Understanding vertigo and how to treat it

Treatments
Written By Timothy Morris

Vertigo is a specific type of dizziness that makes you feel like you are spinning or falling when you are still.

Specifically, Benign Paroxysmal Positional Vertigo (BPPV) is a prevalent vestibular disorder characterised by brief episodes of vertigo - sensations of spinning or dizziness - triggered by specific head movements.

This condition arises due to the displacement of otoconial debris (calcium carbonate crystals) from the utricle (a fluid-filled cavity in the inner ear) into the semicircular canals of the inner ear, leading to inappropriate stimulation during head movements. 

Symptoms of Benign Paroxysmal Positional Vertigo (BPPV)

Individuals with BPPV commonly experience the following symptoms:

  • Vertigo: sudden sensation of spinning or movement, typically lasting less than a minute.

  • Dizziness and light-headedness: feelings of unsteadiness or faintness.

  • Balance problems: difficulty maintaining stability, increasing the risk of falls.

  • Nausea and vomiting

  • Blurred vision

  • Nystagmus: rapid, involuntary eye movements, often observed during vertigo episodes.

Diagnosing BPPV: the role of the Dix-Hallpike manoeuvre

A primary method for diagnosing BPPV is the Dix-Hallpike manoeuvre - a positional test that provokes vertigo and associated nystagmus (involuntary eye movements) by rapidly moving the patient from a seated to a supine position with the head turned to one side.

A positive test elicits vertigo and a characteristic nystagmus pattern, confirming the diagnosis of posterior canal BPPV. 

Nystagmus: a key indicator in BPPV

Nystagmus is typified by rhythmic, involuntary eye movements, and is a critical sign in diagnosing and assessing BPPV.

These eye movements result from the inner ear's disrupted signals to the brain, leading to the sensation of vertigo.

During positional tests like the Dix-Hallpike manoeuvre, the presence, direction and duration of nystagmus provide valuable information about the affected semicircular canal and the severity of the condition.

For instance, a positive Dix-Hallpike test is indicated by the onset of vertigo and observable nystagmus when the patient's head is positioned to provoke symptoms.

The characteristics of nystagmus observed during diagnostic manoeuvres can help identify which semicircular canal is affected:

  • Posterior canal BPPV: typically presents with up-beating torsional nystagmus (eyes moving upwards and with a rotational component) during the Dix-Hallpike manoeuvre.

  • Horizontal canal BPPV: Characterised by horizontal nystagmus, which can be either geotropic (toward the ground) or apogeotropic (away from the ground) during head-turning tests.

This image depicts the semicircular canals in the inner ear where the otoconial debris from the utricle can move, resulting in vertigo. Image from Cleveland Clinic Journal of Medicine.

Observing nystagmus patterns during treatment manoeuvres like the Epley manoeuvre (more on that below) can also provide insights into treatment efficacy.

The presence or absence of nystagmus in specific positions during these manoeuvres may indicate the success of the repositioning procedure.

Treating BPPV: the Epley manoeuvre

The Epley manoeuvre, also known as the canalith repositioning procedure, is a widely recognised treatment for posterior canal BPPV.

This technique involves a series of specific head and body movements designed to guide the displaced otoconial debris from the semicircular canal back into the utricle, where they no longer provoke vertigo.

The Epley manoeuvre has been shown to be highly effective in treating BPPV.

Studies have reported that the Epley manoeuvre effectively resolves symptoms in a significant majority of patients, often after a single session. However, some individuals may require multiple sessions to achieve complete relief.

There are several positions involved in the Epley manoeuvre:

  1. The patient begins in an upright seated posture, with the legs extended and the head turned 45 degrees toward the affected ear.

  2. The patient is then quickly laid back into a supine position (lying on the back) with the head hanging slightly over the edge of the examination table, still turned 45 degrees toward the affected ear. This position is maintained for about 30 seconds.

  3. Next, the head is gently rotated 90 degrees to the opposite side, so the unaffected ear faces downward. This position is held for another 30 seconds.

  4. The patient then rolls onto their side in the direction they are facing, turning the head another 90 degrees so that they are looking downward at a 45-degree angle. This position is also maintained for 30 seconds.

  5. Finally, the patient is slowly brought back up to a seated position, completing the manoeuvre.

The Epley maneuver. Image from Cleveland Clinic.

While generally safe, the manoeuvre can induce temporary dizziness or nausea during the procedure.

Patients are often advised to avoid certain head positions for a short period after the treatment to prevent the otoconia from moving back into the semicircular canals.

Monitoring nystagmus during the Epley manoeuvre can offer insights into treatment efficacy.

For example, the presence of nystagmus in the fourth position of the Epley manoeuvre has been linked to a higher likelihood of requiring additional treatment sessions, whereas its absence may indicate successful repositioning.

At Form Osteopathy, we are specifically trained in diagnosing and treating BPPV using evidence-based techniques like the Dix-Hallpike manoeuvre and the Epley manoeuvre.

By thoroughly assessing nystagmus patterns and employing targeted repositioning strategies, we aim to alleviate vertigo symptoms effectively, enhancing our patients' quality of life.

We have had much success in treating vertigo through these techniques and encourage patients to come and see us for treatment if they are experiencing vertigo.



References:

Timothy Morris
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