Vertigo in multiple sclerosis

Anne Glynn, Neuro-rehab Specialist Physiotherapist
Colchester General Hospital

Open Door - February 2008 pages 10-11

Vertigo is a distressing condition where you feel either you or your environment is moving. Research suggests that about 20% of people with MS will be affected with vertigo at some time.

What causes vertigo?

Our ability to feel orientated while stationary or moving, relies on the complex interaction of a variety of sensory systems; the visual, vestibular (the balance systems in the inner ear including an area called the labyrinths) and somatosensory systems (the information from movement, touch and joint sensors throughout our body). When we turn our head, our eyes, neck muscle sensors and two inner ears all give matching information to the brain. If something causes a mismatch in the information, it affects our sense of orientation and causes vertigo.

Common effects of vertigo

Dizziness
Spinning
Unsteadiness
Falls
Nausea and vomiting
Fatigue
Neck pain and stiffness
Travel sickness
Unable to cope with crowds and supermarkets
Blurred vision
Panic

What causes vertigo in the general population?

The most common form of vertigo is a condition called benign paroxysmal positional vertigo (BPPV). This is caused when small particles of debris in part of the inner ear become dislodged and trigger spinning sensations when the head is in certain positions. Someone with this type of vertigo often describes sitting up in the morning and the room spinning and that lying down, rolling over, bending and looking up will also trigger it.

Another common disorder is vestibular neuronitis. This is usually a viral infection of nerves that leaves some damage to areas involved in balance on one side of the body. The vertigo may be severe for days until the brain begins to compensate for the damage.

Other conditions such as Ménière's disease and migraine can also be a cause. Sometimes it is considered to be caused by a mixture of problems in the visual, vestibular and sensory areas, such as in older people. This is termed multisensory vertigo.

What causes vertigo in MS?

As well as the problems affecting the general population, people with MS can experience vertigo when the condition causes damage to the covering of the nerves in the parts of the central nervous system where information from the labyrinths is processed. This is termed 'central vertigo'.

Assessment

Assessment of vertigo may be done by a neurologist or an ear, nose and throat (ENT) consultant, some of whom have neurological expertise.

An important part of the assessment is the individual's history - the effect vertigo has, when it started, how long it lasts, what brings it on, what helps and medications being taken.

Depending on the history, the doctor will carry out a physical examination and may request tests and investigations. Tests will look at vision and eye movements and can confirm whether or not the problem is BPPV.[1]

The consultant may request an MRI to explore for any new MS activity in the brain and explore whether the symptoms are caused by a peripheral problem, eg in the inner ear, or a central problem in the brain or central nervous system.

Treatment

Treatment will depend on what is considered to be the cause of the vertigo.

Cause	Possible treatment
Acute demyelinating plaque	Corticosteroids
BPPV	Repositioning manoeuvre (eg Epley)
Labyrinthitis	Vestibular sedative medication Vestibular rehabilitation
Multisensory	Vestibular rehabilitation
Migraine	Migraine medication

The Epley manoeuvre (or similar repositioning procedure) is reported to be successful in about 90% of cases of BPPV. During the Epley manoeuvre the head is moved to a series of positions that moves the particles in the inner ear away from areas that cause vertigo. In some people it may need to be repeated, and others may need to attend for vestibular rehabilitation.

A study in 2000[2] reported that out of 25 people with MS with active vertigo, 13 were diagnosed with BPPV. Thus it is important that BPPV screening takes place as this is an easily treatable condition.

Medications for vertigo symptoms

Medication is often prescribed for severe symptoms but is usually only recommended for short-term use. These medications are believed to interfere with the compensation process that is necessary to improve from an episode of vertigo and people are usually advised to reduce and come off them once the acute symptoms have settled.

Vestibular rehabilitation - what is it?

Vestibular rehabilitation is an exercise programme for people with vertigo whose natural compensation process appears to be incomplete. More physiotherapists are developing specialist skills in this area and can provide tailored exercises. These may include eye exercises (eg gaze stabilisation), neck movements and balance exercises.

The basic theory underpinning vestibular rehabilitation is that the movement or activity that produces symptoms needs to be practised. The central nervous system does not learn if it is not challenged. Most people's natural reaction when they feel dizzy and disorientated is not to move and to avoid environments that aggravate their symptoms. This fear and avoidance behaviour has to be overcome to improve from vertigo and the therapist will make the exercises harder as the vertigo starts to improve.

Some therapists may use a set of exercises called Cawthorne-Cooksey exercises which are designed to challenge the vestibular system and encourage compensation.

Vestibular rehabilitation is not a cure. Recovery will depend on many factors, such as the location and the extent of the damage. Other factors such as general health, motivation and mood also play a part.

Vertigo can be a frightening experience. However if you can be assessed and helped to understand why you feel as you do and, importantly, how you can help yourself, you will feel more in control, rather than feeling that the vertigo controls you.