Dizziness: Causes, Treatment

Brief overview

  • Description: Vertigo occurs in different forms (e.g. as spinning or staggering vertigo), once or repeatedly. Mostly it is harmless.
  • Causes: e.g. small crystals in the vestibular organ, neuritis, Meniere’s disease, migraine, epilepsy, disturbed cerebral circulation, motion sickness, cardiac arrhythmia, cardiac insufficiency, hypoglycemia, medication, alcohol, drugs.
  • Dizziness in old age: not uncommon; can have various causes, but can also remain unexplained.
  • When to see a doctor? If dizziness occurs suddenly, violently and repeatedly without an apparent cause or during an infection, is triggered by certain situations or head postures, or is accompanied by other symptoms (nausea, vomiting, headaches, visual disturbances, etc.). Also, always have dizziness in old age clarified.
  • Therapy: depending on the cause, e.g. medication, regular positioning maneuvers of the head, behavioral therapy, aids such as walking stick or rollator.
  • What you can do yourself: including getting enough sleep and drinking, eating regularly, reducing stress, avoiding alcohol and nicotine, regularly measuring blood pressure and, in the case of diabetes, blood sugar, special exercises

What is dizziness?

Dizziness, like headaches, is one of the most common nervous system symptoms. The likelihood of a dizzy spell increases with age: among those over 70, about one-third suffer from intermittent bouts of vertigo, while younger adults are much less likely to be affected.

Infants, i.e. children under two years of age, are almost “immune” to dizziness. Their sense of balance is not yet very well developed. In the first few years of their lives, therefore, car rides on winding roads or being on a swaying boat can do them little harm.

The sense of balance

Three sensory organs work together to enable spatial orientation and control the sense of balance:

The vestibular apparatus, the organ of balance in the inner ear, is located between the eardrum and the cochlea. The fluid-filled cavity system consists of the following components:

  • three semicircular canals (one superior, one lateral and one posterior)
  • two atrial sacs
  • endolymphatic duct (Ductus endolymphaticus)

When the body turns or accelerates (e.g., on a merry-go-round, while driving a car), the fluid in the vestibular apparatus moves. This irritates the sensory cells on its walls. The vestibular nerve transmits these stimuli to the brain.

Stimuli from the eyes also arrive there, informing how spatial fixed points and the horizon move.

Dizziness in old age – a special case?

With increasing age, people suffer from dizziness significantly more often than in younger years. This is often due to age-related changes as well as age-typical diseases. On the one hand, the latter can have dizziness as a symptom themselves. On the other hand, they are often treated with drugs that can trigger dizziness as a side effect. In such cases, one speaks of old-age vertigo.

In addition, there are other forms of dizziness that can occur in old age as well as in younger years, for example benign positional vertigo.

Vertigo: Causes

Vertigo often occurs when the brain receives conflicting information from the aforementioned sensory organs. Alternatively, vertigo can occur when the brain is unable to properly process the incoming signals. In addition, physical and mental illnesses can be responsible for attacks of dizziness. So there are many causes of dizziness. In principle, physicians distinguish between vestibular and non-vestibular dizziness. Vertigo in old age can have both vestibular and non-vestibular causes.

Vestibular vertigo

Vestibular vertigo occurs “in the head” – that is, either due to conflicting stimuli or disturbed processing of that information that is transmitted to the brain by the vestibular organs. The trigger for this is disease or irritation of the vestibular system.

The most common forms and causes of vestibular vertigo are:

Benign paroxysmal positional vertigo (BPPV).

Benign positional vertigo is the most common form of vertigo. It is triggered by tiny crystals or stones (otoliths) in the fluid-filled organ of balance (cupulolithiasis, canalolithiasis). If the affected person changes his or her posture, the pebbles or crystals move in the arcades and thus irritate the sensory cells on the walls. The result is an acute, brief and violent attack of vertigo, which can also occur while lying down. Nausea may also occur. Hearing disorders, however, are not among the accompanying symptoms.

Neuritis vestibularis

Vestibulopathy

Typical for this inner ear disease is a spinning or swaying vertigo. Affected persons can only perceive their surroundings in a blurred way, can no longer read street signs or recognize the faces of oncoming people with certainty. Symptoms can last from a few minutes to a few days and usually worsen in the dark and on uneven ground.

Vestibulopathy can be caused, for example, by medications that damage the inner ear (such as certain antibiotics like gentamycin). Meniere’s disease (see below) and meningitis are also possible triggers.

Vestibular paroxysmia

It is possible that the vertigo attacks are triggered by the auditory and vestibular nerves being briefly compressed by pulsating small arteries nearby. Alternatively or additionally, “short circuits” between adjacent nerve fibers could be the trigger.

Meniere’s disease

Typical of Meniere’s disease are regularly occurring sudden spinning vertigo, unilateral tinnitus, and unilateral hearing loss. The vertigo is not permanent, but occurs in attacks. An attack can last between 20 minutes and 24 hours. Meniere’s disease usually becomes noticeable between the ages of 40 and 60, rarely in childhood.

Basilar migraine (vestibular migraine)

This special form of migraine is accompanied by repeated attacks of vertigo. Accompanying visual disturbances, tinnitus, standing and gait disturbances, and pain in the back of the head occur.

Circulatory disturbances in the brain

Other typical symptoms of vertigo due to disturbed cerebral blood flow are nausea and vomiting, disturbed movement (ataxia), sensory disturbances, dysphagia, and speech motor disturbances (dysarthria).

Acoustic neuroma

This benign tumor of the auditory and vestibular nerves (eighth cranial nerve) originates from the Schwann cells that surround the nerve. Once the tumor reaches a certain size, it can cause symptoms such as hearing loss, vertigo (spinning or staggering vertigo) and nausea.

Fracture of the petrous bone with loss of labyrinth.

Skull bones can break (skull fracture) in a serious accident or fall. If the petrous bone is affected (section of bone surrounding the inner ear), the inner ear with the vestibular system may also be damaged. Vertigo is one of the possible consequences.

Vestibular epilepsy

Motion sickness (kinetosis)

Unaccustomed movements (for example, during car or bus rides on winding roads, turbulence in an airplane, or strong waves) can flood the inner ear with stimuli. If the affected person does not constantly track the causes of these movements with his or her eyes, the brain cannot assign the stimuli and registers them as an error message.

This can happen, for example, when someone looks at a map instead of at the road during a car ride. For the brain, the person is then sitting still – the map is not moving, as the eyes register. But the other organs of equilibrium report fluctuations and vibrations of a locomotion to the brain. Dizziness, nausea, headaches and vomiting are then often the consequences.

Non-vestibular vertigo

In non-vestibular vertigo, the organs of balance function perfectly. Nerves and brain are also completely intact. Instead, the triggers are found in other regions of the body. Accordingly, the causes of non-vestibular vertigo include:

  • Cervical spine syndrome (CSD): symptom complex that includes, for example, neck pain, headache, and sometimes neurological symptoms (such as tingling or numbness), vertigo, and tinnitus. Possible causes: e.g. signs of wear and tear, tension and injuries in the cervical spine area.
  • Low blood pressure and orthostatic dysregulation: the latter refers to a sudden drop in blood pressure after a change in position (e.g., getting up quickly from bed). This causes the blood to drop into the legs – the brain briefly receives too little blood and thus oxygen. Dizziness and blackness before the eyes are the consequences.
  • High blood pressure (hypertension)
  • Anemia (low blood pressure)
  • Cardiac arrhythmia
  • Heart failure (cardiac insufficiency)
  • Pregnancy: The strong physical changes during pregnancy can be associated with blood pressure fluctuations, which sometimes cause dizziness.
  • Low blood sugar level (hypoglycemia).
  • Vegetative diabetic polyneuropathy: Diabetes-related nerve damage in the autonomic nervous system.
  • Vascular calcification and narrowing (arteriosclerosis) in the area of the vessels supplying the brain
  • Carotid sinus syndrome: Here, pressure receptors of the carotid artery react hypersensitively. Even slight pressure causes them to slow down the heartbeat – blood pressure drops, which can trigger dizziness and impaired consciousness (even fainting).
  • Medications (dizziness as a side effect)
  • Alcohol and other drugs
  • hyperventilation: excessively rapid and deep breathing
  • poorly adjusted or unaccustomed glasses

Phobic vertigo is the most common somatoform dizziness disorder. Typical symptoms are drowsiness, staggering vertigo, unsteadiness in standing and gait, and frequent falls. The vertigo attacks occur when sufferers face typical triggers of panic attacks, such as crossing a bridge or being in the middle of a crowd. Phobic vertigo is psychogenic vertigo, meaning it is caused by the mind.

Causes of dizziness in old age

Dizziness in old age can have various triggers. Often it is benign positional vertigo (benign paroxysmal positional vertigo, see above).

Age-typical diseases such as too high or too low blood pressure, vascular diseases, Parkinson’s disease, metabolic disorders or diabetes mellitus (diabetes) can also cause dizziness in older people. The same applies to some medications that are often taken by the elderly (e.g., blood pressure medications).

Thus, the inner ear is sometimes less well supplied with blood, nerve transmission slows down, and stimulus processing in the brain becomes poorer. This can manifest itself in dizziness and vertigo or drowsiness and associated balance disorders in old age. Contributing factors may include the eyes, which deteriorate with age and limit spatial vision. In addition, decreasing muscle mass and strength can interfere with depth and surface perception, which can also cause or exacerbate dizziness.

Another factor that may not be obvious, but is all the more important, is psychological reasons. According to the German Seniors’ League, depression, loneliness, grief or anxiety account for around one third of all cases of dizziness in old age.

Vertigo: Symptoms

A distinction is made between spinning vertigo, staggering vertigo, elevation vertigo and pseudo-vertigo.

Spinning dizziness: The environment seems to spin around the affected person. This typically happens after excessive alcohol consumption. However, spinning dizziness can have many other causes (e.g., suddenly getting up from lying down). It is often accompanied by nausea, vomiting, ringing in the ears and reduced hearing.

Staggering vertigo: sufferers have the feeling that the floor is being pulled out from under their feet. Thus, staggering vertigo makes for an unsteady gait. The affected person feels dizzy even when standing still. Accompanying symptoms occur only very rarely with this form of vertigo.

Elevator vertigo: Those affected think they are falling and feel as if they are going up or down quickly in an elevator.

Vertigo: When do you need to see a doctor?

Behind an acute attack of vertigo is often a harmless positional vertigo that usually subsides on its own (spontaneously) within days or weeks. However, if you suspect that it is another form of vertigo or if the vertigo attacks keep recurring, you should see a doctor. This is especially true if

  • the dizziness occurs suddenly, violently and repeatedly, without any apparent external cause,
  • certain head movements always lead to vertigo,
  • nausea, vomiting, headache, ringing in the ears, drowsiness, blurred vision or shortness of breath accompany the dizziness,
  • @ the dizziness occurs during an infection with or without fever, or
  • @ the balance disturbances appear again and again in certain situations, for example in crowds or when driving a car. A visit to the doctor is also recommended for stress-related dizziness.

Vertigo: What does the doctor do?

First, the doctor must find out what is causing a patient’s dizziness. After that, he or she can initiate a suitable therapy or provide the patient with everyday tips.

Vertigo: Diagnostics

The causes of dizziness involve various medical specialties. Patients therefore often have to visit various specialists (such as ENT specialists, internists, neurologists) until the cause of their dizziness is determined. Today, many cities have outpatient dizziness clinics in which specialists from different fields work together. If such an outpatient clinic is located in your area, you should be examined and advised there. Otherwise, you can turn to your family doctor as your first point of contact.

Medical history and physical examination

First, the doctor will ask you about your medical history (anamnesis). Possible questions here are:

  • How does the dizziness feel (turning, swaying, up and down movement)?
  • Does the dizziness exist more or less permanently or does it occur in attacks?
  • In case of vertigo attacks: How long do they last?
  • Are there certain situations in which you become dizzy(er) (e.g. when turning, when standing up, in the dark)?
  • Is the dizziness accompanied by other symptoms (such as nausea, sweating, rapid heartbeat)?
  • What are your lifestyle habits (diet, physical activity, sleep …)?
  • Do you suffer from any underlying diseases (e.g. diabetes, heart failure)?
  • Are you taking any medications?

It may also be helpful if you keep a dizziness diary for some time. There you note down when and in what form you have experienced dizziness. The detailed information will help the doctor find the cause.

Sometimes further examinations are also necessary to clarify the cause of the dizziness:

Nystagmus examination

Nystagmus is an uncontrollable, rhythmic movement of the eyes (“eye tremor”). It serves to keep the image projected through the eye lens constantly on the retina, i.e. to compensate for movements. In vertigo patients, however, this eye movement also occurs at rest. It can be observed with special glasses (Frenzel glasses).

Sometimes the physician also provokes the nystagmus, for example, by rotating the patient on a swivel chair or by applying a warm ear irrigation that irritates the equilibrium organ in the inner ear.

Balance test

The physician may also check the patient’s gait pattern for fluctuations or lopsided walking.

In the Unterberger stepping test, the affected person steps on the spot with closed eyes. If nerve reflexes are disturbed, he turns on his own axis.

Hearing test

In most cases, the doctor also examines the hearing ability of patients with vertigo, since hearing and the sense of balance use the same nerve pathways. Often, the examination is performed by means of a Weber test. The doctor holds a vibrating tuning fork to the patient’s head and asks him whether he hears the sound equally well in both ears or better in one ear.

Further examinations

If there is a suspicion that a particular condition is responsible for the dizziness, further examinations can help with the diagnosis. Some examples:

  • Schellong test (to check circulation) or tilt table test (to check positional blood pressure adjustment using a movable couch)
  • Long-term blood pressure measurement
  • Computed tomography (CT)
  • Magnetic resonance imaging (MRI)
  • Electroencephalography (EEG): measurement of electrical brain activity
  • Ultrasound examination (Doppler sonography) of the arteries
  • Measurement of cerebrospinal fluid pressure (CSF pressure) in the course of a lumbar puncture
  • Evoked potentials (EP): targeted triggering of bioelectrical brain activity in response to specific stimuli, e.g. motor evoked potentials (MEP) and sensory evoked potentials (SEP)
  • Blood tests
  • Cardiac ultrasound
  • Electromyography (EMG), an examination of the conduction of stimuli into the muscles
  • Electroneurography (ENG), an examination to test the function of peripheral nerves
  • Carotid pressure test to examine the blood pressure reflex of the carotid artery

Vertigo: Therapy

Therapy for positional vertigo

The physician can slowly rotate the head of the lying patient into certain positions so that the small stones or crystals leave the archways of the vestibular organ. These positioning maneuvers are named after their discoverers Epley, Sémont, Gufoni and Brandt-Daroff, respectively. If the affected person additionally trains his sense of balance in physiotherapy, this can accelerate the healing process.

Therapy for neuritis vestibularis

Glucocorticoids (“cortisone”) such as methylprednisolone can support the recovery of the vestibular nerve. In addition, targeted balance exercises are useful. They can also help to ensure that symptoms such as dizziness soon improve.

Therapy for Meniere’s disease

Read more about therapy for Meniere’s disease here.

Therapy for vestibular paroxysmia

Here, too, dizziness is preferably treated with medication. Active substances such as carbamazepine and oxcarbamazepine are used. Both reduce the hyperexcitability of the nerves and are also used against epilepsy. Only in certain cases do doctors consider surgical therapy.

Therapy for motion sickness

So-called antivertiginosa (e.g., drugs with the active ingredient dimenhydrinate) can suppress dizziness and nausea. However, they are not suitable for every case of dizziness, nor are they suitable for long-term treatment.

Antivertiginosa fall into the group of antihistamines (allergy medications), antidopaminergics, or anticholinergics.

Therapy for dizziness in old age

Acute symptoms of vertigo are often successfully alleviated by the active drug ingredient dimenhydrinate. Drugs containing ginkgo as well as the active ingredient betahistine, which is supposed to reduce the overpressure in the cochlea, can stimulate the blood flow and metabolic activity of the vestibular organ in the inner ear in the long term and thus reduce vertigo.

For benign positional vertigo, physical therapy can help: The special exercises described above also help against vertigo of this type in old age.

To avoid falls with (serious) injuries, elderly patients with vertigo should use aids such as walking sticks or walkers / rollators.

Therapy for phobic vertigo

Antidepressants in combination with behavioral therapy can help to combat psychologically induced vertigo attacks.

Dizziness: What you can do yourself

In addition, you should pay attention to the following:

  • Avoid severe physical exhaustion.
  • Drink enough to stabilize blood pressure.
  • Eat regularly to avoid hypoglycemia.
  • Get enough sleep.
  • Reduce stress, for example through relaxation exercises.
  • Refrain from excessive alcohol and nicotine consumption.
  • Check your blood pressure.
  • Do not get up too quickly from sitting or lying positions.
  • Check the package inserts of medications you take for dizziness as a possible side effect – or ask your doctor or pharmacist about this.
  • Diabetes patients should check their blood glucose levels regularly.

Positional vertigo exercises

Tips against motion sickness

To prevent nausea and dizziness when traveling by ship, bus or car, simple behavioral tips are sometimes sufficient: If possible, look straight ahead (in the direction of travel) and fix the horizon in the direction of travel in case of fluctuations. Then the organ of equilibrium can synchronize with the eye. You will then not feel dizzy so quickly.

You may also be able to take motion sickness medication to prevent dizziness and nausea while traveling.

Prevention of senile vertigo

But you don’t have to become a top athlete to prevent dizziness in old age. Exercises that you can easily do at home – some even while sitting – already help against balance problems in old age. Some examples:

  • Look alternately up and down without moving your head.
  • Follow a pencil with your gaze, passing it back and forth in front of your face.
  • While sitting on a chair, bend forward to pick up an object from the floor.
  • Tilt your head in succession toward your chest, neck, right shoulder and left shoulder.

These simple exercises can help prevent or relieve dizziness as you age.

Frequently asked questions

For answers to common questions about this topic, see our post Frequently Asked Questions About Vertigo.