Vertigo: When your world spins out of control.
Ms Simone Quah’s first vertigo attack happened about a year ago and it was a bolt out of the blue.
“I woke up, went to the bathroom and after I got up from the toilet, my whole world began to spin uncontrollably,” said the 55-year-old part-time phonics teacher. “I had to hold onto the wall for support to get back into bed.”
Vertigo is the sensation of the head spinning, such as something you might experience when looking down from a great height. An episode can last for less than a minute to hours or days.
Some people even have to stop working or change their jobs, said Dr Ho Eu Chin, a consultant at the department of otorhinolaryngology (ear, nose and throat) at Tan Tock Seng Hospital (TTSH).
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For Ms Quah, vertigo caused her to experience nausea and confined her to bed. “Whenever I opened my eyes, the objects around me would seem to move towards me and then move away,” she said of her first attack. “I started vomiting and had to call for a doctor to do a house visit as it was a Sunday and there was no way I could stand, let alone walk.”
The doctor prescribed medication to treat the nausea and gave her an injection. For two days, she simply lay in bed, afraid to move.
She had a second attack earlier this year. This time, the spinning sensation was not as strong as the one before but it lasted for about two weeks, she said. “It’s a terrible feeling and makes you immobile and miserable,” said Ms Quah, who is married.
VERTIGO IS NOT A CONDITION
Greater awareness, as well as an ageing population, has contributed to a rise in the number of people here seeking help for vertigo.
Some healthcare institutions here have recognised the need for a service that caters for people with vertigo and balance issues, which are expected to rise in tandem with an ageing society.
Singapore General Hospital (SGH), for instance, set up a clinic for people with such issues in 2012, said Dr Chan Yew Meng, a senior consultant at the department of otolaryngology.
TTSH also set up a clinic that year and, with the yearly rise in the number of patients, there is now a six-month wait for appointments, said Dr Ho.
Most patients do not realise that the word “vertigo” should never be used as a diagnosis, he said. He added that patients tend to be middle-aged or elderly.
Dr Stephen Lee, a specialist in ENT surgery and a consultant at Raffles ENT Centre, said vertigo is a common complaint there as well. Sometimes, patients feel giddy and think they have suffered a stroke, and this can be terrifying, he said.
However, not all who get recurrent vertigo episodes know the cause of the attacks. Without a diagnosis, treatment becomes difficult.
WHY AM I SPINNING?
The two most common medical conditions that result in patients having recurrent vertigo attacks are vestibular migraine and benign paroxysmal positional vertigo (BPPV), said Dr Ho.
People with vestibular migraine suffer troublesome vertigo symptoms as well as headaches. The cause of vestibular migraine is not yet fully understood but may be related to lifestyle and hormonal changes as people get older.
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BPPV, the sudden sensation of spinning, is thought to be due to the degeneration of the inner ear. It is the most common cause of dizziness in older adults and has been shown to be a risk factor for falls, said Dr Chan.
“In this condition, calcium carbonate particles become dislodged and fall into the semicircular canals of the inner ear, causing short durations of spinning sensations when the patient lies down, gets up from bed or looks up.”
Dr Ho said vestibular migraine and BPPV are more common as one gets older. While vertigo symptoms frequently start in people in their 40s and 50s, they can also occur much later in life, he said.
“When they were younger, migraine patients tended to have recurrent headaches. A check among my patients showed that their headaches improved as they got older, but then, they get troublesome vertigo symptoms,” he said.
Uncommon causes of vertigo include Meniere’s disease, a disorder of the inner ear. Dr Chan said most patients affected by this disorder improve with medication and lifestyle changes but some may require surgery to control the bouts of dizziness.
MANAGING THE PROBLEM
If the vertigo is mild, just lie down quietly and wait for it to settle, said Dr Lee. “However, if it is persistent or recurrent, you will need to consult your doctor.”
If a patient is diagnosed with BPPV, a manoeuvre – to move the crystals from the semicircular canals into an area of the inner ear where they do not cause dizziness – can be performed to resolve the vertigo. The Epley manoeuvre is commonly done to resolve BPPV. Dr Chan said one manoeuvre is usually sufficient.
In patients with recurrent BPPV, doing certain exercises at home will be useful after the affected semicircular canal has been identified, he said. These moves include the Semont’s manoeuvre and Brandt Daroff Habituation exercises.
BPPV can affect one or more of the semicircular canals at one time. Overall, treating BPPV has been shown to significantly reduce the number of falls in older adults with the problem, said Dr Chan.
However, patients should be aware that even with BPPV, there is no single manoeuvre that can treat all cases, he said.
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Performing incorrect manoeuvres may cause calcium particles to be lodged in another semicircular canal of the inner ear, which can result in persisting vertigo and unnecessary alarm, concern and discomfort, said Dr Chan.
However, for some patients, physical therapy can cause more symptoms as they may have issues such as motion sensitivity or vestibular migraine, he said.
For those with vestibular migraine, common lifestyle triggers for their vertigo attacks are a lack of sleep, stress and negative emotions, as well as dietary triggers such as a high intake of salt, MSG, caffeine, chocolate, cheese and alcohol, said Dr Ho.
However, patients do not realise the importance of managing the lifestyle and dietary triggers for their condition. Doing so can actually result in a dramatic improvement in the frequency and intensity of vertigo episodes, he said.
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Study or work stress, coupled with worry, anxiety and insomnia, plus eating out, drinking too much coffee, indulging in chocolate or alcoholic beverages will create a perfect storm for vertigo attacks, he added.
As for Ms Quah, she has been diagnosed with BPPV and has gone through two Epley manoeuvres so far.
She has ringing in her ears now and then, and has experienced two more vertigo attacks but they were, thankfully, mild ones.
THERAPY CAN REDUCE SYMPTOMS
Physical therapy or vestibular rehabilitation can greatly benefit people who suffer from vertigo.
This is a customised exercise approach that is used to reduce the symptoms of dizziness, improve mobility and balance, return one to pre-dizziness levels of activity and improve quality of life.
Some of the exercises include:
•Canalith-repositioning procedures: These comprise a series of specific head and upper body movements, to treat benign positional paroxysmal vertigo. Trained physiotherapists or physicians or audiologists can perform these moves to remove dislodged particles from the semicircular canals (vestibular organ) of the inner ear, said Dr Dawn Tan, a senior principal physiotherapist at Singapore General Hospital. The success rate for this treatment can be as high as 90 per cent, she said.
• Gaze-stability exercises: These are for patients with vestibular dysfunction. The exercises involve head turns, with the eyes focusing on a stationary or moving visual target, which can help to decrease visual blurring during head movement, said Dr Tan.
• Habituation exercises: Patients gradually and repeatedly increase their exposure to a stimulus which causes dizziness, such as turning their head horizontally. These exercises can help to reduce the intensity of dizziness experienced or motion sensitivity, Dr Tan said.
A version of this article appeared in the print edition of The Straits Times on October 03, 2017, with the headline ‘When your world spins out of control‘.