Dizziness and vertigo are both symptoms of many physical health disorders, most frequently vestibular disorders.
The words dizziness and vertigo are given many definitions by doctors and patients alike, however they are not the same thing, and do have specific definitions. So, what is the difference between dizziness and vertigo?
The difference between dizziness and vertigo is in their definitions; they have distinct differences and it’s important that we distinguish one from the other. The distinctions are important to help your clinicians understand how you are feeling, and to make sure you have an accurate diagnosis.
Dizziness is an umbrella term. Dizziness can subjectively mean anything from lightheadedness and unsteadiness, to imbalance or vertigo. Dizziness needs to be broken down into what you are feeling more specifically, you should use your own terms to define how you are feeling. Many of my patients are at first nervous to describe how they’re feeling as the words they’re using dont sound ‘medical enough’. However, those non-medical terms are exactly what I am looking for in a description of your symptoms. Your Vestibular Therapist and other providers want to know if you feel like you have a hot air balloon in your head, if you’re floating, or bouncing.
On the other hand, vertigo is the incorrect perception that you, or the room around you, are moving. This can feel like spinning, bobbing, swaying, or whirling. Vertigo is commonly associated with a few different diagnoses, just like dizziness is associated with other diagnoses. Vertigo, although it is under the dizzy-umbrella, is not most of the symptoms of dizziness. Vertigo is NOT: lightheadedness, fogginess, imbalance, or feeling like you have a hot air balloon in your head. Vertigo is the false perception of movement.
Vertigo is a symptom, not a diagnosis. If you leave the doctor, emergency department, or other provider’s office and have received the diagnosis “you have vertigo,” do your best to ask more questions. You cannot just have vertigo, you must have another condition that is causing the vertigo. The most common diagnoses that cause vertigo are: Benign Paroxysmal Positional Vertigo, Vestibular Neuritis, Vestibular Migraine, and Meniere’s Disease. There are a few other causes of Vertigo, such as stroke, head injury, and tumors. These are less frequent, but should be ruled out for safety reasons.
Dizziness and vertigo are typically caused by vestibular dysfunction, and it’s important for your doctor and healthcare team to recognize this and treat you appropriately. Seeking a vestibular diagnosis further than “you have vertigo” with an unknown cause, it so important to getting proper diagnosis and treatment for your vestibular disorder.
Migraine and Vestibular Migraine can be reduced and managed naturally with vitamins, minerals, diet, and exercise! People often ask me which vitamin deficiencies cause migraine and if you should be tested. Although your doctor can test you, that’s not a requirement as most people with migraine do have issues with these deficiencies in most research. These vitamins include Magnesium, CoQ10, D3, Riiboflavin (B2), and Omegas!
Natural migraine treatments can be paired with your medical treatment, however, be sure you tell your doctor what you’re taking as some vitamins for migraine can have an impact on your prescription medication – there are always options, so its best to be safe!. Some people use natural migraine treatment alone, without the need for Here’s a list of vitamins and other accessible over-the-counter treatments you can try. As always, ask your doctor before you change or add anything to your treatment plan!
The most common supplements for Vestibular Migraineurs are CoQ10, Magnesium, and Riboflavin (B2). Some supplements, like Migralief have all 3 combined, which makes remembering to take it easier. However, sometimes just because it’s easier doesn’t mean it’s better – some of my patients have been very successful with taking Migralief, but others have needed to take each one separately for multiple reasons.
Magnesium has so many purposes in our bodies. It helps with mental clarity, digestion, nerve function, blood sugar, and more! Taking keeping magnesium available in your body for use is called bioavailability. Different kinds of magnesium supplements help with different difficulties you may have related to migraine
Magnesium glycinate is used for mental clarity and digestive health, without causing digestive issues or a crash at the end of the day. Glycinate is an amino acid that your body uses to fight inflammation and improve sleep. Magnesium glycinate also occurs in foods such as meat, dairy, and legumes. Since those on a Migraine Diet or Heal Your Headache diet may be avoiding most dairy and some legumes, glycinate may be lacking in your diet. It’s important we have all the necessary amino acids in our diets, so a magnesium glycinate supplement may be a great idea for you!
Magnesium L-Threonate is when we combine threonic acid and magnesium. This form of magnesium is a formed to be easily digestible and is great for mental clarity. Studies have shown that it helped promote learning and memory, and helped prevent memory decline. Threonate is already present in some level in our cerebrospinal fluid, and the presence of extra in neuronal cultures “increased functional synapse density” (2). Really good Magnesium Threonate, like the kind form Pure Encapsulations, is really hard to come by. If you can’t find it from Pure Encapsulations on Amazon, they have another show online here.
Magnesium Citrate is often used for treating digestive issues, such as constipation. Magnesium citrate is the most available form of magnesium – this is the kind of magnesium that you find generically in stores. This form of magnesium is also commonly found in powder form. If you have trouble with the bathroom in general and are a person who deals with chronic constipation it might be good to take Magnesium Citrate. However, if you do not, be more cautious about this – you might spend a little extra time in the bathroom than you had intended if you take Magnesium Citrate.
Coenzyme Q10, or CoQ10, for migraine is used for preventing oxidative change in your brain. Migraine Brains hate change – so preventing large changes in oxidative stressors within your brain will help decrease the number of migraines in your life. CoQ10 helps support mitochondria by creating adenosine triphosphate, which helps us with energy (3, 4). Some studies have shown that CoQ10 can help with episodic migraine prevention up to 15 episodes per month. CoQ10 is made by Pure Encapsulations, like Magnesium, in pill form which is of high quality. It is also in chewable gummies made by NOW Supplements which patients have reported is effective as well.
Riboflavin, which is a form of B2 vitamin, is effective in preventing migraine (5). Migraineurs are frequently B2 deficient, so supplementing your body this vitamin can be incredibly helpful in migraine prevention. Riboflavin is generally well tolerated, affordable, and will likely make you feel better. In the study, of people who took Riboflavin for the 3 month trial, 59% reported decrease in migraine symptoms by at least 50%. Riboflavin is useful in brain function, skin cell production, gut/digestive lining, and more. People who have migraine are typically deficient in B2, so it’s a good idea to supplement it into your diet. B2 can be found in eggs, milk, meat, nuts, enriched flour, and more If you do not tolerate these foods well, especially if you’re on a strict migraine diet, it could be a good idea to supplement it in vitamin form instead of trying to eat enough throughout your day. The typical dose is 400mg/day for at least 3 months, but as always, ask your doctor for more information!
It is significant, however, that riboflavin has been shown to interact with some medications like antidepressants and some cancer drugs, so be sure to check with your doctor first!
A new study found that having more omega-3’s than omega-6’s is helpful for preventing pain and migraine frequency/days. We have two main forms of Omega-fatty-acids in our bodies. The first is Omega-6 and the second is Omega-3. Omega-3 has long been known to be healthier and better to have more of in your body. You can find it in avocados, fatty fish, and other nutrient-rich foods. Its other form is Omega-6, and is known not to be as healthy. This study found that increasing the number of Omega-3’s a person had, without doing any alteration of Omega-6, decreased headache frequency. Both Omege-3 and -6 are not synthesized internally, meaning that we have to eat them to get them in our bodies, or we have to supplement them or eat them!
New research shows that melatonin could be very helpful in treating vestibular dysfunction. MT1 receptors interact with melatonin, and are found all over the same parts of the brain that the vestibular system is! This study says “melatonin has been proposed as a prophylactic agent in the prevention of migraine attacks, a condition that can be associated with vertigo” (8). This study also states that in animal models melatonin has been found that it can be otoprotective (protective for the ear). 3mg was taken daily during this study, and it should be taken at night before you go to bed. This way you can not feel extra sleepy during the day.
Vitamin D3 can be helpful in preventing vestibular migraine, but the mechanism is not clear. There is not a lot of evidence to recommend it to all patients with migraine or vestibular migraine, but it’s great to ask your doctor if it’s a good fit for you. Many people are vitamin D3 deficient, especially with migraine. There is some evidence to show that there is a decrease in migraine frequency and pain when vitamin D3 is supplemented. This is especially important when it is not sunny outside, or if you live in a particularly foggy place! We get D3 via UV waves, but if we don’t live in a sunny place, or you live in a house/apartment without a lot of light, it’s important to find a way to get it in. Supplementation is frequently the answer here!
(5) Schoenen J, Jacquy J, Lenaerts M. Effectiveness of high-dose riboflavin in migraine prophylaxis. A randomized controlled trial. Neurology. 1998 Feb;50(2):466-70. doi: 10.1212/wnl.50.2.466. PMID: 9484373
(6)Wolff, A. (2020, April 5). The Best Magnesium Supplements for Migraine. The Dizzy Cook. https://thedizzycook.com/magnesium-supplements-explained-which-one-is-best-for-vestibular-migraine/
(7) Ramsden, C. E., Zamora, D., Faurot, K. R., MacIntosh, B., Horowitz, M., Keyes, G. S., Yuan, Z.-X., Miller, V., Lynch, C., Honvoh, G., Park, J., Levy, R., Domenichiello, A. F., Johnston, A., Majchrzak-Hong, S., Hibbeln, J. R., Barrow, D. A., Loewke, J., Davis, J. M., … Mann, J. D. (2021, July 1). Dietary alteration of N-3 and N-6 fatty acids for headache reduction in adults with migraine: Randomized controlled trial. The BMJ. Retrieved October 5, 2021, from https://www.bmj.com/content/374/bmj.n1448
(8) Joaquin Guerra, Jesus Devesa, “Melatonin Exerts Anti-Inflammatory, Antioxidant, and Neuromodulatory Effects That Could Potentially Be Useful in the Treatment of Vertigo“, International Journal of Otolaryngology, vol. 2021, Article ID 6641055, 6 pages, 2021. https://doi.org/10.1155/2021/6641055
(9) Nowaczewska M, Wiciński M, Osiński S, Kaźmierczak H. The Role of Vitamin D in Primary Headache-from Potential Mechanism to Treatment. Nutrients. 2020;12(1):243. Published 2020 Jan 17. doi:10.3390/nu12010243
Learning to live with Vestibular Migraine is a life-long process, but tips and tricks from those with Vestibular or other forms Migraine can be so helpful. However, it is sometimes hard to find an all inclusive list of things that people have found helpful in the past. This is a list, which will be continually updated, containing items that patients have found to be helpful!
The Allay lamp’s intention is to decrease migraine triggers by emitting a calming green light that is proven to decrease photophobia, anxiety, and stress. We know that there are many wavelengths of light, which make up the whole world of colors, but for those with Migraine most of those lights are intolerable. Wearing migraine glasses is one solution, but another is to use this lamp. This lamp triggers small electrical responses in your brain, instead of large electrical signals that most bands of light cause. You can dim it, place a shade on one side for decreased light overall, or change it to a whiter light that is still soothing.
Migraine Glasses
There are so many pairs of glasses my patients have found to be helpful. Migraine glasses are intended to block blue light, in addition to yellow and other waves of light. Blue light ranges from 400-750nanometers. Because it is such a wide range, different kinds of blue lights are more and less problematic for your migraine and related symptoms. Some blue light glasses block only some parts of the blue light spectrum, even the parts that are good for you. Blue light around 460-500nm is actually healthy – we use blue light to monitor our melatonin levels, which affects our sleep-wake-cycle. Blue light can even be used to treat Seasonal Affective disorder. Blue light below 430nm is the “bad” blue light. The intention for a good pair of blue light blocking glasses is to block the blue light under 430nm. Special migraine glasses, like Theraspecs and Migraine Shields, and AxonOptics glasses do just that!
Theraspecs are the pair of glasses I let patients use in the clinic. I really like them as the pink hue from the FL-41 glasses are soothing for many of my patients, and they were created by a person in the Migraine Community. According to their website, TheraSpecs wearers experience 74% fewer migraine attacks on average per month, which for people with photophobia (light sensitivity) will make a huge difference. Even if you aren’t sensitive to light, Theraspecs will make a difference!
Theraspecs work to block the harmful blue light waves, provide wrap around protection of your eyes, and focus on blocking blue light the most at 480nm, the most aggravating wavelength for those with Migraine.
Migraine Shields are the best pair of glasses if you don’t want any color distortion in your vision. Most migraine glasses have FL-41 lenses, which are tinted pink – Migraine Shields uses a slightly different technology and aren’t tinted pink. These are great for work environments, using the computer, or choosing anything where color might be important. Migraine Shields do not come in a large enough size to fit over other glasses if you have a prescription! However, Migraine Shields have just released readers. These readers come in many shapes, sizes, and are so much cuter than the ones you find at the drugstore – these really multitask and are SO helpful!
AxonOptics are also a great option for Migraine relief. They are not too pink, lightweight, and come in three different tints. AxonOptics glasses have three tints for three intentions: indoor, outdoor, and transitional. Transitional lenses take a little longer to make, and they are a little more expensive. However, if you are going to purchase 2 pairs anyway, it may be worth it.
Research has found that FL-41 lenses need to be specifically made for people with light sensitivity. AxonOptics creased their specific glasses for Migraine by crafting a lens that is consistent, effective, and a nice color. Additionally AxonOptics has a plethora of frames you can choose from, and an option for contact lenses.
These can also be in the form of prescription eye glasses – if you’d like them to fill your prescription they can do that so you can still be working with these on!
Why Not Just Wear Sunglasses?
Sunglasses, while they may provide relief for your migraine in the moment, block too much light. If light is a trigger for you already, you don’t want to make it an even bigger trigger than it is already. When you wear sunglasses all day, inside and outside, it blocks many wavelengths of light, not just those in the blue light spectrum which work to block the provocative forms of blue light. If you block many kinds of light, not just the ones that typically affect migraine, you may end up sensitizing yourself too all light, making your triggers worse!
The headache hat is a tool you can use to soothe the headache part of your Vestibular Migraine, if you have them. I have found that patients in the middle of an attack will get their headache hat from the freezer, and feel at lease some relief. I would put the entire thing in the freezer, so you don’t have to deal with putting it together when you’re in the middle of a Migraine attack. It’s an easy, natural, way to give yourself a little relief.
Imperfect Foods is a weekly delivery of produce, meat, dairy, and snacks that is completely customized to your liking. You can choose what you’d like to go into the box, and they’ll deliver it to you on a set day for your whole neighborhood. I love Imperfect Foods, as they deliver the food that would normally be thrown out by grocery stores – your produce sometimes looks funny or misshapen, but is perfectly consumable!
They have options for organic or non-organic, and many other fun products that will make your life easier for when you really don’t want to go to the grocery store!
Ritual Zero Proof is a whiskey, tequila, or gin alternative that tastes like the real thing, but without the alcohol! It really does taste like the real thing, but has no alcohol, no hangover, and no migraine! This was started by three people who do drink but wanted an additional way to enjoy a cocktail that wouldn’t give them the tipsy feeling. Although not intended for a vestibular migraine diet, it fits perfectly into your lifestyle!
Sulfites and histamines can be part of your trigger load. Because wine, and other food & beverage categories, can contain quite a few sulfites finding ways to avoid, or remove, the sulfites is helpful! PureWine Wands remove the sulfites from the wine, which are produced by the grape skins during fermentation, and naturally occur in almost all, if not all wines. Removing these will help, but make sure you follow the directions as they do have to sit for a while to be effective.
There are a few books that Migraine patients should read, whether you have Vestibular Migraine or another kind of migraine. These will all help you understand Migraine and how to manage your symptoms
This book is by well-known neuro-otologist, Dr. Shin Beh. He goes through the steps from finding out you have Vestibular Migraine to learning what to do next in order to manage your Vestibular Migraine symptoms. This is an absolute must-read for all vestibular migraine patients – either if you have a new diagnosis or you’ve been managing your symptoms for a long time.
This was the first Migraine book I read when I started treating patients with Migraine. It really helped me understand the vastness of triggers a person can have, how to manage the symptoms, and what a migraine actually is. It’s around 300 pages, but it’s a quick read and it has charts in the back to help you analyze your migraine!
This book will give you a step-by-step guide for dietary recommendations for migraine and vestibular migraine. It will take you through the elimination and reintroduction of foods into your diet for a successful migraine lifestyle!
This is a short list of many Vestibular Migraine Hacks that will help make your lives easier! Check back soon for more helpful products and tips as this list grows!
Let’s talk about being dizzy!
Everyone has probably been dizzy at some point, whether you spun around in a circle too many times, or stood up too quickly, you might know what it feels like to be dizzy! Dizziness has many causes, one of the causes is vestibular, but the feeling of being dizzy is not always an inner ear issue. In reality, it is a a big umbrella term for many different symptoms that present themselves and make you feel differently than you are used to. Because there are so many causes of dizziness, it’s important that your provider understands how you are feeling, when you’re having the sensation, and how long it’s lasting. Dizziness symptoms can be present when someone has low blood pressure, a racing heart, or if you are dehydrated. Those are just a few of the many examples that are not vestibular that could be causing your symptoms. It is for this reason that doctors often have so much trouble with finding the answer to why you specifically are dizzy.
Whether you experience vertigo, spinning, dizziness, lightheadedness, or feel like your head is a hot air balloon, your experience is real and valid. Simultaneously, it is very important to put a name on your specific feelings. Most of your diagnosis will likely come from your subjective feelings – whether you’re swaying, lightheaded, or spinning, your doctor will use this description to help provide you with a diagnosis.
I sometimes find that my patients and clients caveat their symptoms with “I don’t have a good word for this, it’s almost like I am _____” and insert a descriptor like ‘cotton candy headed’. This description is not wrong. All people have different descriptions of dizziness and vertigo because no two people are exactly alike. Your specific description and experience should be incredibly important to you and your healthcare provider in order to come to a diagnosis. The ability to illustrate your specific symptoms will help a healthcare provider determine the best form of treatment for you specifically.
Although vertigo and dizziness can be incredibly frustrating, and hard to describe, there is comfort in the fact that vestibular dizziness can be treated through physical therapy and other healthcare avenues. The description, even though it may feel impossible to describe, is very important to your PT. If you feel like you absolutely can’t put a word on it, say that. Tell your provider that it feels impossible, or lightheaded, or like you’re floating. This will help us determine if you have BPPV, a form of Endolymphatic Hydrops, Vestibular Neuritis, or another vestibular dysfunction. No matter the kind of dysfunction, the ability for your physical therapist to reproduce your symptoms of the most important part of treatment. It is likely that during your evaluation you will be dizzy for a portion of the time. This is normal, but if you are know you’re prone to excessive dizziness and discomfort, bring someone to your appointment to help you get home.
Time is another very important factor in dizziness. How long, how often, and when your symptoms occur is another vital piece to what is causing your dizziness. If your dizziness only happens when you stand up too quickly, your doctor should think one thing, like low blood pressure, but if it happens because you move your head quickly, it may be vestibular and movement related. How long the symptoms last is also important as it will help you doctor conclude if you’re sensing movement incorrectly, or if you have a mechanical problem, like BPPV.
There is no right, or wrong, answer when it comes to your dizziness and your symptoms. Ruling out non-vestibular issues first, like cardiac dysfunction, is part of ruling-in a vestibular diagnosis, but is not the only part of your equation. Some people have more than one kind of dizziness, and that is not abnormal. Try not to become overwhelmed, always talk to your doctor & healthcare team, and bee honest about what is happening with you!
No matter what, we are here to help!
Nystagmus is a word we use in vestibular rehabilitation very frequently. It is an involuntary, uncontrolled, repetitive eye movement. There are two phases of nystagmus, the fast phase and the slow phase. The fast phase is the direction the eye is moving, and the slow phase is a resetting saccade to place the eye back in the middle. Nystagmus is described by the direction it moves toward during the fast phase. Nystagmus can move in almost any direction, its direction is completely dependent on the diagnosis. These include, but are not limited to: Benign Paroxysmal Positional Vertigo (BPPV)Benign Paroxysmal Positional Vertigo (BPPV), Vestibular Neuritis, and Ménière’s Disease. The nystagmus is the cause of your true spinning vertigo symptoms, which is different from other kinds of dizziness.
Your healthcare provider, like a physical therapist or physician, will examine your eyes to observe the nystagmus. We use your nystagmus’ direction to determine the affected ear, canal, and/or nerve that is causing your symptoms. In some cases, you will need to turn your head or move your eyes, so be sure to listen and keep your eyes open through the duration of your testing unless directed otherwise.
The following chart lists the kind of nystagmus and it’s coordinating diagnosis for Benign Paroxysmal Positional Vertigo:
BPPV Diagnosis
Nystagmus
Position
Right Posterior Canal Canalithiasis
Right Up beating Torsional Nystagmus
Right Dix-Hallpike Position
Left Posterior Canal Canalithiasis
Left Up beating Torsional Nystagmus
Left Dix-Hallpike Position
Right Horizontal Canal Canalithiasis
More intense Right Geotropic Nystagmus
Right Roll Test (compared to Left Roll Test Position)
Left Horizontal Canal Canalithiasis
More intense Left Geotropic Nystagmus
Left Roll Test (compared to Right Roll Test position)
Right Horizontal Canal Cupulolithiasis
Less intense Right Ageotropic & more intense Left Ageotropic nystagmus
Right or Left Roll Test position respectively
Left Horizontal Canal Cupulolithiasis
Less intense Left Ageotropic & more intense Right Ageotropic nystagmus
Left or Right Roll Test position Respectively
Right Anterior Canal Canalithiasis
Down beating (and sometimes torsional) Nystagmus
Left Dix-Hallpike Position
Left Anterior Canal Canalithiasis
Down beating (and sometimes torsional) Nystagmus
Right Dix-Hallpike Position
BPPV is not the only vestibular diagnosis that is associated with nystagmus. Acutely, a superior nerve vestibular neuritis (the most common form) will cause spontaneous nystagmus for 12-36 hours. This will present as a horizontal nystagmus that beats away from the affected ear (toward the unaffected year), and will not change direction with the direction of gaze. However, the nystagmus will increase, or become faster, when you look in the direction of the nystagmus. This effect is called Alexander’s Law; nystagmus will continue to beat in the same direction, regardless of gaze, but it will increase when your gaze is in the direction of your nystagmus. If you catch these symptoms within the first 24 hours, a prescription for a steroid from your physician will help your long term outcomes.
Diagnosis
Symptoms
Right Vestibular Neuritis (superior branch)
Left beating horizontal nystagmus, increasing with left gaze
Left Vestibular Neuritis(superior branch)
Right beating horizontal nystagmus, increasing with right gaze
Nystagmus doesn’t only occur due to vestibular disorders, it can also be caused by a central nervous system dysfunction. These central disorders are usually due to brain stem or cerebellar degeneration or dysfunction. Central nystagmus will present at rest as down beating, up beating, or pendular nystagmus. However, central nystagmus can also be gaze-evoked. Gaze evoked nystagmus will increase to the right when you gaze right, and increase to the left when you gaze left.
All nystagmus can cause dizziness and vertigo, but distinguishing between central and peripheral (vestibular) causes of nystagmus is essential to your treatment. If you have a peripheral disorder your best treatment may be from a physical therapist, and if you have a central disorder care from a physician and other healthcare providers, including a vestibular physical therapist, will be your best option. Always talk to your healthcare team about nystagmus, vertigo, dizziness, and other symptoms you may be experiencing.
BPPV, Benign Paroxysmal Positional Vertigo, can be easy to diagnose subjectively, but watching eyes can be difficult. The following is a chart illustrating the direction of eye movement, position of your patient’s head, and the corresponding diagnosis.
As a provider, you need to know what you’re looking at so you know what you’re looking for! In this chart, you will see which type of nystagmus corresponds with which position and which specific BPPV diagnosis.
Please know, when looking at this chart, that it will help you determine the proper diagnosis based on the position and nystagmus. However, if the position and nystagmus don’t seem to match, there is not a crescendo up and down of nystagmus, and a delay does NOT exist upon lying down… it is likely NOT BPPV!
BPPV Diagnosis
Nystagmus
Position
Right Posterior Canal Canalithiasis
Right Upbeating Torsional Nystagmus
Right Dix-Hallpike Position
Left Posterior Canal Canalithiasis
Left Upbeating Torsional Nystagmus
Left Dix-Hallpike Position
Right Horizontal Canal Canalithiasis
More intense Right Geotropic Nystagmus
Right Roll Test (compared to Left Roll Test Position)
Left Horizontal Canal Canalithiasis
More intense Left Geotropic Nystagmus
Left Roll Test (compared to Right Roll Test position)
Right Horizontal Canal Cupulolithiasis
Less intense Right Ageotropic & more intense Left Ageotropic nystagmus
Right or Left Roll Test position respectively
Left Horizontal Canal Cupulolithiasis
Less intense Left Ageotropic & more intense Right Ageotropic nystagmus
Left or Right Roll Test position Respectively
Right Anterior Canal Canalithiasis
Downbeating (and sometimes torsional) Nystagmus
Left Dix-Hallpike Position
Left Anterior Canal Canalithiasis
Downbeating (and sometimes torsional) Nystagmus
Right Dix-Hallpike Position
There are many ways to train your balance, but to truly focus on your vestibular system you need two big factors. The first factor is decreased or eliminated vision, and the second is an uneven surface. Your vestibular system processes your spatial orientation and balance constantly; it works with your proprioception and vision to keep you upright. If you have tested your balance and you have difficulty depending on your vestibular system, it’s time to do some vestibular balance training.
To do this, you’re going to need a balance pad. There are many options to choose from when you’re searching for the perfect surface to do balance training. The most important factor is that you are standing on an unstable surface.
Personally, my favorite balance pad is the Airex balance pad. It’s one of those staples in any good PT clinic and it’s a consistently good product. It has just enough stability that it doesn’t break with overuse, and unstable enough that you won’t be able to feel the floor when you use it. Not being able to feel the floor when practicing balance training is incredibly important.In my opinion, the Airex a fantastic option, however it is pricier than other balance pad options that are pretty comparable.
This balance pad, the Yes4All has different sizes and colors to choose from, and I have used it in my practice many times. This balance pad has a little less give to it, it feels a little more like the floor. For those who are looking for more give and a greater challenge that you would find in the clinic, the Airex is right for you! However, if you have a much harder time balancing, or you’re worried your balance on uneven surfaces, it may actually be a better choice for you!
If you are going to be testing your balance and practicing your balance in the future, it’s a great idea to invest in a balance pad like the ones above! Challenging your balance in a variety of ways, especially with uneven surfaces, helps your overall balance, increases confidence in your ability to get around, and will decrease your risk for falling!
Your inner ear talks to your brain to control your spatial awareness, balance, and hearing through your vestibulocochlear nerve. In a normal vestibular system, your nerves send signals to your brain at the same rate when you’re looking forward to tell your brain, if your eyes are open or closed, you’re looking forwards. When you look to the right, your right vestibulocochlear nerve fires more than the left, and when you look left the opposite happens. This is why, when your eyes are open or closed, you always know where your head is facing. However, if you have a vestibular neuritis, you have swelling, typically caused by a viral infection, in your vestibulocochlear nerve.
A vestibular neuritis in your right vestibulocochlear nerve causes a decreased firing response at baseline in your right side, which makes it seem like you have an increased firing rate in your left ear. This makes your brain think you’re looking, or spinning, to the left. But, you know that you are not doing that; you can override this system and realize “no, I’m looking straight.” This ability to discriminate between what your brain thinks is happening and what is actually happening is really important. But, if you have a vestibular neuritis, your brain is struggling to pair these two things together. This internal confusion can last weeks to months when untreated, although it slowly improves a little bit, until you plateau at baseline lightheadedness, over time. Vestibular Rehabilitation Therapy is the best way to care for yourself post-virus, and will help get you over the plateau of your symptom improvement.
Symptoms & Diagnosis
Neuritis symptoms can vary in severity and presentation. The types can be split into two groups: acute and chronic. Acute symptoms last for the first 1-3 days, and are often so severe it can limit your ability to sit or stand upright, and to walk around. Chronic symptoms remain after the acute symptoms dissipate but can cause general nausea, fatigue, and confusion. The symptoms that are related to acute vestibular neuritis are: (1)
Severe vertiginous dizziness
Nausea
Vomiting
Imbalance
These symptoms will peak within 24 hours and then slowly begin to dissipate over the next few days. When your symptoms relax, you are left with a new set of symptoms: (1)
Lightheadedness
General dizziness
Imbalance
Feeling of being pulled one way or the other
Difficulty with quick head movements
Fatigue
Grogginess
Difficulty with concentration
Feeling like your head is a hot air balloon
The remaining symptoms from your neuritis will slowly improve, but improvements often plateau at one point, leaving you feeling lightheaded and off balance constantly. These symptoms can be difficult to describe to friends, family, and providers, and may cause frustration because although you look healthy, you don’t feel like yourself. These confusing and hard-to-describe symptoms can help your provider get to the diagnosis of vestibular neuritis. There are no specific diagnostic criteria for vestibular neuritis, but there are a few diagnostic tests that can help your provider come to a conclusion.
There are a few diagnostic tests for vestibular neuritis. These include:
M-CTSIB, a balance test
Head Impulse Test (or Head Thrust Test)
Vestibular Evoked Myogenic Potential (VEMP)
Dynamic Visual Acuity Test
Head Shaking Nystagmus Test
Spontaneous Nystagmus Test
Videonystagmography with Caloric Testing (VNG)
These tests should all be considered and evaluated carefully when making a diagnosis of vestibular neuritis. Your clinician should be able to perform all of these in the clinic easily without access to any high tech equipment, with the exception of the VNG and VEMP tests. When your physical therapist or other practitioner takes a thorough subjective history and carefully considers the objective test results, he or she will be able to conclusively diagnose you with signs and symptoms consistent with vestibular neuritis.
Treatment
Proper treatment for vestibular neuritis completely depends on what stage of the neuritis you are currently in. An acute neuritis is treated completely differently than lingering and chronic symptoms of vestibular neuritis.
If it is caught early, within the first 24 hours, your physician can prescribe a steroid. A steroid prescribed and taken within this time period significantly impacts your long term outcome positively (2). Unfortunately, after 24 hours, the use of the steroid is not the same as the immediate effect that it can have. Additionally, your physician may prescribe an antibiotic of an antiviral if a middle or inner ear infection is suspected.
To treat the feeling of spinning and lightheadedness, your physician may also prescribe you Meclizine, which is a vestibular suppressant. Taking Meclizine short term may be necessary, but because it suppresses your vestibular system it is usually recommended you stop taking this after a few days.
Chronic symptoms of vestibular neuritis are the lingering symptoms that seem to not disappear no matter what you do. These symptoms can be treated with physical therapy. Your brain is having a difficult time pairing what is, and is not, moving. Because one nerve had an infection, it is now sending a lesser signal than it would previously have at baseline. Your nerve will be like this forever, but because of neuroplasticity, the ability for your brain to adapt and change, your brain will adjust to its new normal. The most efficient way to adapt your brain this way is Vestibular Rehabilitation Therapy, or VRT. VRT is performed by a physical therapist and will focus on relearning how to adjust and adapt to the stimuli in the world.
Physical Therapy
Finding a vestibular physical therapist will be vital to your healing process. A vestibular physical therapist will provide you with exercises in the clinic and at home that help your brain learn its new normal. Your PT can also help you work through anxiety related to your dizziness and help you return to other exercise and activities you did prior to your vestibular neuritis.
Superior Semicircular Canal Dehiscence (SSCD) is the result of a hole in the bony portion of your vestibular system. Your inner ear system is deep inside your ear and consists of two parts. The first is your cochlea, your hearing organ. And the second is your vestibular system, which consists of three semicircular canals, the utricle, and the saccule; you can find them pictured here. These canals detect angular motion and help with spatial awareness; this is how we know where our head is in space. If you have SSCD, you may have a thinner wall on your superior semicircular canal, or even a hole. This hole or thinned wall causes vestibular symptoms due to pressure fluctuations and/or changes in loud sounds.
There are supposed to be two holes in your inner ear, the oval window (for sound transmission), and the round window (where sound exits) (1). These two windows allow pressure fluctuations and sounds to transmit functionally through our vestibular system (1). However, the addition of a third hole, a dehiscence, allows for improper signals to be sent and causes your dizziness symptoms. It is unlikely there there is anything you did to make this happen – research shows that Semicircular Canal Dehiscence is usually caused by a developmental abnormality. If you have an already thinned superior canal bone, head trauma or pressure caused by the temporal lobe of your brain can cause it to wear down, which forms the dehiscence. The dehiscence causes uncomfortable symptoms that can be either intermittent or chronic.
Symptoms & Diagnosis
Symptoms of Superior Semicircular Canal Dehiscence can vary from hearing to imbalance issues. Because there is a hole in the system, many people present with different symptoms. These symptoms include, but are not limited to: (1, 2,3)
Vertigo
Non-vertiginous dizziness (lightheadedness, feeling like your brain is spinning)
Nystagmus (involuntary eye movement) in response to loud sounds or pressure changes
Unsteadiness and disequilibrium (feeling as though you may fall)
Oscillopsia (the sensation that the world is moving around you)
Aural fullness
Coughing, straining, sneezing cause dizziness or lightheadedness
Hearing yourself speak more loudly in one ear than the other
Hearing your own heartbeat, blood flow, or eye muscles move
Migraines
Many of these symptoms of spontaneous vertigo and lightheadedness have similar symptoms to other vestibular diagnoses such as:
To diagnose your symptoms, there are a few tests that your healthcare team will likely recommend. These diagnostic tests will begin with a thorough history of your symptoms to rule out other vestibular diagnostic possibilities. Then, if SCD is predicted you will be placed through one or more of the following tests:
VEMP
CT scan
Audiogram
VNG
Once you receive a diagnosis, your providers will devise a treatment plan that suits your specific needs.
Treatment
Most patients with Superior Semicircular Canal Dehiscence can manage their symptoms by avoiding stimuli like sudden loud noises. However, for those who cannot manage their symptoms with avoidance, there are other treatment options. These options are tinnitus retraining therapy, using a hearing aid, treating migraines if you have them, and surgical correction (2). If your symptoms are mild and not debilitating, the surgical option is not recommended as the risks often outweigh the benefits.
Surgical correction is for those deeply affected by SSCD. The hole in the canal is plugged with fascia, which is thick connective tissue, to eliminate fluid movement (3). There are many risks to this procedure such as hearing loss, BPPV, high frequency sensorineural hearing loss, and general vestibular dysfunction. Luckily, most people who undergo this procedure have positive results.
If you have any remaining symptoms from the surgery of imbalance, vestibular migraine, or other general vestibular dysfunction, physical therapy can help.
Physical Therapy
Physical therapy for Superior Semicircular Canal Dehiscence will be treating the symptoms that affect you. Your physical therapist can help you with improving your balance, improving your lightheadedness or dizziness symptoms, and assisting with vestibular migraine. Vestibular Rehabilitation Therapy, or VRT, is very effective in improving vestibular dysfunction. Your PT will be able to find what stimuli are increasing your symptoms and slowly help your brain adapt to the stimuli in a more normal way. Having a PT as a part of your healthcare team will be vital to your recovery and management for SSCD. VRT will help you with imbalance, dizziness, and vertigo symptoms.
Sources:
(1) Minor, L. (2020, June 26). Superior Semicircular Canal Dehiscence (SSCD). Retrieved September 10, 2020, from https://vestibular.org/article/diagnosis-treatment/types-of-vestibular-disorders/superior-semicircular-canal-dehiscence-sscd/
Persistent Postural Perceptual Dizziness (PPPD) is chronic, long lasting, dizziness that is non-vertiginous and fluctuating in nature (1). PPPD is a relatively new diagnosis; the diagnostic criteria were created in 2014 and for that reason many providers don’t know about the condition or the criteria (1). PPPD has signs and symptoms that present like many other vestibular diagnoses including vestibular migraine, vestibular neuritis, or anxiety related dizziness making it even more difficult to diagnose. Prior to being titled Persistent Postural Perceptual Dizziness, PPPD was referred to names including: phobic postural vertigo (PPV), space-motion discomfort (SMD), visual vertigo (VV) and chronic subjective dizziness (CSD) (2). The criteria of these have now been combined to form Persistent Postural Perceptual Dizziness and has specific criteria designed to provide an exact diagnosis (3).
It is not always possible to determine an exact cause of PPPD, however it rarely comes on slowly. Your balance system, which consists of three systems working together to keep you stable, is in a state of disequilibrium when you have PPPD. Instead of the three systems seamlessly working together for stability, your body has difficulty processing the information passed between them, making your brain feel like you may fall over at any moment. This feeling places your body on high falls risk alert, and the more you worry, the more anxious you may become. This anxiety causes an increase in dizziness, which then increases anxiety. This is a vicious anxiety cycle. All of this can be treated in vestibular physical therapy with your team of healthcare providers.
Symptoms & Diagnosis
Symptoms of Persistent Postural Perceptual Dizziness vary widely from one individual to the next. The symptoms have an inciting event that caused the original onset of symptoms, and can be either vertiginous or non-vertiginous, even if you can’t remember when it occurred. This event can be any event that caused dizziness, either physical or psychological, and includes: (2)
Any of these, or other vestibular conditions, can be the cause of PPPD. There many symptoms related to Persistent Postural Perceptual Dizziness, including:
Rocking or swaying when you are being still
Unsteadiness
Lightheadedness
Feeling spaced-out or dissociated
Anxiety or fear
Symptoms are exacerbated with:
Sitting or standing (upright posture)
Seeing movement (phone scrolling, traffic passing by, watching TV)
Looking at complex patterns (busy background or carpets)
Walking
Riding in a car
Passive and/or active motion
Other symptoms frequently reported are:
Neck pain or tightness
Fatigue
Fear of falling, imbalance
Problems or changes with how you walk
Fear avoidance (avoiding stimulating activities you would normally participate in)
These symptoms are both directly and indirectly related to your experience with Persistent Postural Perceptual Dizziness. Your healthcare providers, especially your physical therapist, should be made aware of the symptoms you are experiencing. The more information that they have, the better your provider will be able to assist you in a diagnosis recovery.
Because PPPD is such a new diagnosis, the criteria is widely unknown to many providers. However, we are all able to access them, and they can be found below. If you fit this criteria, vestibular therapy will be an avenue to help your recovery. The following are the official diagnostic criteria for Persistent Postural Perceptual Dizziness, all 5 must be met (A-E) to fit the diagnosis: (3)
A. One or more symptoms of dizziness, unsteadiness, or non-spinning vertigo are present on most days for 3 months or more.
1. Symptoms last for prolonged (hours-long) periods of time, but may wax and wane in severity.
2. Symptoms need not be present continuously throughout the entire day.
B. Persistent symptoms occur without specific provocation, but are exacerbated by three factors:
1. Upright posture,
2. Active or passive motion without regard to direction or position, and
3. Exposure to moving visual stimuli or complex visual patterns.
C. The disorder is precipitated by conditions that cause vertigo, unsteadiness, dizziness, or problems with balance including acute, episodic, or chronic vestibular syndromes, other neurologic or medical illnesses, or psychological distress.
1. When the precipitant is an acute or episodic condition, symptoms settle into the pattern of criterion A as the precipitant resolves, but they may occur intermittently at first, and then consolidate into a persistent course.
2. When the precipitant is a chronic syndrome, symptoms may develop slowly at first and worsen gradually.
D. Symptoms cause significant distress or functional impairment.
E. Symptoms are not better accounted for by another disease or disorder.
Treatment
Vestibular Rehabilitation Therapy, or VRT, is effective in treating PPPD in conjunction with Cognitive Behavioral Therapy, education, and potentially some medications. Vestibular Rehabilitation Therapy is effective in habituating and adjusting your brain through neuroplasticity, or the ability for your brain to change and mold to its environment. Although there have been no randomized control trials at this point, clinical experience and reports show that 3-6 months of VRT is often very effective in treating your symptoms (1).
Additionally, Cognitive Behavioral Therapy (CBT) can be effective for some individuals who have new PPPD symptoms, but is less effective for those who have had symptoms for a long time. If you begin Cognitive Behavioral Therapy within 8 weeks of symptom onset, the results from CBT are lasting and effective (1).
Medications can also be effective in treating PPPD, some physicians prescribe SSRI’s and SRNI’s to help with symptoms of anxiety and dizziness. It has been found that symptoms were reduced by at least half in 60-70% of patients who were on one medication or the other for 8-12 weeks. Patients who had lasting effects were on the treatment for at least one year. Medications such as Benzodiazepines and vestibular suppressants, most commonly Meclizine, were found ineffective in treating PPPD symptoms (1).
There are many different treatments for PPPD, however treating the symptoms and the root cause simultaneously will have the longest lasting effect. Combining VRT, CBT, and medication will help you begin to feel like yourself as quickly as possible.
Physical Therapy
The main and most effective form of treatment for PPPD is Vestibular Rehabilitation Therapy. VRT is prescribed by your physical therapist to slowly adjust your tolerance to stimuli that bother you. For some, a stimulus could be patterned carpets and for others it could be head motion. Whatever the stimuli, VRT can help you. Your physical therapist will adjust the dosage of irritating stimuli to your symptoms using the 15 minute rule. In physical therapy your PT will grade the amount of a stimulus you can tolerate and dose your exercises accordingly. Do not attempt to dose PT yourself as I find patients often overstimulate themselves leading to a big flare up.
(3) Staab, J. P., Eckhardt-Henn, A., Horii, A., Jacob, R., Strupp, M., Brandt, T., & Bronstein, A. (2017, January 01). Diagnostic criteria for persistent postural-perceptual dizziness (PPPD): Consensus document of the committee for the Classification of Vestibular Disorders of the Bárány Society. Retrieved September 09, 2020, from https://content.iospress.com/articles/journal-of-vestibular-research/ves622
In my opinion, the 
in a balance pad like the ones above! Challenging your balance in a variety of ways, especially with uneven surfaces, helps your overall balance, increases confidence in your ability to get around, and will decrease your risk for falling!