Understanding Vertigo and Dizziness with Dr. Julie Honaker

Podcast Transcript

Nada Youssef:   Hi. Thank you for joining us. I'm your host, Nada Youssef, and you're listening to Health Essentials Podcast by Cleveland Clinic. Today we're broadcasting from Cleveland Clinic main campus here in Cleveland, Ohio, and where here with Dr. Julie Honaker.

Dr. Honaker is currently the Director of the Vestibular and Balance Disorders Program within the Head and Neck Institute here at Cleveland Clinic. Dr. Honaker is an audiologist, specializing in state of the art assessments and management planning for all patients with dizziness and balance and falling risk concerns. And today we're here to talk about vertigo. Thank you so much for being here today.

Dr. Honaker:     Thank you for having me.

Nada Youssef:   Sure. And please remember this is for informational purposes only, and it's not intended to replace your own physician's advice. Let's talk about vertigo, kind of the overview.

Dr. Honaker:     Okay.

Nada Youssef:   So let's start with very general, what is vertigo and what are the different types?

Dr. Honaker:     Okay, sure. Good question. Well, vertigo is in a class of symptoms that patients may experience. So if we think of symptoms of why patients come to see me, it might be due to vertigo, which is this perception of self-movement or the movement of the surroundings. So perception of the room moving or yourself moving or having distorted movements. Sometimes patients can describe this as a dizziness, which is kind of distortion of your special orientation of where you are. Sometimes it can be postural symptoms, but vertigo is truly this sensation of spinning, of rotation movement of either yourself or what you're visualizing in the environment.

Nada Youssef:   Okay. Now, I want to ask you this. When I first was- we're talking about vertigo.

Dr. Honaker:     Yeah.

Nada Youssef:   In putting this together for you, I was like, "Is vertigo neurological or ENT, audiologists?" How do we know where the dizziness is stemming from?

Dr. Honaker:     Good- Well, if we had that exact answer all the time, that would make our lives a lot easier-

Nada Youssef:   Yes, I'm sure.

Dr. Honaker:     ... as medical professionals. But, honestly, vertigo can stem from so many different problems. So, you're right, it can be neurological issues. So somebody who has a stroke, they can experience vertigo. It can be due to an inner ear problem. So within our inner ear, we have balance receptors on each side, and if one part of that system goes out, it can give us a sensation of false movement that can be very debilitating.

It can be secondary, kind of, what patients may describe as vertigo. It could be due to blood pressure ranges, maybe quick changes in position. There's a lot of different reasons for those. Even medication can cause the sensation. Or if we engage in things on the weekend, sometimes we can have that sensation of vertigo.

Nada Youssef:   Sure. So would you say the vertigo and dizziness could be the same thing?

Dr. Honaker:     I would say it used to be that dizziness was the umbrella term and vertigo fit underneath it, and now we're finding that dizziness is very separate from vertigo. Dizziness is this altered sense of spatial orientation, a distortion of, kind of, where we are within space. Where vertigo is truly the sensation of self-movement or the movement of the surrounding. So think of it more as like a spinning sensation. That's vertigo. Where dizziness can be, "Oh, I'm feeling off or I feel things are not as they should be."

Nada Youssef:   Sure. Okay, great. So when you were talking about balance receptors in your ear, can you describe what those are?

Dr. Honaker:     Oh, sure, sure. So we have what's called the vestibular system on each side deep within our skull. So just imagine deep within our head, right next to our hearing organ, we have side balance receptors and organs on each side of our head.

We have three, what are, tiny little canals that look like little hula hoops in our head that are all fluid-filled. And then we have two organs right next to that that are called are gravity sensor organs. And they're gravity sensors because they have dense particles we refer to as otoconia or sometimes patients and even providers will refer to it as crystals within our head that when we move, with respect to maybe leaning to the side or kind of moving in a car, it's these crystals, that shear receptors, little hair cells within these organs that give us a sense of where we are in space.

Nada Youssef:   I see. Okay. So then what will cause vertigo? What are the causes?

Dr. Honaker:     Sure. Well, if it's inner ear, it could be due to the fact that on each side of our head, we have these balance receptors and they are letting off and emitting information, firing information, at all times just to let us know where we are in space.

As we move our bodies, let's say I do a head turn to the right, I'm getting increased information on the right side. So I'm sending this asymmetrical information to the brain to let my brain know that I've turned to the right and to initiate some reflexes. So I can see things clearly with my eyes, move my eyes, control my head so I have upright head posture and control my spine.

If we have a breakdown, let's say we have some sort of virus or some sort of condition that impacts our inner ear balance system, either a part of those balance receptors or even the adjoining nerve that sends these signals, it can falsely give your brain the perception that you're in motion, even though you are perfectly still. So you have this perception. Because we now have increased vibrate on the good side, we have to decrease on the side that's impaired. Your brain is interpreting this as if you're doing a head or body turn continuously. So that can give the false sensation of movement.

Nada Youssef:   Would head injury cause something like that?

Dr. Honaker:     It can, absolutely. So typically with concussion and head injuries, you can have impaired balance. There are head injuries that can actually impair your vestibular sensors. So depending on where you have head injury, if it's more within your temporal lobe, that can certainly impair those organs. Even just head injury, in general, can you give that sensation of dizziness that I described or just kind of postural imbalance as you're recovering from the head injury.

Nada Youssef:   So is this something that you'd say is hereditary?

Dr. Honaker:     There are some conditions that can be hereditary that can make somebody maybe more susceptible to having inner ear problems that can cause vertigo. Sometimes it's congenital, so we're born with some sort of deficit or anomaly that can cause this, and sometimes it's just due to the aging process where you're just more susceptible to developing conditions that can lead to vertigo.

Nada Youssef:   Can ear infections lead to vertigo or can they be linked at all to vertigo?

Dr. Honaker:     I think vertigo, again, is a symptom that can be from numerous conditions. And, absolutely, if we have an ear infection that's causing, kind of, a feeling of imbalance between our two ears, that certainly can lead to symptoms of dizziness and even- we've had at times patients report two vertigo sensations because of that.

Nada Youssef:   All right. So I want to talk about the most common- is it type of vertigo, the BPPV?

Dr. Honaker:     Yeah, yeah.

Nada Youssef:   Okay. So can you tell me what it is-

Dr. Honaker:     Sure.

Nada Youssef:   ... and what it's triggered by?

Dr. Honaker:     Sure. Well, the acronym BPPV stands for- the B is benign, meaning it's not a life-threatening condition. The first P is paroxysmal, meaning this is something that comes on very suddenly. The second P is positional, meaning this is triggered with changes in position, such as getting into bed, getting out of bed, rolling over in bed. And the V is the vertigo. That sensation of self-movement or movement of the world around you.

And this is the most common inner ear condition and actually one of the most common reasons why patients will report vertigo. Important things to note, so kind of getting back to your original question of how do we differentiate one type of vertigo being neurologic versus an inner ear, and it oftentimes goes to the time course, so how long the symptoms are. With BPPV, these are very short-duration symptoms that are brought on with changes in position.

The reason for this condition, it actually has to go back to the description of crystals that I mentioned before. So we have crystals or what we call otoconia that are our ears and they are these dense particles. And since they're dense, they're gravity-sensitive particles, and the organs that they are adhered to are gravity sensors.

These organs are right next to the hula hoop organs I was talking about, these kinds of semicircular canals. And sometimes, due to disease or even just due to aging process, these little crystals can become dislodged and they can migrate and free float into other parts of our ear where they don't belong. And with respect to gravity, they're going to go down, and they can go into one of these little hula hoops or semicircular canals that's positioned further down, which is called our posterior canal.

And when that occurs, we now have an organ that was not gravity sensitive that becomes gravity sensitive. So when we're moving in bed, typically we sense we've rolled to the right, but after that, we shouldn't have any other sense of our perception of movement. But if we have these little crystals in these canals moving with respect to gravity, it can give this kind of transient response of, "Ooh, something, I'm moving or what just happened?" It can be very scary for patients.

Nada Youssef:   Sure. And is that why people usually realize that they may have vertigo? Is it because the sensation is stronger?

Dr. Honaker:     Yes, absolutely, absolutely. So it can be very debilitating. It can bring on other symptoms of imbalance. I think the scariest thing is just the fact that it comes on so abruptly. Even though it's very short, it's a very, very strong response that patients can experience.

Nada Youssef:   Now, with our society having our smartphone being our third arm, is looking down at our smartphones triggering BPPV or vertigo?

Dr. Honaker:     Well, I would say that it's not a cause for this. But certainly patients who may have this particular condition, if it's in one of these semicircular canals, as I described, these semicircular canals have little receptors that respond to changes in head positions. So quick movements to the right or left, looking up or down, we're activating these little receptors. And if we have these crystals in those canals, it can again activate it to where it can bring on those senses of motion or vertigo.

Nada Youssef:   Sure. So is there any preventive measures that we can do? How do I know my crystals are where they're supposed to be in my ear? Or is the only time I know that they're not aligned or gravity did its toll is having dizzy?

Dr. Honaker:     Well, I always say that- I don't think this is really my coin, but I'll take credit for it-

Nada Youssef:   Take it.

Dr. Honaker:     ... is that our balance system is our sixth sense, and we don't really appreciate it until something goes wrong.

Nada Youssef:   That's a good point.

Dr. Honaker:     So I would say the best thing that you can do for your balance system is to keep up with your health in general. Keep active, keep up with exercise, go to your physician annually just to make sure everything is in check. But really we don't start to appreciate decline until we notice changes, such as symptoms of vertigo, such as problems with our ability to walk or we're not feeling as steady as we used to. That's when we start to notice things go awry. For preventative things, the best thing would be exercise and just maintaining overall good health.

Nada Youssef:   Great. And then, would you say, are there any at-home exercises that someone can do while they're watching TV- or maybe not watching TV, but is there any kind of treatments or anything that we can do at home to help with this, like special exercises?

Dr. Honaker:     Yeah, that's a great question. So if you feel you have to BPPV, the first thing you need to do is reach out to a healthcare provider. So this could be- first off is always primary care, great first off, your internist. From there, if it is something that is truly fitting the characteristics- so, again, it's brief in duration, lasting only seconds to upwards of minutes in duration for these symptoms of vertigo, brought on with changes in position. If you're able to localize which side is triggering this, such as rolling over in bed to the right, getting up from bed from the right or sometimes patients will say, "Well, when I go to reach for my phone in the morning on the right side, that's when I notice my symptoms." Then there are specific exercises that you can do to help treat this condition.

And to do treatment for this condition, we essentially have to move these crystals from the organ, where they're now housed, back into the organ where they belong. And, for that, because all of our inner ear is fluid-filled, we have to move our head and body in certain positions to help migrate these crystals back into the receptor organ where they're supposed to go.

So there's specific exercises. Probably the most common exercise treatment that you could perform is called an Epeley maneuver. It's something that- there's YouTube videos for this. There's certainly a lot of information on the web. I always think it's good, though, to have patients talk to their doctor because, as you mentioned before, there's so many other causes. And we want to make sure that we're attending to the correct thing. And there's also chances with treatment we could do things incorrectly and that can cause more harm than good.

Nada Youssef:   Okay. Good points. So I want to talk about- I know you said it's usually aging people that can get vertigo, correct?

Dr. Honaker:     Yeah, yeah.

Nada Youssef:   Or it could be an underlying disease, things like that. But is there a certain demographic or specific age more prone to vertigo?

Dr. Honaker:     I would say vertigo is any age, any stage. For the condition of BPPV, we see an upward trend as we age. There's a high prevalence of that particular condition. But this is something that a child is not immune to this condition. It happens secondary to head injury. They're playing on the playground and they fall, they could sustain a head injury, and that can cause these little crystals to become dislodged.

Nada Youssef:   So anybody with ears, eyes, and a head can get it?

Dr. Honaker:     Yep, yep. It can happen, absolutely.

Nada Youssef:   Okay. That's good to know. So why do some women report getting vertigo when they're pregnant? When I was doing my research, I saw some of that. Why is that?

Dr. Honaker:     Yeah, I would say it may not be- When we think of vertigo, I think we automatically think of an inner ear condition, but it may not always be. So oftentimes, in women who are pregnant, there's hormonal changes.

Nada Youssef:   Yes.

Dr. Honaker:     Hormone changes cause blood flow to go to baby rather than mom. So then with quick changes in position, mom may be more susceptible to feeling dizziness or lightheadedness because of this. So I'd say the biggest thing is hormonal changes.

Sometimes, also with hormonal changes, one of the other culprits for causing vertigo is underlying history of migraines. So maybe mom is more susceptible to migraines, and this change in hormones is causing her to have migraines with secondary symptoms, such as vertigo.

Nada Youssef:   Sure. And then I also read that it sometimes gets worse at night. Do we know why vertigo can get worse at night, not for pregnant moms, but for anyone that has vertigo?

Dr. Honaker:     Yeah, yeah. I would say it's probably- if we go back to BPPV, this is if it's brought on with changes in position, you're getting into bed at night, right? So you're more likely to sense this.

Nada Youssef:   To turn left and right-

Dr. Honaker:     Absolutely.

Nada Youssef:   ... while you're sleeping?

Dr. Honaker:     You're more likely to sense it then.

Nada Youssef:   Sure. And then would you say it is a symptom of anxiety or depression or just, in general, any kind of mental health can be related to vertigo?

Dr. Honaker:     That's a great point, and there are conditions that can cause symptoms of dizziness. There are issues with panic attack that can bring on even what patients may describe to them as something akin to vertigo. So I think there certainly are mental health conditions that can cause this.

There are some conditions actually in the realm of... not so much fitting with anxiety and depression, but more chronic conditions where patients may have had a vertigo episode in the past, something such as BPPV, but kind of this internal worry, "Is this going to happen again," can lead to other health conditions, and that can increase anxiety, which can then feed to, kind of, our overall- even our body, how we adapt to this can cause us to be more susceptible.

Kind of thinking about our senses, if we're in an environment where we have to maybe rely more on visual information, that can make us have more symptoms when we're in that type of environment because we're maybe not wanting to rely as much on our other senses.

Nada Youssef:   Very good. Very good points. So I want to talk about treatments. When is it time to go see a doctor? You feel dizzy here and there, but when is the time to absolutely have to go see a doctor?

Dr. Honaker:     Well, I'd say the biggest thing would be if you are sensing symptoms of dizziness or even vertigo or even if you notice that you're having some difficulties with your balance control or your walking ability, have the first conversation with your doctor. So this is step number one, go to your primary care or you internist. Again, there could be very common reasons for this. It wouldn't be huge red flags in the beginning. It could be something medication-related that you need to have controlled and addressed with your doctor. But I think if you have these concerns, it's a good thing, always, to check in because there are some other conditions that can be scarier than we have to rule out.

Nada Youssef:   Sure. And then you said to start with primary care, correct?

Dr. Honaker:     Absolutely. I think that's your home base. And, again, if this is something that's more commonly related to medication or blood pressure, we really want your central base to take note of that first, and then from there, send you to the appropriate specialist to take care of things.

Nada Youssef:   Sure. So, now, what kind of treatments are available for vertigo?

Dr. Honaker:     Well, I think it would depend on first identifying the reason for the vertigo. So if it's something that's related to medications, that's something that can be controlled by changing the dosage, changing the type of medication.

If it's something more blood pressure related, that's something that again could possibly be controlled with medications or diet or exercise. If it's something inner ear related, it's really pinpointing what's the common cause. So getting to the root of how long are the symptoms; what's triggering the symptoms; are they occurring- is it one time that you've had these symptoms or they occur for a long time, to really pinpoint the root cause.

From there, it might be medical management with medication and even rehabilitation would be a next step. So physical therapy to help a person-

Nada Youssef:   [crosstalk 00:18:50]

Dr. Honaker:     ... feel rebalanced and also to help correct common conditions, such as BPPV.

Nada Youssef:   Okay. And as the treatment usually like ear drops or are they like pills, medications?

Dr. Honaker:     Again, it would depend.

Nada Youssef:   Depends on what?

Dr. Honaker:     So it would depend on what's wrong and what's the true cause for this. So that's why it's so important to speak to a healthcare provider when you are having symptoms to really understand what the cause is so that we can provide the best management care for these symptoms. Because there can be numerous reasons, just as you've described. Neurological, cardiovascular reasons, ear-related reasons.

Nada Youssef:   Right, right, right, and head injury. So I can imagine if someone has vertigo, it would be very difficult to do something like driving. Are there complications to the point where people cannot drive because of their vertigo?

Dr. Honaker:     Yes. There are times where it may not be safe for a person to drive just for this fact that when we are in a car, if it's an inner ear problem, even just driving the car, looking the straight ahead, we are having information sent to our inner ear balance system. And that, if something is not working between these systems, this can certainly provoke those symptoms of dizziness or vertigo. Head movements in the car, having to look into your mirrors, can trigger responses that can throw somebody's perception of where they are in space off.

Nada Youssef:   Right, right. All right, one last question for you.

Dr. Honaker:     Yeah.

Nada Youssef:   If you are prone to vertigo or feeling dizzy, what precautions can you take? If you can just let our audience know.

Dr. Honaker:     Sure. I'd say, again, first and foremost would be checking in with your doctor. I think the biggest thing that would help providers out is to help understand the triggers. So thinking about what you were doing at the time when your vertigo came on. Is there a pattern to this vertigo? Do you have associated symptoms with the vertigo? Is this something that's brought on with changes in position? Do you have nausea? The short duration? Are you experiencing head pain with these? Those are the real things that we need to better understand to help properly diagnose and get you on the correct management path.

I think the biggest thing just for our balance system in general, as I mentioned before, is just to keep up with your balance system. If we don't use it, we lose it, like the saying. We have to keep it active. We have to keep up with our overall health just so that our body as a whole is working in its prime and that can ward off these symptoms of dizziness and even vertigo.

Nada Youssef:   Great. So for prevention measures, we should sleep well-

Dr. Honaker:     Yes.

Nada Youssef:   ... eat well-

Dr. Honaker:     Yes.

Nada Youssef:   ... exercise-

Dr. Honaker:     Absolutely.

Nada Youssef:   ... all that good stuff. Yeah.

Dr. Honaker:     Keep stress at bay.

Nada Youssef:   Keep stress at bay, I like that. Thank you.

Dr. Honaker:     You're welcome.

Nada Youssef:   Thank you so much for your time today.

Dr. Honaker:     You're welcome.

Nada Youssef:   It's been a pleasure.

Dr. Honaker:     Thank you.

Nada Youssef:   And thanks again to our listeners who joined us today. We hope you enjoyed this podcast. We do offer, at the Cleveland Clinic, many multidisciplinary evaluation of dizziness. So to schedule an appointment, please call (216) 444-8500. And to listen to more of our Health Essentials Podcast from Cleveland Clinic experts, make sure you go to Cleveland Clinic, dot, org, slash, H E podcast, or you can subscribe on iTunes. And for more health tips and information from Cleveland Clinic, please follow us on Facebook, Twitter, and Instagram, at Cleveland Clinic. Just one word. Thank you. We'll see you again next time.