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Navigating the Maze of Vestibular Disorders

When most people think of the vestibular system their first thought tends to be of a dreaded sensation: vertigo. Whether you’ve experienced it yourself or you know somebody that has suffered from vertigo, we can all agree that this condition can be disorientating, disruptive, and even debilitating. What many people don’t know is that vertigo is just one of a plethora of symptoms that can arise as a result of vestibular dysfunction.

The vestibular system, a complex network originating within the inner ear, plays a pivotal role in maintaining our sense of balance and equilibrium. The vestibular apparatus is the end organ for the vestibular system, just like your eye is the end organ for your visual system. It is made up of the semicircular canals and otolith organs. Our brain uses the vestibular apparatus in combination with our vision and our proprioception (body position sense) to enable us to navigate the world with grace and precision. However, disruptions in the vestibular system can give rise to various disorders, each with its unique set of challenges. Let's delve into three such conditions: Vestibular Migraines, Persistent Postural-Perceptual Dizziness (PPPD), and Mal de Debarquement Syndrome (MdDS).

Vestibular Migraines:

While many tend to think of migraines as a severe headache, migraines are really the result of neurological dysfunction causing our brains to become more sensitive to external stimuli. Common symptoms for people who experience migraines often include a unilateral or one-sided throbbing headache, light sensitivity, sound sensitivity, and nausea or vomiting. 

Vestibular migraines are an atypical of migraine that is characterized by the presence of episodic vestibular symptoms, such as vertigo, dizziness, and difficulties with balance and coordination. Unlike typical migraines, vestibular migraines may not always present with a throbbing headache, but these episodes can still cause significant discomfort. The diagnostic criteria for vestibular migraines, as outlined by the International Classification of Headache Disorders are as follows: 

  1. Recurrent episodes of vertigo or dizziness lasting between 5 minutes and 72 hours.

  2. A current or previous history of migraines with or without aura.

  3. The exclusion of other potential causes for the symptoms. 

Persistent Postural-Perceptual Dizziness (PPPD):

PPPD is a common vestibular disorder that is characterized by chronic non-spinning dizziness and the perception of unsteadiness that tends to worsen specifically when sitting upright, standing, walking, or when viewing external motion visual stimuli. The direct cause of PPPD is not yet fully understood, but due to the associated symptoms it is currently thought that this condition is caused by disruptions in systems closely intertwined with our vestibular system that play a significant role in establishing our sense of equilibrium: visual processing and postural control mechanisms. 

PPPD is often associated with conditions such as migraines, some metabolic conditions, and psychological stress such as anxiety or depression. Symptoms commonly manifest following some sort of previous vestibular insult, suggesting that PPPD could also be the result of incomplete recovery from a previous insult, such as; benign paroxysmal positional vertigo (BPPV), vestibular neuritis or concussion. Diagnosis for PPPD is based almost solely on symptoms, and in many cases all imaging and testing will result in normal findings. Diagnostic criteria for PPPD according to the International Classification of Vestibular Disorders is as follows:

  1. Symptoms of unsteadiness, imbalance, dizziness, or non-spinning vertigo must be present on most days for at least 3 months.

  2. Symptoms are provoked by being in an upright position, walking, or by visual stimuli such as moving cars or a crowded store.

  3. Symptom onset must be preceded by a previous condition that disrupts balance, such as BPPV or concussion.

  4. You experience impairment in your ability to do daily tasks such as walk or drive.

  5. All other potential conditions must be ruled out.

Mal de Debarquement Syndrome (MdDS):

MdDS is a disorder where individuals experience a persistent sensation of rocking or swaying after exposure to prolonged repetitive motion typically following air travel, a cruise, or other nautical journeys. The individual may not notice any issue while on the boat, but immediately upon stepping foot on dry land it feels as if they are still aboard. These symptoms are often alleviated by moving, driving, or re-exposing oneself to the motion that preceded the onset of symptoms (such as getting back on a boat). 

For most, this dizzying sensation will resolve after a few hours to a few weeks; for others it may persist for months to years if left untreated. Like PPPD, the exact cause of MdDS remains unclear, but it is theorized to result from maladaptation of the vestibular system. Just as functional neurologists use the nervous system’s ability to change to drive positive adaptation, repeated unfavorable stimuli can also cause negative adaptations. 

Diagnosis of MdDS requires the following: 

  1. Onset of symptoms following prolonged exposure to motion, such as a cruise.

  2. Symptoms improve upon re-exposure to passive motion, such as boat, plane, or car travel.

  3. Lack of nausea.

  4. Minimum of 3 month duration in symptoms (to diagnose persistent MdDS; a diagnosis can still be made if duration is shorter than 3 months.)

CFNC’s Approach

Understanding the vestibular system's crucial role in maintaining balance provides insights into the complexities of disorders like vestibular migraines, PPPD, and MdDS. While each condition presents distinct challenges, early recognition and accurate diagnosis are paramount. 

When working with vestibular patients at CFNC, we complete a thorough examination to ensure the proper diagnosis of your condition and locate the specific areas of neurological and vestibular dysfunction that may be contributing to your symptoms. Initial testing includes a full bedside neurologic exam, an autonomic evaluation, video-oculography, computerized posturography, assessment of neural timing mechanisms, and comprehensive lab work. 

Using this information, we are able to create a patient-centered plan to address your specific treatment goals with strategies such as tilt table therapy, neuromodulation, eye movement therapy, vestibular rehabilitation, musculoskeletal therapy, chiropractic care, nutritional counseling, hyperbaric oxygen therapy, supplementation and more. 

If you are experiencing any of these or similar symptoms, we encourage you to contact us or schedule a consultation with a doctor to discuss your vestibular symptoms and possible treatment options. 


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