the exact cause determined and addressed. If the root of the symptoms are due to a problem within the neck, Chiropractic is a safe and effective form of treatment which may offer additional relief of the dizziness symptoms.
- Home Epley Handouts. Accessed at https://www.activator.com/wp-content/uploads/Home%20Epley%20Handouts.pdf
- Radtke A, Von Brevern M, Tiel-Wilck K, Mainz-Perchalla A, Neuhauser H, Lempert T. Self-treatment of benign positional vertigo: Semont maneuver vs. Epley procedure. Neurology 2004 Jul 13;63(1): 150-2.
- Fife TD, et al. (2008). Practice parameter: Therapies for benign paroxysmal positional vertigo (an evidence-based review). Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology, 70(22): 2067-2074.
- Foster CA, Ponnapan A, Zaccaro K, Strong D. A comparison of two hone exercises for benign positional vertigo: Half somersault versus Epley Maneuver. Audiol Neurotol Extra 2012;2: 16-23. Accessed online from https://www.karger.com/Article/FullText/337947
- Brandt and Daroff Exercise Guide. Accessed from http://www.ncuh.nhs.uk/our-services/brandt-daroff-excercises-quick-guide.pdf.
- Semont Maneuver for Vertigo. Accessed from http://www.webmd.com/a-to-z-guides/liberatory-maneuvers-for-vertigo-semont-maneuver.