Vertigo and Dizziness

Your vestibular system uses the fluid in your inner ears to detect movement of your head. Your vestibular nerves connect (synapse) in your brainstem with motor nerves that reflexively control eye movement. This reflex moves your eyes in response to head movement to maintain focus. This is called the vestibulo-ocular reflex, and it is one of the fastest reflexes in your body at 5—10 milliseconds (5—10/1000 of a second). This enables you to maintain a steady gaze on something while your head is moving, such as walking down the street or keeping your eyes on a ball while playing sport. Vestibular system disorders result in inaccurate information in your brainstem. This results in inaccurate reflexive eye movements. As a result your eyes move to the incorrect position. Your brainstem responds by quickly moving your eyes to where they should be focused. This is a quick jerking movement called nystagmus, and it is important for diagnosis. But your eyes then drift back to their previous position. As your eyes drift back the image of the environment moves across your visual field and across your retina. Your brain falsely perceives that the environment is moving when it isn’t. This is the false or distorted sense of motion responsible for vertigo. Episodes can last from seconds to several hours, depending on the cause. Head movement worsens vertigo because the brain is depending on the dysfunctional vestibular system to detect accurate head movement. Vertigo always involves your vestibular system.

Your brainstem plays an important role regulating your autonomic nervous system (ANS), which automatically and subconsciously manages many of your bodily functions. This includes your heart rate and digestion, and dilation or constriction of your pupils. Your vestibular system also communicates with your ANS. It is thought that this may be an evolutionary trait to protect us if we ingest something toxic. Vertigo signals part of your ANS (area postrema) to induce nausea and vomiting to expel an ingested toxin. Vestibular dysfunction causes the brainstem to respond with nausea and vomiting, even if nothing toxic has been ingested.

Your vestibular nerves in your brainstem send sensory information to other parts of your brainstem called the reticular formation and the parabrachial nucleus. These areas forward neural information to a part of your sympathetic nervous system that is located in your thoracic spinal cord (the sympathetic nervous system is the part of your ANS that is responsible for fight, flight or freeze). This part of your sympathetic nervous system innervates your heart and lungs, as well as your gastrointestinal tract (GIT). These signals can initiate nausea and vomiting. A sensory mismatch between visual, vestibular and proprioceptive systems can affect this part of your brainstem, resulting in abnormal sympathetic nervous system responses and associated cardiovascular and GIT symptoms, such as nausea and vomiting.

There are many causes, including infections, medications, low blood pressure to the brain, low blood sugar levels, and dehydration. Low blood pressure to your brain (also known as orthostatic hypotension) usually occurs when you stand up quickly from sitting or lying down. It is commonly described as lightheadedness or presyncope. Perfusion to your brain is monitored by your autonomic nervous system, medulla oblongata (part of your brainstem) and hypothalamus. These can dilate or constrict blood vessels, as well as control heart rate to increase of decrease blood pressure. As we get older these systems can sometimes slow down, resulting in a brief episode of lightheadedness or presyncope. Likewise, these symptoms can be caused by problems with your cardiovascular system. Some medications can also affect the function of these systems, such as diuretics, hypotensives (to lower blood pressure) and sedatives. Dehydration can lower your blood plasma volume, causing a drop in blood pressure. There are many types of anaemia, but all result in reduced oxygen supply to your brain. Low blood sugar can also cause these symptoms because the neurons in your brain require huge amounts of glucose to function.

A common musculoskeletal cause is cervicogenic dizziness. This is due to pain or dysfunction that impairs muscles, ligaments and joints in your neck. The highest concentration of proprioceptors exists in your ankles, because walking around on 2 feet is notoriously unstable. The 2nd highest concentration is found in your upper neck. Dizziness can result when your brain receives inaccurate proprioception from these tissues in your neck. This leads to an inaccurate sense of head positioning relative to your trunk. It also causes a sensory mismatch with your visual and vestibular systems. The result is a false or distorted sense of your spatial orientation, resulting in a sense of unsteadiness or imbalance. Your brain uses proprioception to co-ordinate muscle activation sequences to maintain balance and stability, and to co-ordinate movements of your whole body. When your brain receives incorrect information from proprioceptors it can’t accurately control movement, posture and stability. Normally, milliseconds before you move, your central nervous system (CNS) stabilises your body by activating the muscles necessary to stabilise your spine and other parts of your body, such as your shoulders. Pain or dysfunction impairs your CNS’s ability to stabilise your spine or shoulders before moving. This is one of the causes of injuries that causes low back or neck pain, and shoulder injuries. So why does this cause dizziness, but not vertigo? Proprioceptive system dysfunction doesn’t cause vertigo. This is because the vestibular system is still functioning correctly and the vestibulo-ocular reflex hasn’t been affected. This is why there is no false or distorted sense of motion.

This is the most common musculoskeletal cause of dizziness. Its cause is dysfunction of your neck, right below the base of your skull. The joints, muscles and tendons in your upper neck, between your skull and the top 2 vertebrae in your neck (C1 and C2) contain specialised sensory nerves called proprioceptors. Your upper neck has the 2nd highest concentration of these nerves, which tells us how important proprioception of your head and neck is. These signal your brain the accurate movement or position of your head relative to your trunk. Your brain uses this information to stabilise and accurately move your head, as well as the rest of your body. It does this by controlling and sequencing muscle activity to maintain posture, balance and controlled accurate movements of your body relative to your head. Dysfunction of your neck results in inaccurate proprioception. When this information doesn’t match vestibular and visual information it results in a sensory mismatch, poor stabilisation and inaccurate and poorly controlled movements. You perceive this as dizziness and unsteadiness.

• neck trauma such as whiplash or sports injuries
• joint or ligament sprains in the neck
• muscle strains in the neck
• disc injury in the cervical spine
• inflammation
• degeneration or arthritis of cervical joints
• muscle fatigue or spasm
• neck pain

• worsens with neck movement or prolonged postures
• usually occurs after neck pain
• associated with a tight or stiff neck that restricts movement
• associated with disorientation
• associated with unsteadiness
• episodes last minutes to hours, but can persist for weeks, months or even years following trauma
• recurring over days, months or years
• accompanied by cervicogenic or tension-type headaches

Your practitioner will take a detailed history and perform a physical examination to help rule out other causes of dizziness. They will perform a physical examination of your musculoskeletal, nervous, and cardiovascular systems, including checking your blood pressure and cardiac auscultation (checking your heart function with a stethoscope) to help rule out other causes of your signs or symptoms, and may also perform orthopaedic and neurologic exams. They will assess your posture and movements, including other areas of your body that can affect your kinetic chain, looking for painful or dysfunctional postures and movements. They may also perform orthopaedic and neurologic exams, and check neurologic and vascular structures in your neck that may be affected. There are no blood tests or imaging biomarkers that are useful for diagnosing dizziness, unless there is an underlying clinical suspicion of a pathological cause, such as trauma, anaemia or infection, in which case you may be referred for imaging, such as x-rays, CT scans or MRI, or for blood tests. Fortunately, most causes are benign and not due to a sinister pathology. It is important that your healthcare professional accurately diagnoses the cause of your signs and symptoms because the treatments for the different causes of dizziness and vertigo require different treatments and rehabilitation exercises.

You will be given a diagnosis, and presented with recommended treatment options. The recommended treatments will be tailored specifically to your neck, and will be discussed with you so that you are comfortable with the treatment approach. Manipulation (also called adjustment) may be recommended, but if you are not comfortable with this then other techniques can be used.

Research shows that cervicogenic dizziness responds well to manual treatments and exercises, such as joint manipulation (adjustments), mobilisation, dry needling, soft tissue treatments, muscle energy and neuromuscular inhibition techniques, and stretches. The treatments and exercises aim to reduce tight muscles, stretch short muscles, and strengthen weakened muscles or muscles that need more endurance. The treatments and exercises will also strengthen muscles essential to neck and head stabilisation, and restore correct and accurate movement to joints that are not moving correctly.

Your brain controls balance, posture and co-ordinated movements. It relies on accurate sensory input from the nerves in your upper neck to do this. The same problems that can cause cervicogenic dizziness can also cause unsteadiness and imbalance, and clumsiness due to poor movement control. If these signs and symptoms are also present they will be addressed with treatments and exercises specifically tailored to you.

Dizziness doesn’t only affect the parts of your brain associated with stabilisation and movement. It can also affect other areas that regulate your emotions and mood, cognition (your ability to concentrate and remember things) and your social and professional interactions. Every person is different — it affects some people more than others. This is known as the biopsychosocial framework, which considers the biological, psychological and social effects of dizziness on you, as a whole person. This is also taken into account with your treatments.

Analgesic (painkiller), anti-inflammatory and anti-nausea medications have a mixed track record, working for some but not others. Importantly, medications won’t fix your underlying functional, stability, postural or proprioceptive problems. They only mask the symptoms. Medications are commonly prescribed to reduce nausea, but they can also suppress some neural functions. While this can reduce troubling symptoms, it can suppress signs and symptoms important for accurate diagnosis. Pharmaceuticals do not correct a sensory mismatch or neck dysfunction. They do not retrain proprioception or central nervous system function. They may even make diagnosis more difficult because they suppress signs and symptoms that are important in clinical diagnosis. Unfortunately, this may prolong your recovery. If a musculoskeletal cause is diagnosed, rehabilitation exercises and stretches are prescribed specifically tailored to you, and the problem with your neck. You will also be given occupational and lifestyle strategies. All of these are designed to improve the function of your neck, and reduce the probability of recurrence.

Treatments are focussed on the underlying cause and not simply providing short-term relief. Many people are back to normal within a few treatments. The research, and experience shows that other people may take up to 12 weeks. This is common if the underlying cause has been present for a long time, or there has been a delay in seeking treatment. It is important to seek treatment early. If treatment is delayed, or signs and symptoms are suppressed with pharmaceutical drugs, treatment and rehabilitation will usually take longer because adaptations (compensations) will have started within 1 week. Strengthening and retraining muscles and restoring correct, accurate function to the neck takes time. There are no quick fixes. We will always recommend treatment and exercises that are specifically tailored to you and your needs, with the aim of getting long-term, lasting results for you.

You can book an appointment online or call The Headache and Neck Pain Clinic today to make an appointment.

You can also download the Dizziness and Vertigo Questionnaire here.

This is the most common cause of recurrent vertigo. It affects your vestibular system, which relies on the fluid in your inner ears to inform your brain about the position and movement of your head. It causes one-third of all vestibular disorders. It affects 2.4% of the population, or about 625,000 Australians. Women are afflicted 3.2 times more than men, usually during their 40s and 50s, whereas it can affect men at any age. It is benign (as the name suggests), and not caused by a sinister pathology. The most common cause in people under 50 years of age is mild head trauma or whiplash.

Your vestibular system monitors the movement and position of your head in space. The semicircular canals in your inner ears form your vestibular organs. These canals contain hair-like nerves that move within fluid when you move your head. These hairs have small calcium crystal weights on their tips. These crystals can dislodge and float around in the fluid. When they bump into a hair-like nerve, that nerve will then send a false signal to your brainstem about movement or position of your head that is not occurring. Your brainstem normally uses this information to co-ordinate accurate head and eye movements via the vestibulo-ocular reflex. This incorrect information doesn’t match the incoming information from your eyes or proprioceptors, leading to a sensory mismatch. Your vestibulo-ocular reflex now positions your eyes incorrectly, based on the incorrect information received from your vestibular system. Your brainstem attempts to correct this by redirecting your gaze to where it should be. Your eyes move quickly, visible as rapid repetitive jerking movements called nystagmus. Your eyes then slowly drift back to their previous inaccurate position before the nystagmus repeats. Your visual system doesn’t process visual information from very rapid eye movements, but it does process visual information from slower movements. As your eyes slowly reposition, the image of the environment slowly moves across your visual field, across your retinas at the back of your eyes. This creates the perception of the environment slowly moving across your visual field, like you are turning, or the environment is spinning. However, your brain receives proprioceptive information that you are not moving, like your vision suggests, creating a sensory mismatch. This is the false sense of movement associated with vertigo, when there is no actual movement occurring. BPPV vertigo episodes last less than 1 minute, usually less than 30 seconds, depending on the part of the vestibular organ that is affected. The duration of the episode is important for diagnosis, as well as movements or positions that trigger an episode. Your brain also relies on this information to control posture, stability, balance and movement. This is why you may fall or bump into things with vertigo.

Some factors increase the risk of BPPV:

• head trauma
• advancing age
• female
• physical inactivity, such as bed rest
• low body mass index (BMI)
• ear disease or infection
• migraine
• diseases of the blood vessels that perfuse your brain (cerebrovascular disease)
• anxiety
• genetic factors
• osteoporosis and osteopenia
• diabetes mellitus type I
• low vitamin D status

BPPV occurs when you move your head in a specific direction (positional vertigo, as the name suggests). The offending direction depends on which semicircular canal is affected. It most commonly affects the posterior semicircular canal. Most BPPV vertigo occurs when you roll over in bed, or get up out of bed. It can also occur when you look up or bend forward. Vertigo begins 2–10 seconds after moving your head in the offending direction. The episode lasts less than 1 minute, usually about 20 seconds, but this depends on the part of the vestibular organ that is affected.

Symptoms include:

• poor balance or a sensation of tilting to the affected side
• difficulty walking
• vertigo
• visual disturbances such as blurred or jumping vision
• headache
• increased sensitivity to widespread pain
• lightheadedness
• nausea
• tinnitus

Your practitioner will take a detailed history and perform a physical examination to help rule out other causes of vertigo. They will perform a physical examination of your musculoskeletal, nervous, and cardiovascular systems, including checking your blood pressure and cardiac auscultation (checking your heart function with a stethoscope) to help rule out other causes of your signs or symptoms, and may also perform orthopaedic and neurologic exams. They may also perform orthopaedic and neurologic exams, and check neurologic and vascular structures in your neck that may be affected. There are no blood tests or imaging biomarkers that are useful for diagnosing vertigo, unless there is an underlying clinical suspicion of a pathological cause, such as trauma or infection, in which case you may be referred for imaging, such as x-rays, CT scans or MRI, or for blood tests. Fortunately, most causes of vertigo are benign and not due to a sinister pathology. It is important that your healthcare professional accurately diagnoses the cause of your signs and symptoms because the treatments for the different causes of dizziness and vertigo require different treatments and rehabilitation exercises.

You will be given a diagnosis, and presented with recommended treatment options. The recommended treatments will be tailored specifically to you, and will be discussed with you so that you are comfortable with the treatment approach. Manipulation (also called adjustment) may be recommended, but if you are not comfortable with this then other techniques can be used.

Research shows that BPPV responds well to manual treatments and exercises. Specific gentle techniques are used to clear the free-floating crystals out of the canals of your vestibular organ. These are called canalith repositioning manoeuvres, and differ according to the affected semicircular canal. Studies show that 80-90% of BPPV resolves with these manoeuvres. When there is a problem with your vestibular system your brain will increase reliance on your visual and proprioceptive systems. This compensation occurs within days. Other supportive manual treatments may be recommended, such as joint manipulation (adjustments), mobilisation, dry needling, soft tissue treatments, muscle energy and neuromuscular inhibition techniques, and stretches. The treatments and exercises aim to restore correct function to your vestibular system, so that you are no longer affected by vertigo.

Vertigo doesn’t only affect the parts of your brain associated with stabilisation and movement. It can also affect other areas that regulate your emotions and mood, cognition (your ability to concentrate and remember things) and your confidence to engage in social and professional interactions. Every person is different — it affects some people more than others. This is known as the biopsychosocial framework, which considers the biological, psychological and social effects of vertigo on you, as a whole person. This is also taken into account with your treatments.

Vestibular suppressant and anti-nausea medications have a mixed track record, working for some but not others. Importantly, medications won’t fix BPPV; they only mask the symptoms. Medications are commonly prescribed to reduce nausea and anxiety, but they can also suppress some neural functions if they are used for longer than a few days. While this can reduce troubling symptoms, it can suppress signs and symptoms important for accurate diagnosis. Pharmaceuticals do not clear free-floating calcium crystals out of your semicircular canals. They may even make diagnosis more difficult because they suppress signs and symptoms that are important in clinical diagnosis. Unfortunately, this may prolong your recovery. Once BPPV is diagnosed, and the affected semicircular canal has been identified, rehabilitation exercises are prescribed specifically tailored to you, and the problem with your affected semicircular canal. You will also be given occupational and lifestyle strategies. All of these are designed to reduce the probability of recurrence.

Treatments are focussed on the underlying cause and not simply providing short-term relief. Many people are back to normal within a few treatments. It is important to seek treatment early. If treatment is delayed, or signs and symptoms are suppressed with pharmaceutical drugs, treatment and rehabilitation will usually take longer because adaptations (compensations) will have started within 1 week. We will always recommend treatment and exercises that are specifically tailored to you and your needs, with the aim of getting long-term, lasting results for you.

You can book an appointment online or call The Headache and Neck Pain Clinic today to make an appointment.

You can also download the Dizziness and Vertigo Questionnaire here.