Vertigo

Vertigo is a symptom characterised by the sensation of spinning or movement, affecting either the individual or their surroundings. Unlike dizziness, which involves a floating sensation, or imbalance, which reflects unsteadiness, vertigo conveys a distinct sense of motion. While it is not a condition in itself, vertigo often indicates an underlying issue and can range from mild to debilitating, significantly impairing balance and daily activities.

Physiology of vertigo

Physiologically, vertigo is primarily linked to the inner ear and the vestibular system, which is responsible for maintaining balance and spatial orientation. The vestibular apparatus consists of semicircular canals and otolith organs, which detect angular and linear movements, respectively. Dysfunction in these structures, or their neural pathways to the brainstem and cerebellum, can disrupt normal sensory input, causing vertigo. Symptoms (Figure 1) may include a spinning sensation, nausea, vomiting, nystagmus (involuntary eye movements), sweating, and difficulty with balance. Triggers vary widely and may include head movements, changes in position, or even psychological stress. The underlying causes can be peripheral, such as inner ear disorders, or central, involving the brain or central nervous system.

Causes and prevalence

Vertigo is particularly common among middle-aged and older adults, where it presents a considerable risk of falls and associated injuries. This demographic is especially vulnerable due to age-related changes in the vestibular system, such as a decline in vestibular hair cells and neurons, as well as alterations in central pathways. Vestibular disorders are among the most frequent causes of vertigo episodes in the elderly, often contributing to a cycle of psychological distress and physical limitation. Anxiety and depressive syndromes further exacerbate this cycle by increasing fear of attacks and falls, ultimately limiting daily activities and lowering perceived quality of life.

Benign Paroxysmal Positional Vertigo (BPPV) is the most common cause of vertigo and is featured in multiple studies within the literature (Figure 2). BPPV is typically triggered by changes in head position, leading to brief episodes of intense vertigo. Despite its prevalence, management can be challenging due to the nonspecific nature of symptoms and the diverse underlying causes. Recent research has also identified a strong association between vitamin D deficiency and recurrent BPPV, as vitamin D plays an important role in calcium metabolism and the maintenance of the calcium crystals (otoconia) within the inner ear. In some patients, correcting vitamin D deficiency may help reduce the risk of recurrence.

Other common vestibular disorders include labyrinthitis and vestibular neuritis, which are usually caused by viral infections such as the common cold or influenza. These conditions result in inflammation of the inner ear or vestibular nerve and can cause sudden, severe vertigo lasting several days, often accompanied by nausea, vomiting, and imbalance. Vestibular migraine is another increasingly recognised cause of recurrent vertigo and may occur with or without a typical migraine headache, making diagnosis challenging.

The COVID-19 pandemic has also highlighted Long COVID (Post-COVID Condition) as an emerging cause of persistent dizziness and vertigo. Some individuals continue to experience balance disturbances and vestibular symptoms for weeks or months following their initial infection, contributing to ongoing functional impairment.

Polypharmacy, or the use of multiple medications, has also emerged as a significant factor in vertigo among older adults. Prescriptions involving several drugs, particularly antihypertensives and sedative hypnotics, have been linked to an increased likelihood of vertigo. Careful assessment of medication interactions and side effects during medical consultations is therefore essential.

Metabolic disorders, such as diabetes and hypoglycaemia, also contribute to vertigo in some individuals. Although the majority of vertigo cases originate from disorders of the inner ear, neurological conditions should also be considered. Stroke and other central nervous system disorders account for an estimated 10–20% of vertigo presentations in acute care settings and are more likely when vertigo is accompanied by symptoms such as slurred speech, facial weakness, numbness, double vision, severe headache, or difficulty walking. These features require urgent medical assessment to exclude a potentially life-threatening cause.

However, in a proportion of cases, the exact cause of vertigo remains unidentified, highlighting the complexity of diagnosis and the importance of a comprehensive clinical assessment.

Conclusion

As one of the most common and disabling symptoms in the elderly, vertigo requires comprehensive and individualised care. Understanding its underlying physiological mechanisms, as well as recognising the multifactorial influences such as medication use, psychological health, and metabolic disorders, is essential for effective management. By adopting an integrated approach that prioritises accurate diagnosis and targeted interventions, clinicians can improve both symptom control and overall quality of life for individuals affected by vertigo. Further research is needed to enhance treatment strategies and address the remaining gaps in knowledge.

Written by Maria Z Kahloon