FAQ
Browse a selection of our most frequently asked questions and answers about balance and dizziness disorders. Submit your own question here.
Acoustic Neuroma
Most of the time, doctors ordering a CT scan or MRI of your temporal bone – the bone enclosing your inner ear – are looking for major structural abnormalities. Usually, they want to see the health of the bone, whether or not it is intact, and if there are any tumours on the balance and hearing nerve or on the structures at the back of your head. An acoustic neuroma, for example, is a benign tumour causing hearing loss and dizziness as it grows around the hearing and balance nerve. Acoustic neuromas show up on an MRI.
Neither CT scans nor MRIs can, however, help diagnose most causes of dizziness and imbalance. Imaging cannot show if the tiny inner-ear balance sensors are working. In summary, the role of medical imaging is to rule out – or in – certain structural causes for balance and dizziness disorders.
Advocate for Yourself
Physiotherapists do not diagnose. Physiotherapists work with you based on how your imbalance or dizziness presents. Well-trained physiotherapists can make a working hypothesis of what is wrong and can help guide your medical doctor or specialist towards a diagnosis.
Vestibular audiologists do diagnostic vestibular testing. They can, for example, test to see if you have bilateral vestibular hypofunction or a bilateral vestibular disorder. Similar to how audiologists can say, “You have a sensory hearing loss,” vestibular audiologists can say, “You have a loss of balance function.” They will not label your disorder, but will say things like, “This balance sensor seems to be 50% functional” or “There is a dysfunction on this or that balance sensor.” This information will be passed on to your doctor to make a diagnosis.
Gravol is a drug that acts on the central nervous system. It can be thought of as a numbing agent. It reduces the sensitivity of your central nervous system, and it usually works very well at reducing nausea. It is a symptomatic medication. If it helps you, it will not tell you the reason for your nausea. If you respond to Gravol, that is good because you will have less symptoms. But your healthcare team will need to continue to dig deeper to understand why you are having nausea.
Most of the time, doctors ordering a CT scan or MRI of your temporal bone – the bone enclosing your inner ear – are looking for major structural abnormalities. Usually, they want to see the health of the bone, whether or not it is intact, and if there are any tumours on the balance and hearing nerve or on the structures at the back of your head. An acoustic neuroma, for example, is a benign tumour causing hearing loss and dizziness as it grows around the hearing and balance nerve. Acoustic neuromas show up on an MRI.
Neither CT scans nor MRIs can, however, help diagnose most causes of dizziness and imbalance. Imaging cannot show if the tiny inner-ear balance sensors are working. In summary, the role of medical imaging is to rule out – or in – certain structural causes for balance and dizziness disorders.
Not all specialists have a particular interest or specialization in vestibular migraine. Ask your referring doctor to match you to one who does. For example, some neuro-otologists, neurologists and neuro-ophthalmologists are comfortable diagnosing and managing headache disorders, including vestibular migraine. This is less common, however, for generalist otologists (ear, nose and throat doctors). Some physiotherapists may be knowledgeable about headaches. Many, however, are more interested in balance and muscle- and joint-related issues. Read more about vestibular migraine.
Auditory Disorders
The diagnostic criteria for Ménière’s disease include having a documented hearing loss on the affected side. A diagnosis of probable Ménière’s disease can be made in the absence of a documented hearing loss, but with a history of fluctuating symptoms (hearing loss, tinnitus or fullness) in the affected ear.
Pain is not a symptom usually associated with otosclerosis. If you suspect otosclerosis, but you are experiencing ear pain, please consult with your ENT doctor (otolaryngologist) again to have your ears re-checked for other causes for pain.
Balance
“I’ve started to feel more unbalanced lately, even having a fall. I don’t have any dizziness I’m over 90 years of age. I do the Epley manoeuvre daily, but it doesn’t help. What might be my problem?”
There are many reasons for increasing imbalance without dizziness as we age. Often, there are overlapping reasons. As a starting point, we suggest reading our Age-Related Dizziness and Imbalance page as well as visiting a general practitioner or geriatrician for a thorough physical checkup as well as a referral for testing of your vestibular system.
In addition, a physiotherapist will be able to assess your gait and muscle strength. It is likely that you can make progress towards greater stability be getting and practicing a set of exercises tailored for your needs by a physiotherapist.
The last thing you want is a serious fall. Ask about falls prevention workshops or classes in your area. A family doctor or physiotherapist should be able to help you with tracking down something suitable in your area.
In the meantime, be particularly mindful of your risk of falling, particularly on uneven ground, on stairs, and in the dark. Wear supportive shoes even inside. Our Falls Prevention page has many more tips. A physiotherapist will be able to give you more advice specific to your needs.
The Epley manoeuvre is helpful only for people with one specific condition, BPPV. The hallmark symptom of this condition is brief, spinning dizziness (vertigo) that lasts less than a minute. As you report not being dizzy, it is unlikely you have BPPV. While there is no harm in doing the Epley, it won’t help unless you have BPPV. As a retired engineer, you may find it interesting to read about the physics of displaced crystals in the inner ear on our BPPV page. It is an interesting topic.
Physiotherapists do not diagnose. Physiotherapists work with you based on how your imbalance or dizziness presents. Well-trained physiotherapists can make a working hypothesis of what is wrong and can help guide your medical doctor or specialist towards a diagnosis.
Vestibular audiologists do diagnostic vestibular testing. They can, for example, test to see if you have bilateral vestibular hypofunction or a bilateral vestibular disorder. Similar to how audiologists can say, “You have a sensory hearing loss,” vestibular audiologists can say, “You have a loss of balance function.” They will not label your disorder, but will say things like, “This balance sensor seems to be 50% functional” or “There is a dysfunction on this or that balance sensor.” This information will be passed on to your doctor to make a diagnosis.
Most of the time, doctors ordering a CT scan or MRI of your temporal bone – the bone enclosing your inner ear – are looking for major structural abnormalities. Usually, they want to see the health of the bone, whether or not it is intact, and if there are any tumours on the balance and hearing nerve or on the structures at the back of your head. An acoustic neuroma, for example, is a benign tumour causing hearing loss and dizziness as it grows around the hearing and balance nerve. Acoustic neuromas show up on an MRI.
Neither CT scans nor MRIs can, however, help diagnose most causes of dizziness and imbalance. Imaging cannot show if the tiny inner-ear balance sensors are working. In summary, the role of medical imaging is to rule out – or in – certain structural causes for balance and dizziness disorders.
Vestibular audiologists report on the results of hearing, balance and vestibular function tests. If you had a VEMP test, they may say, “Your utricle and saccule are within normal range.” Or, they may say, “Your water test was normal or abnormal.” Ask for a written report of hearing tests as well as diagnostic tests of the balance sensors in your inner ear. Get an understanding of what these reports mean by reading our Diagnostic Tests for Balance and Dizziness Disorders.
If you feel more anxious when on these surfaces, here are some suggestions you could explore.
You may try to first just stand on the edge of that surface. While standing there, just notice your body. “Scan” it with your attention, all the way from the soles of your feet to your head. Notice any areas of tension and soften them if you can. Notice whether your heart is beating fast, your breathing is shallow or you are sweating. If that is happening, take some deep breaths, with a longer out-breath, like a sigh of relief. Intentionally relax and slow down. Take as much time as you need to feel calm, relaxed and safe just standing there.
Then you may also want to work on some sort of habituation to these surfaces. I’d try starting with some walking poles and see if you feel more stable and less like falling when on these types of surfaces. You’d want to try perhaps just a few steps at a time, for just as long as you feel safe. You would want to repeat this several times a week for some practice and exposure. If the process works, you should start to feel that you don’t tense up as much and feel more relaxed. Then you could try using only one pole and repeat until you feel stable. You could then try using no poles and see how you are.
These are the poles we normally recommend, but you may be able to find a cheaper alternative:
There are many causes for dizziness and balance disorders, including life-threatening conditions. The CT and MRI scans you had were to rule out more serious causes for vertigo. They are not meant to find out exactly what is happening. When the scans come back clear, your primary care physician may try medications that are available and see what happens.
However, the vestibular/balance system is very complex and sometimes the cause is neither sinister nor straight forward. An example is Persistent Postural-Perceptual Dizziness (PPPD).
In less straight-forward cases, specialized professionals and/or diagnostic testing may be needed to lead you to understanding what is causing your dizziness and to implement appropriate management strategies.
The road to diagnosis and management of a dizziness and balance disorder is often a journey and we understand that it can be confusing and frustrating.
BPPV
The half-somersault manoeuvre is meant to be self-taught and performed, but, depending on how dizzy, fit and healthy you are, it may be difficult to do. It is an alternative to the Epley manoeuvre, which can also be self-administered. You can read more about the half-somersault maoneuvre here.
Alternatively, you can see a vestibular physiotherapist who can help you with the manoeuvres, both teaching you how to do them and performing them for you. You can find a Vestibular Physiotherapist in your area here. Choose “Find a Physio” or “Find a Clinic” and select the “Advanced Search” option. Enter your criteria, including your city.
I couldn’t help but notice that you mentioned in your email that you suffer from Ménière’s Disease. Note that these manoeuvres are aimed at positional vertigo, which may occur in Ménière’s disease. Positional vertigo presents as short-lived episodes of spinning dizziness that occur only when you move your head in certain ways. On the other hand, Ménière’s Disease presents with intense spinning (dizziness) episodes, that come on suddenly, often for no apparent reason. These are often accompanied by vomiting and last for hours. The manoeuvres for positional vertigo are not recommended when these longer and more severe episodes occur.
In general, there is nothing in particular that links vestibular exercises to making the crystals dislodge from where they belong, and thereby causing BPPV. Vestibular therapists have people doing a lot of different activities – in general, these are exercises done in an upright position, whereas BPPV is typically brought on by laying the head back. Vestibular exercises done for vestibulo-ocular reflex (VOR) or for balance do not tend to provoke BPPV. If BPPV is going to happen, it is going to happen – there is really no rhyme nor reason why the crystals tend to slide into a semicircular canal. And if they do, it is fairly easy for a vestibular therapist to correct.
You might feel a bit off balance, dizzy and/or nauseous for a day or two after an Epley manoeuvre, but these symptoms should settle down over time. For the most part, people tolerate the Epley manoeuvre quite well. If the therapist does repeated Epley or other manoeuvres – one, after the other, after the other – and your situation does not improve, it may be that something other than BPPV is causing your dizziness. In that case, following up with your vestibular professional and getting reassessed may help narrow down the cause.
You have expressed the feelings of many people affected by dizziness! It is not always easy to find support in your community; you end up seeing quite a few professionals and they are not always on the same page as to your diagnosis and treatment plan. You may be left with uncertainty about what you can expect in the future. Without getting into too much detail about your diagnosis and treatment (you can read more about BPPV here) you are encouraged to do the following:
1) Get informed (learning more about BPPV is a start) and then clarify with your healthcare professionals what their treatment plan is. Ask as many questions as you need. Read some more if you need to. Here is a list of recommended books.
2) Once you feel you have a direction to follow for treatment, stick with it for a set amount of time. Six weeks is a reasonable time frame. During this time, try your very best to stick with the treatment plan and to stay positive.
3) Use the online resources of our Society and your local sources of support. Since you mentioned that there are no specific dizziness support groups, how about you try your community for balance exercises, for example? You can also look for tai chi classes and classes designed for falls prevention. You will most likely find others dealing with similar issues.
4) At the end of your “trial” with this plan, reassess your symptoms and your goals. You may find that you were on the right track, or you may need to start on number one all over again and try a different treatment plan.
Keep in mind that, even if you need to go back and follow a different course of action, that is okay. It will not be forever. Give yourself again about six weeks time and reassess. Stay in the present moment as much as you can, focusing on what you can effectively do right then and there.
The otoliths are a chandelier-like structure hanging from the ceiling of the inner ear. As we move, its canals bend from side to side and we sense these movements. Like a chandelier, this structure is weighted by crystals. These tiny rocks can come loose and fall into the canals causing BPPV (benign paroxysmal positional vertigo).
Every time someone with BPPV does a particular head movement, for example putting their head back to look for something on an upper shelf or rolling over in bed, they get dizzy. This happens because the loose crystals overstimulate the movement sensors in the canal. There are canal-specific manoeuvres that can be performed by a doctor, audiologist or physiotherapist to shift the crystals back to where they belong.
Between 85 to 90% of BPPV affects the posterior canal; for most patients, it is easily fixed using the Epley manoeuvre. The Barbeque Roll (rotational) manoeuvre is used when the horizontal canal is affected. Read more about BPPV and its treatment.
You might have an underlying condition that behaves like BPPV. A second possibility is recurrent BPPV; it can be fixed by a manoeuvre but then comes back. It is also possible that the source of your problem is not in the inner ear, but higher up in your brain. If the sensors in your brain that interpret the information sent by the ear are not working properly, these manoeuvres will be of no use.
Cervical Vertigo
With neck pain, a vestibular therapist tries to narrow down if there is an underlying association between the pain and the dizziness. The therapist often does an assessment of the neck, looking at joint stiffness, stability, and so on. They will put together a lot of different information to try and come to an understanding of the cause. The therapist should be able to identify whether it is a cervicogenic type of dizziness (related to neck movement – think turning your head) or something wrong with the vestibular system (related to head movement – think “lying down in bed”).
Diagnosis
Physiotherapists do not diagnose. Physiotherapists work with you based on how your imbalance or dizziness presents. Well-trained physiotherapists can make a working hypothesis of what is wrong and can help guide your medical doctor or specialist towards a diagnosis.
Vestibular audiologists do diagnostic vestibular testing. They can, for example, test to see if you have bilateral vestibular hypofunction or a bilateral vestibular disorder. Similar to how audiologists can say, “You have a sensory hearing loss,” vestibular audiologists can say, “You have a loss of balance function.” They will not label your disorder, but will say things like, “This balance sensor seems to be 50% functional” or “There is a dysfunction on this or that balance sensor.” This information will be passed on to your doctor to make a diagnosis.
Most of the time, doctors ordering a CT scan or MRI of your temporal bone – the bone enclosing your inner ear – are looking for major structural abnormalities. Usually, they want to see the health of the bone, whether or not it is intact, and if there are any tumours on the balance and hearing nerve or on the structures at the back of your head. An acoustic neuroma, for example, is a benign tumour causing hearing loss and dizziness as it grows around the hearing and balance nerve. Acoustic neuromas show up on an MRI.
Neither CT scans nor MRIs can, however, help diagnose most causes of dizziness and imbalance. Imaging cannot show if the tiny inner-ear balance sensors are working. In summary, the role of medical imaging is to rule out – or in – certain structural causes for balance and dizziness disorders.
Dizziness
If you feel more anxious when on these surfaces, here are some suggestions you could explore.
You may try to first just stand on the edge of that surface. While standing there, just notice your body. “Scan” it with your attention, all the way from the soles of your feet to your head. Notice any areas of tension and soften them if you can. Notice whether your heart is beating fast, your breathing is shallow or you are sweating. If that is happening, take some deep breaths, with a longer out-breath, like a sigh of relief. Intentionally relax and slow down. Take as much time as you need to feel calm, relaxed and safe just standing there.
Then you may also want to work on some sort of habituation to these surfaces. I’d try starting with some walking poles and see if you feel more stable and less like falling when on these types of surfaces. You’d want to try perhaps just a few steps at a time, for just as long as you feel safe. You would want to repeat this several times a week for some practice and exposure. If the process works, you should start to feel that you don’t tense up as much and feel more relaxed. Then you could try using only one pole and repeat until you feel stable. You could then try using no poles and see how you are.
These are the poles we normally recommend, but you may be able to find a cheaper alternative:
Falls
“I’ve started to feel more unbalanced lately, even having a fall. I don’t have any dizziness I’m over 90 years of age. I do the Epley manoeuvre daily, but it doesn’t help. What might be my problem?”
There are many reasons for increasing imbalance without dizziness as we age. Often, there are overlapping reasons. As a starting point, we suggest reading our Age-Related Dizziness and Imbalance page as well as visiting a general practitioner or geriatrician for a thorough physical checkup as well as a referral for testing of your vestibular system.
In addition, a physiotherapist will be able to assess your gait and muscle strength. It is likely that you can make progress towards greater stability be getting and practicing a set of exercises tailored for your needs by a physiotherapist.
The last thing you want is a serious fall. Ask about falls prevention workshops or classes in your area. A family doctor or physiotherapist should be able to help you with tracking down something suitable in your area.
In the meantime, be particularly mindful of your risk of falling, particularly on uneven ground, on stairs, and in the dark. Wear supportive shoes even inside. Our Falls Prevention page has many more tips. A physiotherapist will be able to give you more advice specific to your needs.
The Epley manoeuvre is helpful only for people with one specific condition, BPPV. The hallmark symptom of this condition is brief, spinning dizziness (vertigo) that lasts less than a minute. As you report not being dizzy, it is unlikely you have BPPV. While there is no harm in doing the Epley, it won’t help unless you have BPPV. As a retired engineer, you may find it interesting to read about the physics of displaced crystals in the inner ear on our BPPV page. It is an interesting topic.
Hearing Loss
The diagnostic criteria for Ménière’s disease include having a documented hearing loss on the affected side. A diagnosis of probable Ménière’s disease can be made in the absence of a documented hearing loss, but with a history of fluctuating symptoms (hearing loss, tinnitus or fullness) in the affected ear.
Pain is not a symptom usually associated with otosclerosis. If you suspect otosclerosis, but you are experiencing ear pain, please consult with your ENT doctor (otolaryngologist) again to have your ears re-checked for other causes for pain.
Medications
If vestibular rehabilitation can help you with a balance problem related to medication, it will depend on how the medication has affected your vestibular system, and if you have the ability to activate that part of the vestibular system. For example, there are certain antibiotics, such as gentamicin, that are highly toxic to the vestibular system. People who have taken these antibiotics may have difficulty training their vestibular system because the input from their inner ears may have been affected. If you have imbalance related to less toxic medication, balance training can often help to improve your functioning. If, however, medication has affected your vestibular system, the visual system and peripheral system (dysfunction of the balance organs of the inner ear), the treatment effect might be limited.
Ménière's Disease
The half-somersault manoeuvre is meant to be self-taught and performed, but, depending on how dizzy, fit and healthy you are, it may be difficult to do. It is an alternative to the Epley manoeuvre, which can also be self-administered. You can read more about the half-somersault maoneuvre here.
Alternatively, you can see a vestibular physiotherapist who can help you with the manoeuvres, both teaching you how to do them and performing them for you. You can find a Vestibular Physiotherapist in your area here. Choose “Find a Physio” or “Find a Clinic” and select the “Advanced Search” option. Enter your criteria, including your city.
I couldn’t help but notice that you mentioned in your email that you suffer from Ménière’s Disease. Note that these manoeuvres are aimed at positional vertigo, which may occur in Ménière’s disease. Positional vertigo presents as short-lived episodes of spinning dizziness that occur only when you move your head in certain ways. On the other hand, Ménière’s Disease presents with intense spinning (dizziness) episodes, that come on suddenly, often for no apparent reason. These are often accompanied by vomiting and last for hours. The manoeuvres for positional vertigo are not recommended when these longer and more severe episodes occur.
Yes, some types of vestibular disorders are less responsive to vestibular rehabilitation than others.
The principle of vestibular rehabilitation is to decrease symptoms by training the brain to optimize the use of the inner-ear input and to integrate that input effectively with the visual and proprioceptive information. Sudden changes in inner ear function can produce severe symptoms of vertigo and vomiting but once the inner ear function stabilizes, the brain can be trained to readjust to it.
However, if the nature of the vestibular disorder is to fluctuate or to deteriorate progressively, it can be extremely challenging for the brain to adjust to these repetitive changes. Individuals suffering from Ménière’s disease, for example, are not good candidates for vestibular rehabilitation when they are going through active stages of the disorder in which spells are happening often. Patients with recurrent types of vestibular disorders often benefit more from medical management of the attacks than from vestibular rehabilitation.
One vestibular disorder that does not classically fluctuate but also does not respond well to vestibular rehabilitation is semicircular canal dehiscence (SCD). In cases not treated surgically, avoidance of triggers remains the best management strategy; for example, patients should avoid exposure to loud sounds that can trigger dizziness or imbalance.
Even if vestibular rehabilitation exercises don’t help you, vestibular therapists may be able to educate you on ways to manage your condition or symptoms. Examples include learning how to pace activity, using mobility aids such as a walker or cane, or even just moving more slowly and not doing quick movements that might make you feel dizzy or off balance. A therapist may also work with your on improving your strength and balance to either avoid losing your balance or, if possible, better controlling the force of a fall to minimize injury.
The diagnostic criteria for Ménière’s disease include having a documented hearing loss on the affected side. A diagnosis of probable Ménière’s disease can be made in the absence of a documented hearing loss, but with a history of fluctuating symptoms (hearing loss, tinnitus or fullness) in the affected ear.
All of us experience the need to “pop” our ears when changes in elevation occur. However, people who suffer from Ménière’s disease are more markedly affected by the change in atmospheric pressure. While normal people feel instant relief opening the Eustachian tube and equalizing pressure in the middle ear, people who suffer from Ménière’s Disease also get the inner ear affected by the pressure. This may cause increased tinnitus, dizziness and changes in hearing.
The ventilation tube aims at equalizing the middle ear pressure with the outside environment, but it will likely not change the inner ear effects of the atmospheric pressure changes. Studies done comparing symptoms between groups of people with and without ventilation tubes fail to show a significant improvement in the group with tubes.
In summary, ventilation tubes have been shown to be effective in middle ear disorders (such as fluid behind the eardrum), but may not alleviate inner ear symptoms associated with changes in atmospheric pressure. The tube may help equalize the pressure and you may feel less of an urge to “pop,” but you may continue to experience these symptoms due to the inner ear disorder. Make sure to discuss pros and cons of having ventilation tubes put in with your ENT doctor (otolaryngologist). Read more about Ménière’s disease.
The relationship between changes in barometric pressure and dizziness has been described in medical literature, particularly in patients suffering from migraine related vertigo and Ménière’s disease. Both of these vestibular disorders are characterized by an episodic nature. This means that the symptoms come and go, in spells.
For some people, these episodes can be triggered by changes in atmospheric pressure, such as weather changes before a storm or travelling from sea level to higher altitude. Read our post on Facebook about this topic.
You mention the recurrent nature of your dizziness – vestibular neuritis is not classically recurrent like you describe. It is usually caused by a single viral or bacterial attack on the vestibular nerve. Symptoms typically start quite suddenly and may include severe vertigo and vomiting lasting for several hours. This is due to a loss in function of the vestibular nerve that can be temporary or permanent. During the recovery stage, which can last for several weeks, symptoms gradually improve and plateau.
We recommend speaking to your family doctor and/or your ENT doctor (otolaryngologist) about the episodic/recurrent nature of your dizziness and vasovagal spells. Further investigation may be warranted into their cause.
Complex vestibular disorders are challenging to treat. For example, it can be very difficult to tease out the symptoms that distinguish Ménière’s disease or migrainous vertigo; they have very similar symptoms, but are treated very differently.
More complex cases are very individual and cannot always be pigeon-holed as Ménière’s or migrainous vertigo or some other particular disorder link i en blogg. Patients may have some but not all of the characteristics of Ménière’s disease, for example, and that is frustrating for doctors.
About a third of patients benefit from medications such as betahistine. Others benefit from a reduced salt diet and other dietary changes. When spells happen often and quality of life is reduced, intratympanic (within the middle ear) steroid injections may be used by the ear specialist (otologist). The objective of the injections is to prevent or reduce further attacks as each attack results in a further loss of hearing and balance. Read more about Ménière’s disease.
Vestibular rehabilitation usually does not help in the early stages of Ménière’s disease. Patients will have attacks that can neither be predicted nor be kept under control with exercises. Vestibular rehabilitation does not work well when a patient’s condition fluctuates – that is, good hearing and balance between attacks and poor during attacks.
With continued attacks, patients lose much of their hearing and balance. Once the balance function is greatly diminished and does not change a lot when in or between attacks, the patient is a candidate for vestibular rehabilitation. If a patient has lost balance function on one side, the brain can be trained to compensate for the loss; however, it takes practice.
Migrainous Vertigo
If there are signs of vestibular dysfunction, vestibular rehabilitation may help because the migraine has affected the functioning of the vestibular system. However, if there is more permanent damage or it is a chronic long-term condition that happens over years and years, vestibular rehabilitation might get people used to (habituated) to some of the symptoms. Vestibular therapists can also educate people on how to avoid possible triggers that could worsen their migraines. For example, avoiding processed foods, stress or certain modifiable factors.
Motion sickness and an overall reduced tolerance to movement is often reported in patients who suffer from migraine. The recommendation is to treat the migraine first. When migrainous episodes are under control, patients benefit greatly from vestibular rehabilitation aimed at increasing motion tolerance. Identifying and avoiding triggers is one way to keep migraines under control as well reduce the number of episodes. Triggers include stress, foods (e.g., cheese), alcohol (e.g., red wine), smells. Preventative medications can also be used to avoid migraine episodes from happening.
The relationship between changes in barometric pressure and dizziness has been described in medical literature, particularly in patients suffering from migraine related vertigo and Ménière’s disease. Both of these vestibular disorders are characterized by an episodic nature. This means that the symptoms come and go, in spells.
For some people, these episodes can be triggered by changes in atmospheric pressure, such as weather changes before a storm or travelling from sea level to higher altitude. Read our post on Facebook about this topic.
You mention the recurrent nature of your dizziness – vestibular neuritis is not classically recurrent like you describe. It is usually caused by a single viral or bacterial attack on the vestibular nerve. Symptoms typically start quite suddenly and may include severe vertigo and vomiting lasting for several hours. This is due to a loss in function of the vestibular nerve that can be temporary or permanent. During the recovery stage, which can last for several weeks, symptoms gradually improve and plateau.
We recommend speaking to your family doctor and/or your ENT doctor (otolaryngologist) about the episodic/recurrent nature of your dizziness and vasovagal spells. Further investigation may be warranted into their cause.
Not all specialists have a particular interest or specialization in vestibular migraine. Ask your referring doctor to match you to one who does. For example, some neuro-otologists, neurologists and neuro-ophthalmologists are comfortable diagnosing and managing headache disorders, including vestibular migraine. This is less common, however, for generalist otologists (ear, nose and throat doctors). Some physiotherapists may be knowledgeable about headaches. Many, however, are more interested in balance and muscle- and joint-related issues. Read more about vestibular migraine.
Complex vestibular disorders are challenging to treat. For example, it can be very difficult to tease out the symptoms that distinguish Ménière’s disease or migrainous vertigo; they have very similar symptoms, but are treated very differently.
More complex cases are very individual and cannot always be pigeon-holed as Ménière’s or migrainous vertigo or some other particular disorder link i en blogg. Patients may have some but not all of the characteristics of Ménière’s disease, for example, and that is frustrating for doctors.
Motion Sensitivity
If your problem is “central positional nystagmus,” the treatment approach is through habituation. Instead of having Epley or other manoeuvres performed, you can try Brandt-Daroff or other vestibular rehabilitation exercises. These habituation exercises retrain the brain and are beneficial for most patients. They are helpful for both peripheral and central types of dizziness.
If you are motion sensitive, you can start by doing tiny doses of movements that make you feel nauseated. For example, move your head back and forth for just 30 seconds. Then push yourself for one or two seconds longer and give your brain a chance to overcome the feeling of nausea. Gradually, your brain will get habituated to more motion.
If done properly and routinely, those with motion sensitivity, BPPV or central positional nystagmus should start to feel some benefit from habituation exercises in three to four weeks and feel a lot better in about five to six weeks. If you are unsure how to do these exercises, have back or neck problems, or can’t do them quickly enough on your own, have a physiotherapist, audiologist or ENT (otolaryngologist) do them.
If you feel more anxious when on these surfaces, here are some suggestions you could explore.
You may try to first just stand on the edge of that surface. While standing there, just notice your body. “Scan” it with your attention, all the way from the soles of your feet to your head. Notice any areas of tension and soften them if you can. Notice whether your heart is beating fast, your breathing is shallow or you are sweating. If that is happening, take some deep breaths, with a longer out-breath, like a sigh of relief. Intentionally relax and slow down. Take as much time as you need to feel calm, relaxed and safe just standing there.
Then you may also want to work on some sort of habituation to these surfaces. I’d try starting with some walking poles and see if you feel more stable and less like falling when on these types of surfaces. You’d want to try perhaps just a few steps at a time, for just as long as you feel safe. You would want to repeat this several times a week for some practice and exposure. If the process works, you should start to feel that you don’t tense up as much and feel more relaxed. Then you could try using only one pole and repeat until you feel stable. You could then try using no poles and see how you are.
These are the poles we normally recommend, but you may be able to find a cheaper alternative:
The balance system is complex and in fact involves 3 major sensory input systems, all controlled by the brain. The inner ear sensors for balance, eyes and the proprioceptors on the body all send information to the brain. Balance centres receive, analyze and integrate these bits of information and then send orders to the body to readjust according to the movement done in the first place.
When you are dizzy with computer use, it usually means that the balance system is relying more heavily on the visual input. It is not fully reassured by the inner ear sensors telling them you are not moving. For more information, read our Motion and Cyber Sickness article.
Having the weights on you or changing your posture as you walk is increasing the cues coming from the proprioceptive system to the brain. This additional input seems to help you balance.
I would recommend you to have your inner ear sensors tested. It might be that they are working just fine but your centres in the brain are not using their information properly or it might be that your brain is in need of all this additional information (visual and proprioception) because your inner ear sensors are dysfunctional.
It is very common to have dizziness triggered by watching things move, as opposed to moving oneself. Many people feel dizzy in busy visual environments, such as browsing in a crowded grocery store, at busy intersections, or even seeing someone carrying a boldly striped bag. This problem is caused by your brain not being able to match up the information coming from your eyes, your inner ear and the proprioception sensors on your joints. When you watch a 3-D movie, your eyes follow things around as if you were actually moving. If your brain is hard-wired to believe your eyes more than your inner ear or body, the message from your eyes will dominate and you’ll feel dizzy.
A treatment for visually-stimulated vertigo consists of watching things in motion. Repeatedly watching full-screen versions of the NED Leader (right and left) video clips on YouTube is recommended. When you get the feeling that you want to look away, watch for three to five seconds longer. Becoming accustomed to doing the tai chi “cloud hands” movement follows the same principle; it habituates your brain to the movement of your hands. Read more about motion and cyber sickness.
Below are some optokinetic videos.
Once you are used to these, try this one:
The following playlists compile complex exercises:
Otosclerosis
Pain is not a symptom usually associated with otosclerosis. If you suspect otosclerosis, but you are experiencing ear pain, please consult with your ENT doctor (otolaryngologist) again to have your ears re-checked for other causes for pain.
Positional Vertigo
The half-somersault manoeuvre is meant to be self-taught and performed, but, depending on how dizzy, fit and healthy you are, it may be difficult to do. It is an alternative to the Epley manoeuvre, which can also be self-administered. You can read more about the half-somersault maoneuvre here.
Alternatively, you can see a vestibular physiotherapist who can help you with the manoeuvres, both teaching you how to do them and performing them for you. You can find a Vestibular Physiotherapist in your area here. Choose “Find a Physio” or “Find a Clinic” and select the “Advanced Search” option. Enter your criteria, including your city.
I couldn’t help but notice that you mentioned in your email that you suffer from Ménière’s Disease. Note that these manoeuvres are aimed at positional vertigo, which may occur in Ménière’s disease. Positional vertigo presents as short-lived episodes of spinning dizziness that occur only when you move your head in certain ways. On the other hand, Ménière’s Disease presents with intense spinning (dizziness) episodes, that come on suddenly, often for no apparent reason. These are often accompanied by vomiting and last for hours. The manoeuvres for positional vertigo are not recommended when these longer and more severe episodes occur.
PPPD
Vestibular therapy can help with the ongoing motion sensitivity of PPPD. Therapy is used to try and dampen down a person’s sensitivity to movement and their sensitivity to visual stimuli, with the goal of trying to get them used to movement. If someone has been living in fear of movement and is quite anxious, vestibular therapy tries to bring down some of those underlying factors. By gradually practicing movements and activities over time, people with PPPD get more comfortable with day-to-day movement.
There are many causes for dizziness and balance disorders, including life-threatening conditions. The CT and MRI scans you had were to rule out more serious causes for vertigo. They are not meant to find out exactly what is happening. When the scans come back clear, your primary care physician may try medications that are available and see what happens.
However, the vestibular/balance system is very complex and sometimes the cause is neither sinister nor straight forward. An example is Persistent Postural-Perceptual Dizziness (PPPD).
In less straight-forward cases, specialized professionals and/or diagnostic testing may be needed to lead you to understanding what is causing your dizziness and to implement appropriate management strategies.
The road to diagnosis and management of a dizziness and balance disorder is often a journey and we understand that it can be confusing and frustrating.
Self Help
“I’ve started to feel more unbalanced lately, even having a fall. I don’t have any dizziness I’m over 90 years of age. I do the Epley manoeuvre daily, but it doesn’t help. What might be my problem?”
There are many reasons for increasing imbalance without dizziness as we age. Often, there are overlapping reasons. As a starting point, we suggest reading our Age-Related Dizziness and Imbalance page as well as visiting a general practitioner or geriatrician for a thorough physical checkup as well as a referral for testing of your vestibular system.
In addition, a physiotherapist will be able to assess your gait and muscle strength. It is likely that you can make progress towards greater stability be getting and practicing a set of exercises tailored for your needs by a physiotherapist.
The last thing you want is a serious fall. Ask about falls prevention workshops or classes in your area. A family doctor or physiotherapist should be able to help you with tracking down something suitable in your area.
In the meantime, be particularly mindful of your risk of falling, particularly on uneven ground, on stairs, and in the dark. Wear supportive shoes even inside. Our Falls Prevention page has many more tips. A physiotherapist will be able to give you more advice specific to your needs.
The Epley manoeuvre is helpful only for people with one specific condition, BPPV. The hallmark symptom of this condition is brief, spinning dizziness (vertigo) that lasts less than a minute. As you report not being dizzy, it is unlikely you have BPPV. While there is no harm in doing the Epley, it won’t help unless you have BPPV. As a retired engineer, you may find it interesting to read about the physics of displaced crystals in the inner ear on our BPPV page. It is an interesting topic.
The half-somersault manoeuvre is meant to be self-taught and performed, but, depending on how dizzy, fit and healthy you are, it may be difficult to do. It is an alternative to the Epley manoeuvre, which can also be self-administered. You can read more about the half-somersault maoneuvre here.
Alternatively, you can see a vestibular physiotherapist who can help you with the manoeuvres, both teaching you how to do them and performing them for you. You can find a Vestibular Physiotherapist in your area here. Choose “Find a Physio” or “Find a Clinic” and select the “Advanced Search” option. Enter your criteria, including your city.
I couldn’t help but notice that you mentioned in your email that you suffer from Ménière’s Disease. Note that these manoeuvres are aimed at positional vertigo, which may occur in Ménière’s disease. Positional vertigo presents as short-lived episodes of spinning dizziness that occur only when you move your head in certain ways. On the other hand, Ménière’s Disease presents with intense spinning (dizziness) episodes, that come on suddenly, often for no apparent reason. These are often accompanied by vomiting and last for hours. The manoeuvres for positional vertigo are not recommended when these longer and more severe episodes occur.
The balance system is complex and in fact involves 3 major sensory input systems, all controlled by the brain. The inner ear sensors for balance, eyes and the proprioceptors on the body all send information to the brain. Balance centres receive, analyze and integrate these bits of information and then send orders to the body to readjust according to the movement done in the first place.
When you are dizzy with computer use, it usually means that the balance system is relying more heavily on the visual input. It is not fully reassured by the inner ear sensors telling them you are not moving. For more information, read our Motion and Cyber Sickness article.
Having the weights on you or changing your posture as you walk is increasing the cues coming from the proprioceptive system to the brain. This additional input seems to help you balance.
I would recommend you to have your inner ear sensors tested. It might be that they are working just fine but your centres in the brain are not using their information properly or it might be that your brain is in need of all this additional information (visual and proprioception) because your inner ear sensors are dysfunctional.
Tai Chi
You have expressed the feelings of many people affected by dizziness! It is not always easy to find support in your community; you end up seeing quite a few professionals and they are not always on the same page as to your diagnosis and treatment plan. You may be left with uncertainty about what you can expect in the future. Without getting into too much detail about your diagnosis and treatment (you can read more about BPPV here) you are encouraged to do the following:
1) Get informed (learning more about BPPV is a start) and then clarify with your healthcare professionals what their treatment plan is. Ask as many questions as you need. Read some more if you need to. Here is a list of recommended books.
2) Once you feel you have a direction to follow for treatment, stick with it for a set amount of time. Six weeks is a reasonable time frame. During this time, try your very best to stick with the treatment plan and to stay positive.
3) Use the online resources of our Society and your local sources of support. Since you mentioned that there are no specific dizziness support groups, how about you try your community for balance exercises, for example? You can also look for tai chi classes and classes designed for falls prevention. You will most likely find others dealing with similar issues.
4) At the end of your “trial” with this plan, reassess your symptoms and your goals. You may find that you were on the right track, or you may need to start on number one all over again and try a different treatment plan.
Keep in mind that, even if you need to go back and follow a different course of action, that is okay. It will not be forever. Give yourself again about six weeks time and reassess. Stay in the present moment as much as you can, focusing on what you can effectively do right then and there.
Tinnitus
The diagnostic criteria for Ménière’s disease include having a documented hearing loss on the affected side. A diagnosis of probable Ménière’s disease can be made in the absence of a documented hearing loss, but with a history of fluctuating symptoms (hearing loss, tinnitus or fullness) in the affected ear.
Vestibular Disorders
“I’ve started to feel more unbalanced lately, even having a fall. I don’t have any dizziness I’m over 90 years of age. I do the Epley manoeuvre daily, but it doesn’t help. What might be my problem?”
There are many reasons for increasing imbalance without dizziness as we age. Often, there are overlapping reasons. As a starting point, we suggest reading our Age-Related Dizziness and Imbalance page as well as visiting a general practitioner or geriatrician for a thorough physical checkup as well as a referral for testing of your vestibular system.
In addition, a physiotherapist will be able to assess your gait and muscle strength. It is likely that you can make progress towards greater stability be getting and practicing a set of exercises tailored for your needs by a physiotherapist.
The last thing you want is a serious fall. Ask about falls prevention workshops or classes in your area. A family doctor or physiotherapist should be able to help you with tracking down something suitable in your area.
In the meantime, be particularly mindful of your risk of falling, particularly on uneven ground, on stairs, and in the dark. Wear supportive shoes even inside. Our Falls Prevention page has many more tips. A physiotherapist will be able to give you more advice specific to your needs.
The Epley manoeuvre is helpful only for people with one specific condition, BPPV. The hallmark symptom of this condition is brief, spinning dizziness (vertigo) that lasts less than a minute. As you report not being dizzy, it is unlikely you have BPPV. While there is no harm in doing the Epley, it won’t help unless you have BPPV. As a retired engineer, you may find it interesting to read about the physics of displaced crystals in the inner ear on our BPPV page. It is an interesting topic.
Physiotherapists do not diagnose. Physiotherapists work with you based on how your imbalance or dizziness presents. Well-trained physiotherapists can make a working hypothesis of what is wrong and can help guide your medical doctor or specialist towards a diagnosis.
Vestibular audiologists do diagnostic vestibular testing. They can, for example, test to see if you have bilateral vestibular hypofunction or a bilateral vestibular disorder. Similar to how audiologists can say, “You have a sensory hearing loss,” vestibular audiologists can say, “You have a loss of balance function.” They will not label your disorder, but will say things like, “This balance sensor seems to be 50% functional” or “There is a dysfunction on this or that balance sensor.” This information will be passed on to your doctor to make a diagnosis.
The diagnostic criteria for Ménière’s disease include having a documented hearing loss on the affected side. A diagnosis of probable Ménière’s disease can be made in the absence of a documented hearing loss, but with a history of fluctuating symptoms (hearing loss, tinnitus or fullness) in the affected ear.
Pain is not a symptom usually associated with otosclerosis. If you suspect otosclerosis, but you are experiencing ear pain, please consult with your ENT doctor (otolaryngologist) again to have your ears re-checked for other causes for pain.
Vision is an essential part of the balance system. It works with the inner ear sensors for balance, the proprioceptors (sensation of touch) and the brain to keep us balanced. Any vision problems can negatively affect your balance and should, therefore, be addressed as much as possible. In general, the vision improvement after a successful cataract surgery has a positive impact on balance and quality of life.
We would recommend that you consult with your family doctor (GP) since you have been feeling dizzy for a few days days and the symptoms have not subsided spontaneously. Should you have other symptoms or your current symptoms become acute, we recommend you go to the nearest emergency services. For instance, if you are vomiting, you could become dangerously dehydrated.
Your family doctor will be able to identify any risk factors for dizziness in your medical history and on your medication list. They will obtain a detailed description of your dizziness and other associated symptoms and may perform some clinical tests to decide whether a referral to an ENT doctor (otolaryngologist), neurologist or any other specialist, such as a vestibular therapist, is warranted.
Often the vestibular therapist can provide you with a trial rehabilitation program while you wait to the see the specialists. This program may be effective in addressing your symptoms and may therefore be worthwhile exploring sooner rather than later. Visit our Health Professionals Directory to find a qualified provider near you.
The balance system is complex and involves the brain analyzing and interpreting information from three major systems: the inner ear sensors for balance (vestibular system), the visual system, and the sensation that goes from the skin, muscles and joints (proprioceptive system).
Any sensation of dizziness and imbalance may result when one or more of these four parts are not functioning well. Therefore, the perceived asymmetries you experience may stem from the vestibular organs, from the proprioceptive system and/or from the brain’s processing of the their information. You did not mention visual issues, but treating these symptoms often involve also addressing the processing of visual information, with and without head movements.
You may wish to pursue assessments to clarify whether you do have asymmetries in your balance system, namely a vestibular assessment (for the inner ear sensors and their connections with eyes and brain) and a physiotherapy assessment, for the proprioceptive and musculo-skeletal systems. Proper treatment/rehabilitation can then be tailored to your needs.
Gravol is a drug that acts on the central nervous system. It can be thought of as a numbing agent. It reduces the sensitivity of your central nervous system, and it usually works very well at reducing nausea. It is a symptomatic medication. If it helps you, it will not tell you the reason for your nausea. If you respond to Gravol, that is good because you will have less symptoms. But your healthcare team will need to continue to dig deeper to understand why you are having nausea.
Most of the time, doctors ordering a CT scan or MRI of your temporal bone – the bone enclosing your inner ear – are looking for major structural abnormalities. Usually, they want to see the health of the bone, whether or not it is intact, and if there are any tumours on the balance and hearing nerve or on the structures at the back of your head. An acoustic neuroma, for example, is a benign tumour causing hearing loss and dizziness as it grows around the hearing and balance nerve. Acoustic neuromas show up on an MRI.
Neither CT scans nor MRIs can, however, help diagnose most causes of dizziness and imbalance. Imaging cannot show if the tiny inner-ear balance sensors are working. In summary, the role of medical imaging is to rule out – or in – certain structural causes for balance and dizziness disorders.
Vestibular audiologists report on the results of hearing, balance and vestibular function tests. If you had a VEMP test, they may say, “Your utricle and saccule are within normal range.” Or, they may say, “Your water test was normal or abnormal.” Ask for a written report of hearing tests as well as diagnostic tests of the balance sensors in your inner ear. Get an understanding of what these reports mean by reading our Diagnostic Tests for Balance and Dizziness Disorders.
It is great that you notice that you are hyperventilating. From that awareness, you can try voluntarily changing your breathing pattern. Slowing down, holding your breath in for at least three seconds improves your oxygenation. Another conscious effort you can make is to breathe deep into your belly. Place your hand on your abdomen and feel it expanding as you breathe in and contract as you breathe out.
There are many causes for dizziness and balance disorders, including life-threatening conditions. The CT and MRI scans you had were to rule out more serious causes for vertigo. They are not meant to find out exactly what is happening. When the scans come back clear, your primary care physician may try medications that are available and see what happens.
However, the vestibular/balance system is very complex and sometimes the cause is neither sinister nor straight forward. An example is Persistent Postural-Perceptual Dizziness (PPPD).
In less straight-forward cases, specialized professionals and/or diagnostic testing may be needed to lead you to understanding what is causing your dizziness and to implement appropriate management strategies.
The road to diagnosis and management of a dizziness and balance disorder is often a journey and we understand that it can be confusing and frustrating.
Vestibular Migraine
If there are signs of vestibular dysfunction, vestibular rehabilitation may help because the migraine has affected the functioning of the vestibular system. However, if there is more permanent damage or it is a chronic long-term condition that happens over years and years, vestibular rehabilitation might get people used to (habituated) to some of the symptoms. Vestibular therapists can also educate people on how to avoid possible triggers that could worsen their migraines. For example, avoiding processed foods, stress or certain modifiable factors.
Not all specialists have a particular interest or specialization in vestibular migraine. Ask your referring doctor to match you to one who does. For example, some neuro-otologists, neurologists and neuro-ophthalmologists are comfortable diagnosing and managing headache disorders, including vestibular migraine. This is less common, however, for generalist otologists (ear, nose and throat doctors). Some physiotherapists may be knowledgeable about headaches. Many, however, are more interested in balance and muscle- and joint-related issues. Read more about vestibular migraine.
Complex vestibular disorders are challenging to treat. For example, it can be very difficult to tease out the symptoms that distinguish Ménière’s disease or migrainous vertigo; they have very similar symptoms, but are treated very differently.
More complex cases are very individual and cannot always be pigeon-holed as Ménière’s or migrainous vertigo or some other particular disorder link i en blogg. Patients may have some but not all of the characteristics of Ménière’s disease, for example, and that is frustrating for doctors.
Vestibular Neuritis
The relationship between changes in barometric pressure and dizziness has been described in medical literature, particularly in patients suffering from migraine related vertigo and Ménière’s disease. Both of these vestibular disorders are characterized by an episodic nature. This means that the symptoms come and go, in spells.
For some people, these episodes can be triggered by changes in atmospheric pressure, such as weather changes before a storm or travelling from sea level to higher altitude. Read our post on Facebook about this topic.
You mention the recurrent nature of your dizziness – vestibular neuritis is not classically recurrent like you describe. It is usually caused by a single viral or bacterial attack on the vestibular nerve. Symptoms typically start quite suddenly and may include severe vertigo and vomiting lasting for several hours. This is due to a loss in function of the vestibular nerve that can be temporary or permanent. During the recovery stage, which can last for several weeks, symptoms gradually improve and plateau.
We recommend speaking to your family doctor and/or your ENT doctor (otolaryngologist) about the episodic/recurrent nature of your dizziness and vasovagal spells. Further investigation may be warranted into their cause.
Vestibular Rehabilitation
“I’ve started to feel more unbalanced lately, even having a fall. I don’t have any dizziness I’m over 90 years of age. I do the Epley manoeuvre daily, but it doesn’t help. What might be my problem?”
There are many reasons for increasing imbalance without dizziness as we age. Often, there are overlapping reasons. As a starting point, we suggest reading our Age-Related Dizziness and Imbalance page as well as visiting a general practitioner or geriatrician for a thorough physical checkup as well as a referral for testing of your vestibular system.
In addition, a physiotherapist will be able to assess your gait and muscle strength. It is likely that you can make progress towards greater stability be getting and practicing a set of exercises tailored for your needs by a physiotherapist.
The last thing you want is a serious fall. Ask about falls prevention workshops or classes in your area. A family doctor or physiotherapist should be able to help you with tracking down something suitable in your area.
In the meantime, be particularly mindful of your risk of falling, particularly on uneven ground, on stairs, and in the dark. Wear supportive shoes even inside. Our Falls Prevention page has many more tips. A physiotherapist will be able to give you more advice specific to your needs.
The Epley manoeuvre is helpful only for people with one specific condition, BPPV. The hallmark symptom of this condition is brief, spinning dizziness (vertigo) that lasts less than a minute. As you report not being dizzy, it is unlikely you have BPPV. While there is no harm in doing the Epley, it won’t help unless you have BPPV. As a retired engineer, you may find it interesting to read about the physics of displaced crystals in the inner ear on our BPPV page. It is an interesting topic.
With neck pain, a vestibular therapist tries to narrow down if there is an underlying association between the pain and the dizziness. The therapist often does an assessment of the neck, looking at joint stiffness, stability, and so on. They will put together a lot of different information to try and come to an understanding of the cause. The therapist should be able to identify whether it is a cervicogenic type of dizziness (related to neck movement – think turning your head) or something wrong with the vestibular system (related to head movement – think “lying down in bed”).
The half-somersault manoeuvre is meant to be self-taught and performed, but, depending on how dizzy, fit and healthy you are, it may be difficult to do. It is an alternative to the Epley manoeuvre, which can also be self-administered. You can read more about the half-somersault maoneuvre here.
Alternatively, you can see a vestibular physiotherapist who can help you with the manoeuvres, both teaching you how to do them and performing them for you. You can find a Vestibular Physiotherapist in your area here. Choose “Find a Physio” or “Find a Clinic” and select the “Advanced Search” option. Enter your criteria, including your city.
I couldn’t help but notice that you mentioned in your email that you suffer from Ménière’s Disease. Note that these manoeuvres are aimed at positional vertigo, which may occur in Ménière’s disease. Positional vertigo presents as short-lived episodes of spinning dizziness that occur only when you move your head in certain ways. On the other hand, Ménière’s Disease presents with intense spinning (dizziness) episodes, that come on suddenly, often for no apparent reason. These are often accompanied by vomiting and last for hours. The manoeuvres for positional vertigo are not recommended when these longer and more severe episodes occur.
Yes, some types of vestibular disorders are less responsive to vestibular rehabilitation than others.
The principle of vestibular rehabilitation is to decrease symptoms by training the brain to optimize the use of the inner-ear input and to integrate that input effectively with the visual and proprioceptive information. Sudden changes in inner ear function can produce severe symptoms of vertigo and vomiting but once the inner ear function stabilizes, the brain can be trained to readjust to it.
However, if the nature of the vestibular disorder is to fluctuate or to deteriorate progressively, it can be extremely challenging for the brain to adjust to these repetitive changes. Individuals suffering from Ménière’s disease, for example, are not good candidates for vestibular rehabilitation when they are going through active stages of the disorder in which spells are happening often. Patients with recurrent types of vestibular disorders often benefit more from medical management of the attacks than from vestibular rehabilitation.
One vestibular disorder that does not classically fluctuate but also does not respond well to vestibular rehabilitation is semicircular canal dehiscence (SCD). In cases not treated surgically, avoidance of triggers remains the best management strategy; for example, patients should avoid exposure to loud sounds that can trigger dizziness or imbalance.
Even if vestibular rehabilitation exercises don’t help you, vestibular therapists may be able to educate you on ways to manage your condition or symptoms. Examples include learning how to pace activity, using mobility aids such as a walker or cane, or even just moving more slowly and not doing quick movements that might make you feel dizzy or off balance. A therapist may also work with your on improving your strength and balance to either avoid losing your balance or, if possible, better controlling the force of a fall to minimize injury.
Vestibular therapy can help with the ongoing motion sensitivity of PPPD. Therapy is used to try and dampen down a person’s sensitivity to movement and their sensitivity to visual stimuli, with the goal of trying to get them used to movement. If someone has been living in fear of movement and is quite anxious, vestibular therapy tries to bring down some of those underlying factors. By gradually practicing movements and activities over time, people with PPPD get more comfortable with day-to-day movement.
If vestibular rehabilitation can help you with a balance problem related to medication, it will depend on how the medication has affected your vestibular system, and if you have the ability to activate that part of the vestibular system. For example, there are certain antibiotics, such as gentamicin, that are highly toxic to the vestibular system. People who have taken these antibiotics may have difficulty training their vestibular system because the input from their inner ears may have been affected. If you have imbalance related to less toxic medication, balance training can often help to improve your functioning. If, however, medication has affected your vestibular system, the visual system and peripheral system (dysfunction of the balance organs of the inner ear), the treatment effect might be limited.
In general, there is nothing in particular that links vestibular exercises to making the crystals dislodge from where they belong, and thereby causing BPPV. Vestibular therapists have people doing a lot of different activities – in general, these are exercises done in an upright position, whereas BPPV is typically brought on by laying the head back. Vestibular exercises done for vestibulo-ocular reflex (VOR) or for balance do not tend to provoke BPPV. If BPPV is going to happen, it is going to happen – there is really no rhyme nor reason why the crystals tend to slide into a semicircular canal. And if they do, it is fairly easy for a vestibular therapist to correct.
You might feel a bit off balance, dizzy and/or nauseous for a day or two after an Epley manoeuvre, but these symptoms should settle down over time. For the most part, people tolerate the Epley manoeuvre quite well. If the therapist does repeated Epley or other manoeuvres – one, after the other, after the other – and your situation does not improve, it may be that something other than BPPV is causing your dizziness. In that case, following up with your vestibular professional and getting reassessed may help narrow down the cause.
If there are signs of vestibular dysfunction, vestibular rehabilitation may help because the migraine has affected the functioning of the vestibular system. However, if there is more permanent damage or it is a chronic long-term condition that happens over years and years, vestibular rehabilitation might get people used to (habituated) to some of the symptoms. Vestibular therapists can also educate people on how to avoid possible triggers that could worsen their migraines. For example, avoiding processed foods, stress or certain modifiable factors.
Motion sickness and an overall reduced tolerance to movement is often reported in patients who suffer from migraine. The recommendation is to treat the migraine first. When migrainous episodes are under control, patients benefit greatly from vestibular rehabilitation aimed at increasing motion tolerance. Identifying and avoiding triggers is one way to keep migraines under control as well reduce the number of episodes. Triggers include stress, foods (e.g., cheese), alcohol (e.g., red wine), smells. Preventative medications can also be used to avoid migraine episodes from happening.
You have expressed the feelings of many people affected by dizziness! It is not always easy to find support in your community; you end up seeing quite a few professionals and they are not always on the same page as to your diagnosis and treatment plan. You may be left with uncertainty about what you can expect in the future. Without getting into too much detail about your diagnosis and treatment (you can read more about BPPV here) you are encouraged to do the following:
1) Get informed (learning more about BPPV is a start) and then clarify with your healthcare professionals what their treatment plan is. Ask as many questions as you need. Read some more if you need to. Here is a list of recommended books.
2) Once you feel you have a direction to follow for treatment, stick with it for a set amount of time. Six weeks is a reasonable time frame. During this time, try your very best to stick with the treatment plan and to stay positive.
3) Use the online resources of our Society and your local sources of support. Since you mentioned that there are no specific dizziness support groups, how about you try your community for balance exercises, for example? You can also look for tai chi classes and classes designed for falls prevention. You will most likely find others dealing with similar issues.
4) At the end of your “trial” with this plan, reassess your symptoms and your goals. You may find that you were on the right track, or you may need to start on number one all over again and try a different treatment plan.
Keep in mind that, even if you need to go back and follow a different course of action, that is okay. It will not be forever. Give yourself again about six weeks time and reassess. Stay in the present moment as much as you can, focusing on what you can effectively do right then and there.
If your problem is “central positional nystagmus,” the treatment approach is through habituation. Instead of having Epley or other manoeuvres performed, you can try Brandt-Daroff or other vestibular rehabilitation exercises. These habituation exercises retrain the brain and are beneficial for most patients. They are helpful for both peripheral and central types of dizziness.
If you are motion sensitive, you can start by doing tiny doses of movements that make you feel nauseated. For example, move your head back and forth for just 30 seconds. Then push yourself for one or two seconds longer and give your brain a chance to overcome the feeling of nausea. Gradually, your brain will get habituated to more motion.
If done properly and routinely, those with motion sensitivity, BPPV or central positional nystagmus should start to feel some benefit from habituation exercises in three to four weeks and feel a lot better in about five to six weeks. If you are unsure how to do these exercises, have back or neck problems, or can’t do them quickly enough on your own, have a physiotherapist, audiologist or ENT (otolaryngologist) do them.
The balance system is complex and involves the brain analyzing and interpreting information from three major systems: the inner ear sensors for balance (vestibular system), the visual system, and the sensation that goes from the skin, muscles and joints (proprioceptive system).
Any sensation of dizziness and imbalance may result when one or more of these four parts are not functioning well. Therefore, the perceived asymmetries you experience may stem from the vestibular organs, from the proprioceptive system and/or from the brain’s processing of the their information. You did not mention visual issues, but treating these symptoms often involve also addressing the processing of visual information, with and without head movements.
You may wish to pursue assessments to clarify whether you do have asymmetries in your balance system, namely a vestibular assessment (for the inner ear sensors and their connections with eyes and brain) and a physiotherapy assessment, for the proprioceptive and musculo-skeletal systems. Proper treatment/rehabilitation can then be tailored to your needs.
You might have an underlying condition that behaves like BPPV. A second possibility is recurrent BPPV; it can be fixed by a manoeuvre but then comes back. It is also possible that the source of your problem is not in the inner ear, but higher up in your brain. If the sensors in your brain that interpret the information sent by the ear are not working properly, these manoeuvres will be of no use.
If you feel more anxious when on these surfaces, here are some suggestions you could explore.
You may try to first just stand on the edge of that surface. While standing there, just notice your body. “Scan” it with your attention, all the way from the soles of your feet to your head. Notice any areas of tension and soften them if you can. Notice whether your heart is beating fast, your breathing is shallow or you are sweating. If that is happening, take some deep breaths, with a longer out-breath, like a sigh of relief. Intentionally relax and slow down. Take as much time as you need to feel calm, relaxed and safe just standing there.
Then you may also want to work on some sort of habituation to these surfaces. I’d try starting with some walking poles and see if you feel more stable and less like falling when on these types of surfaces. You’d want to try perhaps just a few steps at a time, for just as long as you feel safe. You would want to repeat this several times a week for some practice and exposure. If the process works, you should start to feel that you don’t tense up as much and feel more relaxed. Then you could try using only one pole and repeat until you feel stable. You could then try using no poles and see how you are.
These are the poles we normally recommend, but you may be able to find a cheaper alternative:
It is very common to have dizziness triggered by watching things move, as opposed to moving oneself. Many people feel dizzy in busy visual environments, such as browsing in a crowded grocery store, at busy intersections, or even seeing someone carrying a boldly striped bag. This problem is caused by your brain not being able to match up the information coming from your eyes, your inner ear and the proprioception sensors on your joints. When you watch a 3-D movie, your eyes follow things around as if you were actually moving. If your brain is hard-wired to believe your eyes more than your inner ear or body, the message from your eyes will dominate and you’ll feel dizzy.
A treatment for visually-stimulated vertigo consists of watching things in motion. Repeatedly watching full-screen versions of the NED Leader (right and left) video clips on YouTube is recommended. When you get the feeling that you want to look away, watch for three to five seconds longer. Becoming accustomed to doing the tai chi “cloud hands” movement follows the same principle; it habituates your brain to the movement of your hands. Read more about motion and cyber sickness.
Below are some optokinetic videos.
Once you are used to these, try this one:
The following playlists compile complex exercises:
Vestibular rehabilitation usually does not help in the early stages of Ménière’s disease. Patients will have attacks that can neither be predicted nor be kept under control with exercises. Vestibular rehabilitation does not work well when a patient’s condition fluctuates – that is, good hearing and balance between attacks and poor during attacks.
With continued attacks, patients lose much of their hearing and balance. Once the balance function is greatly diminished and does not change a lot when in or between attacks, the patient is a candidate for vestibular rehabilitation. If a patient has lost balance function on one side, the brain can be trained to compensate for the loss; however, it takes practice.
Vestibular Testing
Physiotherapists do not diagnose. Physiotherapists work with you based on how your imbalance or dizziness presents. Well-trained physiotherapists can make a working hypothesis of what is wrong and can help guide your medical doctor or specialist towards a diagnosis.
Vestibular audiologists do diagnostic vestibular testing. They can, for example, test to see if you have bilateral vestibular hypofunction or a bilateral vestibular disorder. Similar to how audiologists can say, “You have a sensory hearing loss,” vestibular audiologists can say, “You have a loss of balance function.” They will not label your disorder, but will say things like, “This balance sensor seems to be 50% functional” or “There is a dysfunction on this or that balance sensor.” This information will be passed on to your doctor to make a diagnosis.
You have expressed the feelings of many people affected by dizziness! It is not always easy to find support in your community; you end up seeing quite a few professionals and they are not always on the same page as to your diagnosis and treatment plan. You may be left with uncertainty about what you can expect in the future. Without getting into too much detail about your diagnosis and treatment (you can read more about BPPV here) you are encouraged to do the following:
1) Get informed (learning more about BPPV is a start) and then clarify with your healthcare professionals what their treatment plan is. Ask as many questions as you need. Read some more if you need to. Here is a list of recommended books.
2) Once you feel you have a direction to follow for treatment, stick with it for a set amount of time. Six weeks is a reasonable time frame. During this time, try your very best to stick with the treatment plan and to stay positive.
3) Use the online resources of our Society and your local sources of support. Since you mentioned that there are no specific dizziness support groups, how about you try your community for balance exercises, for example? You can also look for tai chi classes and classes designed for falls prevention. You will most likely find others dealing with similar issues.
4) At the end of your “trial” with this plan, reassess your symptoms and your goals. You may find that you were on the right track, or you may need to start on number one all over again and try a different treatment plan.
Keep in mind that, even if you need to go back and follow a different course of action, that is okay. It will not be forever. Give yourself again about six weeks time and reassess. Stay in the present moment as much as you can, focusing on what you can effectively do right then and there.
The balance system is complex and involves the brain analyzing and interpreting information from three major systems: the inner ear sensors for balance (vestibular system), the visual system, and the sensation that goes from the skin, muscles and joints (proprioceptive system).
Any sensation of dizziness and imbalance may result when one or more of these four parts are not functioning well. Therefore, the perceived asymmetries you experience may stem from the vestibular organs, from the proprioceptive system and/or from the brain’s processing of the their information. You did not mention visual issues, but treating these symptoms often involve also addressing the processing of visual information, with and without head movements.
You may wish to pursue assessments to clarify whether you do have asymmetries in your balance system, namely a vestibular assessment (for the inner ear sensors and their connections with eyes and brain) and a physiotherapy assessment, for the proprioceptive and musculo-skeletal systems. Proper treatment/rehabilitation can then be tailored to your needs.
Most of the time, doctors ordering a CT scan or MRI of your temporal bone – the bone enclosing your inner ear – are looking for major structural abnormalities. Usually, they want to see the health of the bone, whether or not it is intact, and if there are any tumours on the balance and hearing nerve or on the structures at the back of your head. An acoustic neuroma, for example, is a benign tumour causing hearing loss and dizziness as it grows around the hearing and balance nerve. Acoustic neuromas show up on an MRI.
Neither CT scans nor MRIs can, however, help diagnose most causes of dizziness and imbalance. Imaging cannot show if the tiny inner-ear balance sensors are working. In summary, the role of medical imaging is to rule out – or in – certain structural causes for balance and dizziness disorders.
Vestibular audiologists report on the results of hearing, balance and vestibular function tests. If you had a VEMP test, they may say, “Your utricle and saccule are within normal range.” Or, they may say, “Your water test was normal or abnormal.” Ask for a written report of hearing tests as well as diagnostic tests of the balance sensors in your inner ear. Get an understanding of what these reports mean by reading our Diagnostic Tests for Balance and Dizziness Disorders.
There are many causes for dizziness and balance disorders, including life-threatening conditions. The CT and MRI scans you had were to rule out more serious causes for vertigo. They are not meant to find out exactly what is happening. When the scans come back clear, your primary care physician may try medications that are available and see what happens.
However, the vestibular/balance system is very complex and sometimes the cause is neither sinister nor straight forward. An example is Persistent Postural-Perceptual Dizziness (PPPD).
In less straight-forward cases, specialized professionals and/or diagnostic testing may be needed to lead you to understanding what is causing your dizziness and to implement appropriate management strategies.
The road to diagnosis and management of a dizziness and balance disorder is often a journey and we understand that it can be confusing and frustrating.
Complex vestibular disorders are challenging to treat. For example, it can be very difficult to tease out the symptoms that distinguish Ménière’s disease or migrainous vertigo; they have very similar symptoms, but are treated very differently.
More complex cases are very individual and cannot always be pigeon-holed as Ménière’s or migrainous vertigo or some other particular disorder link i en blogg. Patients may have some but not all of the characteristics of Ménière’s disease, for example, and that is frustrating for doctors.
The balance system is complex and in fact involves 3 major sensory input systems, all controlled by the brain. The inner ear sensors for balance, eyes and the proprioceptors on the body all send information to the brain. Balance centres receive, analyze and integrate these bits of information and then send orders to the body to readjust according to the movement done in the first place.
When you are dizzy with computer use, it usually means that the balance system is relying more heavily on the visual input. It is not fully reassured by the inner ear sensors telling them you are not moving. For more information, read our Motion and Cyber Sickness article.
Having the weights on you or changing your posture as you walk is increasing the cues coming from the proprioceptive system to the brain. This additional input seems to help you balance.
I would recommend you to have your inner ear sensors tested. It might be that they are working just fine but your centres in the brain are not using their information properly or it might be that your brain is in need of all this additional information (visual and proprioception) because your inner ear sensors are dysfunctional.
Vestibular Toxicity
If vestibular rehabilitation can help you with a balance problem related to medication, it will depend on how the medication has affected your vestibular system, and if you have the ability to activate that part of the vestibular system. For example, there are certain antibiotics, such as gentamicin, that are highly toxic to the vestibular system. People who have taken these antibiotics may have difficulty training their vestibular system because the input from their inner ears may have been affected. If you have imbalance related to less toxic medication, balance training can often help to improve your functioning. If, however, medication has affected your vestibular system, the visual system and peripheral system (dysfunction of the balance organs of the inner ear), the treatment effect might be limited.
Vision
Vision is an essential part of the balance system. It works with the inner ear sensors for balance, the proprioceptors (sensation of touch) and the brain to keep us balanced. Any vision problems can negatively affect your balance and should, therefore, be addressed as much as possible. In general, the vision improvement after a successful cataract surgery has a positive impact on balance and quality of life.
The balance system is complex and involves the brain analyzing and interpreting information from three major systems: the inner ear sensors for balance (vestibular system), the visual system, and the sensation that goes from the skin, muscles and joints (proprioceptive system).
Any sensation of dizziness and imbalance may result when one or more of these four parts are not functioning well. Therefore, the perceived asymmetries you experience may stem from the vestibular organs, from the proprioceptive system and/or from the brain’s processing of the their information. You did not mention visual issues, but treating these symptoms often involve also addressing the processing of visual information, with and without head movements.
You may wish to pursue assessments to clarify whether you do have asymmetries in your balance system, namely a vestibular assessment (for the inner ear sensors and their connections with eyes and brain) and a physiotherapy assessment, for the proprioceptive and musculo-skeletal systems. Proper treatment/rehabilitation can then be tailored to your needs.
The balance system is complex and in fact involves 3 major sensory input systems, all controlled by the brain. The inner ear sensors for balance, eyes and the proprioceptors on the body all send information to the brain. Balance centres receive, analyze and integrate these bits of information and then send orders to the body to readjust according to the movement done in the first place.
When you are dizzy with computer use, it usually means that the balance system is relying more heavily on the visual input. It is not fully reassured by the inner ear sensors telling them you are not moving. For more information, read our Motion and Cyber Sickness article.
Having the weights on you or changing your posture as you walk is increasing the cues coming from the proprioceptive system to the brain. This additional input seems to help you balance.
I would recommend you to have your inner ear sensors tested. It might be that they are working just fine but your centres in the brain are not using their information properly or it might be that your brain is in need of all this additional information (visual and proprioception) because your inner ear sensors are dysfunctional.
Visual Vertigo
Vision is an essential part of the balance system. It works with the inner ear sensors for balance, the proprioceptors (sensation of touch) and the brain to keep us balanced. Any vision problems can negatively affect your balance and should, therefore, be addressed as much as possible. In general, the vision improvement after a successful cataract surgery has a positive impact on balance and quality of life.
It is great that you notice that you are hyperventilating. From that awareness, you can try voluntarily changing your breathing pattern. Slowing down, holding your breath in for at least three seconds improves your oxygenation. Another conscious effort you can make is to breathe deep into your belly. Place your hand on your abdomen and feel it expanding as you breathe in and contract as you breathe out.
The balance system is complex and in fact involves 3 major sensory input systems, all controlled by the brain. The inner ear sensors for balance, eyes and the proprioceptors on the body all send information to the brain. Balance centres receive, analyze and integrate these bits of information and then send orders to the body to readjust according to the movement done in the first place.
When you are dizzy with computer use, it usually means that the balance system is relying more heavily on the visual input. It is not fully reassured by the inner ear sensors telling them you are not moving. For more information, read our Motion and Cyber Sickness article.
Having the weights on you or changing your posture as you walk is increasing the cues coming from the proprioceptive system to the brain. This additional input seems to help you balance.
I would recommend you to have your inner ear sensors tested. It might be that they are working just fine but your centres in the brain are not using their information properly or it might be that your brain is in need of all this additional information (visual and proprioception) because your inner ear sensors are dysfunctional.
It is very common to have dizziness triggered by watching things move, as opposed to moving oneself. Many people feel dizzy in busy visual environments, such as browsing in a crowded grocery store, at busy intersections, or even seeing someone carrying a boldly striped bag. This problem is caused by your brain not being able to match up the information coming from your eyes, your inner ear and the proprioception sensors on your joints. When you watch a 3-D movie, your eyes follow things around as if you were actually moving. If your brain is hard-wired to believe your eyes more than your inner ear or body, the message from your eyes will dominate and you’ll feel dizzy.
A treatment for visually-stimulated vertigo consists of watching things in motion. Repeatedly watching full-screen versions of the NED Leader (right and left) video clips on YouTube is recommended. When you get the feeling that you want to look away, watch for three to five seconds longer. Becoming accustomed to doing the tai chi “cloud hands” movement follows the same principle; it habituates your brain to the movement of your hands. Read more about motion and cyber sickness.
Below are some optokinetic videos.
Once you are used to these, try this one:
The following playlists compile complex exercises:
