• Meclizine (Antivert)
• Dimenhydrinate (Dramamine)
• Diazepam (Valium)
• Lorazepam (Ativan)
• Metoclopramide (Reglan)
• Prochlorperazine (Compazine)
• Promethazine (Phenergan)

1. What Are the Most Common Causes of Vertigo?

Vertigo can be caused by acute unilateral vestibular lesions (Labyrinth or vestibular nerve) known as peripheral vertigo, or by lesions affecting the cerebellum or brainstem, known as central vertigo. The most common causes of vertigo are associated with the following disorders:

• Benign Paroxysmal Positional Vertigo
• Acute Vestibular Neuronitis
• Labyrinthitis
• Ménière’s Disease
• Migraine
• Anxiety disorders
• Vascular Ischemia or Stroke
• Acoustic Neuroma
• Cerebellar Degeneration
• Cerebellar Tumor
• Multiple Sclerosis
• Vestibular Ototoxicity
• Perilymphatic fistula

1.1. What Is Benign paroxysmal positional vertigo (BPPV)?

Benign paroxysmal positional vertigo (BPPV) is a disorder of the inner ear labyrinth that manifests with symptoms of episodic vertigo, loss of balance, dizziness, nausea, and vomiting.

It is caused by the displacement of calcium crystal structures within the inner ear saccule and utricle known as uroliths which help hair cells (stereocilia) in converting sound and head movement into neural signals.

The misplacement of these calcium crystal structures can be due to sudden head movement or head trauma [2].

1.2. What Is Labyrinthitis?

Labyrinthitis is the inflammation of the inner ear labyrinth causing symptoms such as vertigo, hearing loss, nausea, vomiting, and tinnitus [3].

Labyrinthitis is caused by viral and bacterial infection, and rarely by the formation of new bone in the inner ear labyrinth (Labyrinthitis Ossificans).

1.3. What Is Acute Vestibular Neuronitis?

Vestibular neuritis is the inflammation of the vestibulocochlear nerve which transmits to the brain, sound, and head movement neural signals that are received from hair cells.

Vestibular neuritis may be caused by infection with viruses such as herpes simplex virus (HSV-1), measles, mumps, or chickenpox [4].

1.4. What Is Ménière’s Disease?

Ménière’s disease is a disorder of the inner ear characterized by recurrent vertigo, tinnitus, and hearing loss. The causes of these diseases are unknown and may involve genetic and environmental factors [5].

1.5. What Is Vestibular Migraine?

Vestibular migraine is vertigo with migraine that does not necessarily manifest with headaches. The causes of vestibular migraine are unknown; however, genetic factors may be involved [6].

Vestibular migraine has been associated with Meniere’s disease and Benign paroxysmal positional vertigo (BPPV).

1.6. What Are Anxiety disorders?

Anxiety disorders are the most prevalent psychiatric disorders characterized by uncontrollable worries and fear associated with emotions, thoughts, ideas, and places.

Anxiety disorders can significantly affect the daily life of an individual and commonly manifest with symptoms, including irritability, focusing difficulties, chest pain, increased heart rate, and abdominal discomfort [7].

1.7. What Is Vascular Ischemia or Stroke?

Vascular ischemia or stroke are characterized by the reduction (ischemia) or absence (Stroke) of blood supply to the cerebellum or brainstem resulting in their damage and leading to acute vertigo.

1.8. What Is Acoustic Neuroma?

Acoustic neuroma or vestibular schwannoma is a tumor that develops from the Schwann cells on the vestibulocochlear nerve [8].

Schwann cells produce the Schwann myelin sheet that insulates nerves and helps with the transmission of nerve impulses.

The pressure from an acoustic neuroma on the vestibulocochlear nerve results in hearing loss, tinnitus, and unsteadiness.

Acoustic neuroma may be associated with neurofibromatosis type 2, a genetic disease characterized by tumors that grow along nerves.

1.9. What Is Cerebellar Degeneration?

Acquired cerebellum disorders are characterized by cerebellar degeneration associated with ischemic or hemorrhagic stroke, which limits blood flow or oxygen to the cerebellum.

These acquired disorders can also be associated with Multisystem atrophy, cerebellar cortical atrophy, and olivopontocerebellar degeneration.

Transmissible spongiform encephalopathies, such as Creutzfeldt-Jakob disease, can cause inflammation in the brain, including the cerebellum.

Damages to the neurons’ myelin sheath during diseases, such as multiple sclerosis can also affect nerve cells of the cerebellum.

Chronic alcohol abuse can lead to temporary or permanent cerebellar damage that can cause cerebellar degeneration.

Paraneoplastic disorders that are triggered by the body’s own immune system in response to cancers (e.g., lung, ovarian, lymphatic, or breast cancer) can result in the production of substances that cause immune system cells to attack neurons in the cerebellum leading to cerebellar degeneration.

1.10. What Is a Cerebellar Tumor?

Cerebellar tumors are lesions that mainly manifest with severe symptoms due to the compression of the cerebellum and adjacent brainstem or obstruction of cerebrospinal fluid (CSF) flow within the fourth ventricle [9].

The most common cerebellar are low-grade-gliomas which can cause symptoms such as gait ataxia and nystagmus

1.11. What Is Multiple Sclerosis?

The axons of neurons are covered by a sheath of a fatty acid (lipid), known as myelin, which insulates them and increases the rate of nerve impulses.

In multiple sclerosis (MS), the myelin sheath is damaged through a process called demyelination which disrupts the capacity of the affected neurons to conduct nerve impulses.

It is proposed that multiple sclerosis (MS) is due to a mix between genetics and infections; however, there is no evidence yet to support these hypotheses.

1.12. What Is Vestibular Ototoxicity?

Ototoxicity is the poisoning of the ear by chemicals or drugs that leads to damage to the inner ear causing balance and hearing difficulties.

1.13. What Is Perilymphatic fistula?

Perilymphatic Fistula is an abnormal opening between the inner ear and the surrounding structures due to congenital abnormalities or an injury (Head trauma, barotrauma) [10].

The symptoms of Perilymphatic Fistula include hearing loss, vertigo, tinnitus, dizziness, spatial disorientation, and nausea.

2. How Do I Know If I Have Vertigo or Dizziness?

Although dizziness and vertigo have been interchangeably used, dizziness is a perception associated with feeling light-headed and unsteady, while vertigo is the perception of being in movement or that your surrounding is in movement. 

3. How Is Vertigo Treated?

3.1. What Are Vestibular Rehabilitation Exercises?

Vestibular rehabilitation exercises are used in combination with antivertigo drugs and are aimed at training the brain to use different visual and proprioceptive signals to maintain gait and balance [11].

3.2. What Are Antivertigo Drugs?

Antivertigo drugs are used for the treatment of acute vertigo that lasts for hours to days.

3.2.1. What Is Meclizine?

Meclizine (Antivert, Bonine) is an antihistamine drug that blocks H1 receptors which prevents their activation by histamine.

Histamine is a well know actor in local immune responses, and is produced by mast cells and basophils; however, it is also an important neurotransmitter involved in itching following inflammation, and in the regulation of the sleep-wakefulness cycle [12].

Meclizine blockage of histamine binding to H1 receptors may reduce the function of the sensory vestibular organs and increase vestibulocochlear blood flow [13].

3.2.2. What Is Dimenhydrinate?

Dimenhydrinate (Dramamine, Draminate) is an antihistamine drug that blocks H1 receptors which prevents their activation by histamine. It has also an anticholinergic activity by inhibiting the activity of the neurotransmitter acetylcholine [14].

3.2.3. What Is Diazepam?

Diazepam (Valium) belongs to the class of drugs known as benzodiazepines which prevent the excitation of neurons by enhancing the effect of GABA on GABA_A receptors.

GABA (Gamma-Aminobutyric acid) is a chemical messenger and the major inhibitor of neurotransmission by reducing nerve impulses (action potential).

Therefore, it has an opposite action to that of glutamate and ensures balanced neurotransmission [15].

Benzodiazepines are used for the treatment of anxiety, panic disorder, sleep disorders (e.g., insomnia), epileptic seizures, as a muscle relaxant, and for the treatment of alcohol withdrawal.

3.2.4. What is Lorazepam?

Lorazepam (Ativan) also belongs to the benzodiazepines family of drugs which act by preventing the excitation of neurons through enhancing the effect of GABA on GABA_A receptors.

3.2.5. What Is Metoclopramide?

Metoclopramide (Reglan) is an antiemetic (prevent nausea and vomiting) drug that is mainly used for post-chemotherapy nausea and vomiting.

Metoclopramide is a blocker of serotonin receptors known as 5-HT3 receptors. Serotonin is a chemical messenger involved in the neurotransmission of information related to mood, reward, learning, memory, and cognition. 

3.2.6. What Is Prochlorperazine?

Prochlorperazine (Compazine) is an antiemetic, antipsychotic, and anxiolytic drug that inhibits the dopamine receptors known as dopaminergic D₂ receptors in the central nervous system.

Dopamine is an organic chemical involved in the transmission of instructions between neurons to control movement and reward-motivated behavior, such as pleasure, craving, decision making based on rewards, associative learning (learning new things), and short-term memory [16].

3.2.7. What Is Promethazine?

Promethazine (Phenergan) is an antihistaminic, antiemetic, and antipsychotic drug that mainly blocks H1 receptors, and therefore, prevents their activation by histamine. It has also a moderate anticholinergic activity.

Conclusion

Vertigo can be physiologic such as motion sickness; however, it can also be caused by disorders that require antivertigo drugs.

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What Are the Causes of Dizziness?

The common causes of dizziness are labyrinthitis, stress and anxiety, headache and migraine, hypoglycemia, vertebrobasilar insufficiency, and dehydration. Less common causes are associated with excessive alcohol consumption (binge drinking), Illness, and Carbon Monoxide Poisoning.

1- Labyrinthitis

Labyrinthitis is an inflammation of the inner ear and specifically of the membranous labyrinth that leads to its irritation and swelling. This ear structure is made of a network of passages full of liquid which play an essential role in the control of sound detection and balance by the inner ear. Labyrinthitis is usually caused by a bacterial or viral infection (e.g., cold or flu).

2- Stress and Anxiety

Dizziness has been associated with panic symptoms in stressed and anxious individuals due to central-neurologic links between the vestibular system which controls the sense of balance and spatial orientation and the autonomous nervous system controls the nervous system’s unconscious activity [2].

3- Migraine

Dizziness is one of the symptoms of vestibular migraine whose causes are unknown. However, one possible explanation is a potential link between pain and swelling during inner ear inflammation and migraine and dizziness.

4- Hypoglycaemia

To function the brain requires energy that is produced from glucose that is supplied by the blood. Normally, glucose is maintained in the range of 3.9 to 6.1 millimoles per liter (mmol/L) of blood; however, diabetes patients receiving a diabetic treatment can periodically experience hypoglycemia (Low glucose level) which causes dizziness, fatigue, and weakness.

5- Hypotension

The normal blood pressure in a healthy adult is between 90/60 and 120/80 mmHg. A blood pressure of less than 90/60 mmHg can lead to dizziness. This is commonly observed in individuals with diabetes or cardiovascular diseases.

6- Vertebrobasilar Insufficiency

Vertebrobasilar Insufficiency is transitory ischemia of the vertebrobasilar circulation associated with decreased blood flow in the posterior circulation of the brain that is provided by the basilar artery. Diseases such as atherosclerosis can block or narrow this artery causing a reduced blood supply to several parts of the brain leading to dizziness and imbalance [3].

7- Dehydration

Dehydration prevents a sufficient supply of water and electrolytes to the body resulting in blood dehydration and a decrease in blood flow leading to an insufficient supply of nutrients to tissues and organs, including the brain.

8- Excessive Alcohol Consumption

Excessive alcohol consumption leads to alcohol intoxication and alcoholic ketoacidosis reduces the secretion of insulin by the pancreas which affects glucose usage by the cells in tissue and organs of the body. Diabetes can also lead to ketoacidosis, known as diabetic ketoacidosis.

9- Medication

Discontinuation of antidepressant medication, such as selective serotonin reuptake inhibitors (e.g., Prozac) results in a high frequency of dizziness that may be due to their role in improving balance control and cognitive functioning [4]. Blood pressure medication can also induce hypotension leading to dizziness.

10- Illness

Disorders such as vestibular neuritis or diseases such as Ménière’s Disease comprise dizziness as one of the main symptoms.

• Vestibular neuritis

This disorder affects the vestibulocochlear nerve within the inner ear that sends balance and head position information from the inner ear to the brain. Damage to this nerve (e.g., viral infections) disturbs the function of the nerve which results in dizziness and unbalance [5].

• Ménière’s Disease

Although the causes are not well known, this disease affects the inner ear, and its symptoms include tinnitus (Perception of internal sounds), loss of hearing, and vertigo.

11- Carbon Monoxide Poisoning

The blood transport oxygen to tissues and organs of the body to produce the energy necessary for their functions. Following, carbon monoxide exposure, blood oxygen is replaced by carbon monoxide which results in cellular toxicity.

What Is the Difference Between Dizziness and Vertigo?

Although dizziness and vertigo have been interchangeably used, dizziness is a perception associated with feeling light-headed and unsteady, while vertigo is the perception of being in movement or that your surrounding is in movement. Vertigo is also characterized by symptoms such as nausea, vomiting, sweating, and walking difficulty.

How to Prevent or Treat Dizziness?

The prevention or treatment of dizziness is focused on dealing with its causes. For instance, labyrinthitis and Vestibular neuritis, are treated with antihistamines or motion-sickness tablets. Vestibular rehabilitation through physiotherapeutic exercises is also recommended to help restore balance. Changes in lifestyle, staying hydrated, avoiding binge drinking, and reducing stress levels can prevent dizziness.

Conclusion

Dizziness is not generally associated with a serious condition; however, in certain cases, it can be due to chronic conditions such as diabetes and cardiovascular diseases which require specific treatments. It can also be related to mental disorders such as migraines, and anxiety, which also rely on anti-depressant treatments.

Unfortunately, the causes of Ménière’s disease are not well-known and the potential involvement of hereditary transmission has been proposed. In this case, the treatment relies on the use of medications that reduce nausea and diuretics to reduce liquid build-up in the inner ear.

Finally, dizziness is a symptom that is shared by several disorders such as vertigo, and therefore, it is confusing to differentiate between the two if the right questions are not asked during the diagnostic stage.

References

[1] Neuhauser, H.K., 2016. The epidemiology of dizziness and vertigo. Handbook of clinical neurology, 137, pp.67-82.

[2] Balaban, C.D. and Thayer, J.F., 2001. Neurological bases for balance–anxiety links. Journal of anxiety disorders, 15(1-2), pp.53-79.

[3] Lima, A.C., Bittar, R., Gattas, G.S., Bor-Seng-Shu, E., Oliveira, M.D.L., Monsanto, R.D.C. and Bittar, L.F., 2017. Pathophysiology and diagnosis of vertebrobasilar insufficiency: a review of the literature. International archives of otorhinolaryngology, 21, pp.302-307.

[4] Ramos, R.T., 2006. Antidepressants and dizziness. Journal of Psychopharmacology, 20(5), pp.708-713.

[5] Jeong, S.H., Kim, H.J. and Kim, J.S., 2013, July. Vestibular neuritis. In Seminars in neurology (Vol. 33, No. 03, pp. 185-194). Thieme Medical Publishers.

[6] Harcourt, J., Barraclough, K. and Bronstein, A.M., 2014. Meniere’s disease. Bmj, 349.

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