Managing a Vertigo Attack - Stuff I Wish I Had Been Told by My Doctors

Despite seeing a couple of very highly-respected neurotologists and at least two caring ENTs since being diagnosed with Meniere's disease almost six years ago, much of what I know today about the the disease and how to cope with it has come from online forums and Meniere's and hearing loss websites.  Among the contradicting advice I've received over the years involves the use of hearing aids (don't get me started), vestibular suppressants (doctors say don't use them, but the following article - and most sufferers - will beg to differ), and information on the underlying causes (the doctors tend to quickly say 'we don't know', implying they have no idea, but the literature offers at least a few good working theories which the doctors will only talk about if pressed).  Anyway, I digress.

Today I received the following article in my email inbox and found it to contain information I wish I had been given the day I was diagnosed with this miserable disease,  I hope someone finds it at least a little bit helpful during their next attack.

Managing a Meniere’s Attack

By Editor On February 4, 2015

Editor’s Note: Today’s post appeared last month at the Dizziness Depot. We thought it was worth sharing this week at Hearing Views in case you missed it. In today’s post, Dr. Desmond discusses how to manage the debilitating dizzy spells, or “attacks”, caused by Meniere’s disease.[1]
By Alan Desmond, AuD

If you have the flu or a bad cold, the natural response would be to drink fluids and to go to bed until you are feeling better. If you have a bad migraine, lying down in a dark room often provides some relief. Of course, due to the contrarian nature of Meniere’s disease, these activities will most likely make you feel worse. First, I will reprint a short passage from Dr. Tim Hain’s website (I highlighted some text), followed by an explanation of why his advice makes sense.

“How do I manage an attack?”

During an acute attack, lie down on a firm surface. Stay as motionless as possible, with your eyes open and fixed on a stationary object. Do not try to drink or sip water immediately, as you’d be very likely to vomit. Stay like this until the severe vertigo (spinning) passes, then get up SLOWLY. After the attack subsides, you’ll probably feel very tired and need to sleep for several hours.

If vomiting persists and you are unable to take fluids for longer than 24 hours (12 hours for children), contact your doctor. He can prescribe nausea medication, and/or vestibular suppressant medication. He/she may wish to see you or even admit you to the hospital if you are dehydrated. Meclizine (Antivert), Lorazepam and Clonazepam are commonly used vestibular suppressant medications and Compazine, Phenergan or Ondansetron are commonly used medications for nausea. In our practice in Chicago, we commonly prescribe an “emergency kit,” consisting of a small prescription of lorazepam and ondansetron, to be taken sublingually for an acute attack.”

Why a firm surface rather than going to bed?

During a Meniere’s attack, the inner ear is telling you that you are moving. When you are in bed, you have reduced tactile cues about movement and position. Think about how much more difficult it is to maintain your balance of a soft surface like a pillow or foam cushion. The brain is searching for reliable information and tactile feedback, which is much more reliable when received from a solid, ungiving surface. I recommend patients lie down on the floor, up against the wall in a corner and give themselves as much tactile feedback as possible.

Why keep your eyes open and fixed on a stationary target?

The nystagmus (rapid involuntary jerking eye movements) generated from the asymmetric output of your two labyrinths during an attack is what is making you feel as if you are (or your world is) spinning around. By staring at a fixed object, you can slow down the speed of the nystagmus, more so if you look out of the corner of your eye, opposite the direction that the nystagmus are beating. You have to experiment with this: Look out of the right corner of your eye for several seconds, then the left. Make a judgment about whether one side seems better or worse than the other.

This advice incorporates two basic rules of vestibular science:

1. Nystagmus of labyrinthine origin is suppressed by visual fixation –meaning the eye movements (nystagmus) and associated vertigo slow down when the eyes are open and staring at a target.

2. Nystagmus of labyrinthine origin increases in speed when gaze is directed toward the fast phase, and decreases when gaze is directed toward the slow phase –meaning that the eye movements and associated vertigo slow down when the eye is directed away from the direction that the nystagmus is beating. That direction isn’t always predictable and may change during an attack, so you have to experiment with this.

Why take a vestibular suppressant?

Vestibular suppressants may help reduce nausea during an attack.

The nausea is nature’s way of telling you that something is wrong with your vestibular system and that you should probably stay home. You are unsafe to be out hunting or gathering or whatever. Vestibular suppressant medication dampens the information received by the brain from the labyrinths. During a Meniere’s attack, that information is asymmetric, incorrect and making you miserable, so a vestibular suppressant reduces that asymmetry, and reduces the nausea. Of course, the effects will linger after the attack is over and you need to be cautious about sedating effects of the medication if you try to drive. Most people just want to sleep for several hours.

Why take the medication sublingually?

Once an attack starts, medications must be taken sublingually or through a suppository because the vomiting response won’t allow anything to stay down very long.

The bottom line – During an acute Meniere’s attack the inner ear is telling you that you are moving, while the brain, the eyes, and the sense of touch tell you that you are not. This sensory conflict produces nausea and disorientation. Shutting down the labyrinthine response and increasing the visual and tactile feedback will most effectively combat the error signal coming from the affected ear.

Footnotes
Ménière’s disease is a disorder of the inner ear that causes severe dizziness (vertigo), ringing in the ears (tinnitus), hearing loss, and a feeling of fullness or congestion in the ear. Ménière’s disease usually affects only one ear.

Informative Article About Living with Vestibular Disorders

Articles portraying accurate accounts of what it is like to live with a vestibular disorder and their various causes are far and few between.  Most perpetuate misinformation or give false hope.  I thought this article did a good job of touching on the known causes of vertigo and the difficulty diagnosing and treating them.  I encourage you to use the link to go straight to the article itself as it contains an embedded video and links to other articles and stories.  Thanks to Caroline for sharing this from Canada.

Misunderstood and often misdiagnosed, the mystery of vertigoDebilitating chronic dizziness can result from viruses, sports injuries and is difficult to cure

By Meredith Levine, CBC News Posted: Oct 13, 2014 5:00 AM ET Last Updated: Oct 13, 2014 7:59 PM ET

Word went round Janice Mackay's quiet neighbourhood that she was hitting the bottle hard. She'd been seen more than once weaving along the sidewalk in front of her suburban home in Pickering, just outside Toronto, in a sad, drunken stagger.

But Mackay wasn't drunk. As it turned out, her inner ear, the body's balance centre, had been destroyed by medication when she was hospitalized for over a month back in May 2005.

At the time, Mackay was diagnosed with a life-threatening infection in one of her ovaries, and so was put on a cocktail of medication, including an IV drip of gentamicin, a well-known, inexpensive antibiotic that is one of the few that hasn't fallen prey to antibiotic-resistant bacteria.

A few weeks later, the infection was almost gone when Mackay, still hospitalized, suddenly developed the bed spins and vomiting.

Her medical team told her she'd been lying down too long and gave her Gravol, but the symptoms didn't go away.

In a follow-up appointment after her discharge, Mackay was told that the dizziness was a side effect of the gentamicin, and that she would probably have to get used to it.

But she didn't discover the extent of the damage until later when neurotologist Dr. John Rutka assessed her condition and concluded that the gentamicin had essentially destroyed her vestibular system, the body's motion detector, located deep within the inner ear.

After a lengthy legal fight, Mackay eventually settled a civil suit with the suburban hospital that treated her. But nine years later, the spinning hasn't stopped, and Mackay lives with chronic vertigo, the constant illusion of motion.

Her balance is so unstable that she's been unable to get medical clearance to return to work with the City of Toronto, to a job she loved.

A professional hazard

Gentamicin ototoxicity, or poisoning of the ear, is just one way people end up with chronic vertigo. (Though it is one of the worst in that it can damage both sides of the inner ear.)

The problem with gentamicin
In the majority of cases, vestibular damage is the result of a virus. Head injury, autoimmune disease and genetic conditions are also culprits. As are some jobs.

Vestibular problems are a professional hazard for studio sound engineers, soldiers and military trainees who are exposed to bomb blasts, as well as football and hockey players, including Sidney Crosby, who develop chronic vertigo from vestibular concussions.

hi-hadfield-852.jpg
Canadian astronaut Chris Hadfield said he had problems with balance and dizziness on his return to Earth. (Canadian Press)

Even space flight has been implicated. Canadian astronaut Chris Hadfield acknowledged that life back on Earth, after five months of living on the International Space Station, came with dizziness and motion disturbances.

As he told one news organization, "your eye and inner ear are telling you different things."

In the U.S., the National Institute on Deafness and other Communication Disorders estimates that around five per cent of the American population, or roughly 15 million people, suffer from chronic vestibular problems.

There is no comparable Canadian figure, but the usual rule of thumb would suggest that amounts to about 1.5 million Canadians.

A 2009 study published in the Annals of Internal Medicine suggested that 35 per cent of all people aged 40 and older will experience at least some vestibular problems.

In fact, vertigo and dizziness are two of the fastest growing health search terms on Google, according to David Pothier, an inner ear specialist and researcher at Toronto’s University Health Network.

Unfortunately, says Pothier, "vestibular patients are often not taken seriously. They're repeatedly brushed aside as making up their symptoms. But what they experience is very serious and very real."

Often misdiagnosed

The patients who make it to Dr. Pothier's clinic in Toronto have spent, on average, two years bouncing around the health-care system looking for answers before they find him.

Lisa-Tanner
Lisa Tanner, a former college track star from Atlanta, Ga., says she has to hold herself very still mostly to get through her daily routine, and that many doctors wanted to diagnose her with depression. (Meredith Levine/CBC)

And they are among the lucky ones. There is a pronounced shortage of inner ear specialists, in Canada, and most vestibular patients don't end up under the care of a neurotologist.

As a result, their cases are often misdiagnosed as mental illness, and many are then prescribed tranquilizers.

But tranquilizers decrease brain activity, which in turn impedes the regeneration of the vestibular system. So patients on long-term prescriptions often get worse, not better.

Lisa Tanner, a 44-year-old former college track star from Atlanta, Ga., says that most of the physicians she's consulted "wanted to put me on Valium."

See Lisa Tanner's story: 'Don't jump around too much around Mummy'
During a typical consult, Tanner says, she would be asked if she cries frequently. "I'm honest, I say yes because it's hard some days. I do want to just have a cry and then get mad."

But she also tells her doctors that she's not depressed. "I'm not happy about this, but I do want to get better."

Piecing together clues

Diagnosing the cause of dizziness and balance problems is notoriously difficult.

The vestibular system is really just a string of microscopic hairs at the end of cells, inaccessibly encased in bone, beyond the reach of biopsy or current imaging technology.

Accurate diagnosis requires both specialized equipment, which many health-care institutions lack, and specialists willing to invest inordinate amounts of time puzzling over patient charts and test results.

Janice-Mackay-John-Rutka
Janice Mackay, left, talks with Dr. John Rutka, right, head of neurotology at the University Health Network in Toronto and the specialist who finally diagnosed her problem. (Meredith Levine/CBC)

​

"You have to be like Sherlock Holmes," says Dr. Rutka. "You have to put all the pieces together, find all the clues."

Rutka, a leading international researcher and head of neurotology at the University Health network in Toronto, is the specialist who finally diagnosed Janice Mackay's problem.

For him, one of the rewards of his work is being able to tell these patients, "You're not crazy, you're not psychotic, you're not nuts. Forget what other doctors have told you."

The link to anxiety

But while patients with chronic vertigo are certainly not crazy, there is a complex and fascinating biological link between damage to the vestibular system and the development of anxiety disorders.

Ancient Greek medical texts noted the connection first, but a few millennia on we have yet to fully decode the brain circuitry that connects the two.

"It is difficult to prove, it's difficult to show. But I think it's almost certainly something that's there," says Dr. Pothier.

David Pothier
Inner ear specialist Dr. David Pothier at Toronto's University Health Network says a big problem for vestibular patients is that their complaints are often not taken seriously. (Meredith Levine/CBC)

"When you want to comfort a child, you rock the child. When someone is upset, you rock them gently. People who are under extreme mental pressure often rock themselves."

If there is some kind of biological connection between movement and mood calming, then when the vestibular system — our internal motion sensor — is on the fritz, mood, it would follow, would also likely be affected.

What has been proven is that serotonin receptors, which play a role in mood regulation, exist in the vestibular system, and that there is some link between serotonin levels and vestibular regulation, according to the University of Pittsburgh's Dr. Carey Balaban, a leading researcher in this area.

"If you don't trust your balance system, anxiety is a natural protective process," he explains.

Vestibular patients' blogs and online groups are filled with discussion of anxiety and depression, especially, it seems, when there is little to alleviate the symptoms and patients are sometimes dismissed as fakers.

Joni Church, a 36-year-old video editor in Winnipeg, suddenly developed vertigo six years ago, the cause unknown , and describes struggling with "an inner despair where I felt like my life as I knew it was gone.

"The future for me was just sickness and the inability to do everything I love."

Most chronic vestibular disorders don't respond to medication, and there is currently no way to regenerate inner ear cells, though scientists are working on it.

Joni Church
Winnipegger Joni Church has recovered enough to return to work as a video editor. But it's a tough job for someone with a tendency to vertigo. (Meredith Levine/CBC)

About two-thirds of chronic vestibular patients do improve, although most will never be completely symptom free.

Essentially, these people learn through experience, and through rehab and behavioural therapy, to function as much as possible even when dizzy or off-balance.

Joni Church has recovered enough to return to work as a video editor, but it's a tough job for someone with a tendency to vertigo.

"It does make me a bit ill sometimes," she concedes, but she loves the work so she adapts her life around the condition.

Because her vestibular system has remained faulty, though, Church has been forced to relinquish a second passion: boxing. She was training for her first competitive fight when she became ill.

Next: Rehab, the latest techniques for dealing with chronic vertigo

Hearing Aids and Balance

Another long absence between posts, sorry, but it just means I've been well and with not too much new to report.  I'm still stable on my current treatment.  But an article I read today prompted me to write this post.

As most of you know, I am a huge fan of my hearing aid (HA).  Based on my own experience and the experiences others have related to me, it seems those of us with Meniere's-related hearing loss tend to be discouraged from getting an HA.  I suspect this is probably not based on any good evidence that HAs have been proven NOT to be beneficial, but more likely on the lack of evidence that they are.  Just about everything I've read or been told on the subject has only been anecdotal.

Understandably, our hearing often does fluctuate, making it a challenge to get and keep the HA properly adjusted.  Also, HAs are expensive so it might seem a waste of money if there's little reason to think it's going to significantly improve one's quality of life,  But in speaking with others with Meniere's disease who have tried an HA and also on what my doctors have said, I'd beg to differ.  The idea that an HA might not be effective for us seems to be based on (1) unrealistic expectations of how an HA can help in ways other than perfecting our hearing (it won't) and (2) not giving the brain enough time to adjust to the HA (in my case, it seemed to take 6-8 weeks for my brain to really rewire and adjust to processing and interpreting sound again).

Anyway, here's an article reporting on a small study which found that HAs might actually improve balance function in people with hearing loss.  After adjusting to my HA, I definitely felt it helped with my balance, as well as echolocation and reducing mental fatigue from straining to hear and process all the sound around me all the time.  I hope more work is done in this area to validate that HAs may do more than just amplify sound for those of us with Meniere's.

Do Hearing Aids Improve Balance?
By Alan Desmond On January 13, 2015 ·

A couple of years ago, I published a post on this blog about a study connecting hearing loss with increased risk of falls. My angle in the post was “Maybe there is a connection, maybe there isn’t, but what should we do with this information?”

Researchers at Washington University of St. Louis decided to investigate whether balance could be improved by treating those with hearing loss with hearing aids. They were specifically interested in whether hearing (in addition to vestibular, visual and proprioceptive) feedback contributed to improved performance on simple balance function testing.

Patients underwent two simple balance tests: the Romberg (eyes closed on foam) and tandem stance (heel to toe) with eyes closed. Throughout the test period, the patients were provided with what is described as “a point-source broadband white-noise sound (0–4 kHz).” Balance was assessed both with and without hearing aids in place.

The study did show that balance performance was improved, both objectively and subjectively, when hearing aid wearers had their hearing aids on and functioning. As noted by the authors “This is a small study. Obviously it needs to be repeated in a much larger study, and we’re seeking funding to do that.”

This is interesting on many levels: It helps support the idea of an association between hearing loss and increased fall risk, and it adds one more potential treatment option in the battle to reduce falls in the elderly. It will be more interesting to see where this research takes us.

Coping Strategies

I've written before about how important meditation has been to me in coping with Meniere's and all the fun stuff that goes along with it.  But I'm sure I've never said it as well as this blogger does.  Just insert vertigo or your symptom du jour if, or where, he says anxiety or depression.  Although, most of us have those, too!  I can relate to every word he writes and have worked through each of these mistakes along the way.  I'm not perfect in avoiding them all, but at least I usually recognize them more quickly for what they are: thoughts and nothing more.

6 Mistakes We Make When Depressed or Having a Panic Attack

By Nikolay Perov

“You are today where your thoughts have brought you; you will be tomorrow where your thoughts take you.” ~James Allen

When I was eighteen I went through a very stressful period, which led to the onset of panic attacks. I often remember how in bed one night I was suddenly overwhelmed by a feeling of terror. I’d never experienced such fear before. Sure, I was scared of lots of things, but this new feeling was unique.

The most accurate way I can describe it is a kind of animal-like horror. It seemed to have come from the deepest, darkest recesses of my subconscious mind, caused by primeval, bestial mechanisms.

The feeling was so deep and all encompassing that it was as if nothing else existed, just this fear coursing through my body as I writhed about, sweaty and tense.

The most unfamiliar and therefore terrifying aspect of the fear was that it didn't have an object: it wasn't clear what I was actually afraid of. From the very start, it was simply fear—unconnected to any tangible thing.

That night marked the beginning of my period of panic attacks. Over time, depression, anxiety, sleep problems, and general health issues augmented these.

At the age of twenty-four, I started to fight back; with the help of meditation I managed to get over my depression and panic, and now they no longer torment me.

During my struggle I came to realize that I was hindering myself with mistakes I was making, and it was only when I overcame these that I started to make real progress.

I often talk with people who have been or are going through the same kinds of problems, and I notice just how many of them also come up against these mistakes. So what are they?

1. Resisting.

When we feel a bad mood, depression, or panic coming on, our first wish is to get rid of it as quickly as possible, to change the “bad” mood into a “good” one. This is natural; it’s how we’re made. But all too often our attempts just make everything worse.

Resistance forces us to think constantly about our condition, to focus all of our attention on it, to feel bad because it won’t go away, to wait tensely for relief.

But the simple truth is that you can’t control everything. Attempting to get your condition “under control” often leads to extra stress and unwanted bad feelings. It’s sometimes best just to relinquish control and cease resistance.

If we relax and let our depression or panic come without trying to control anything, accepting that they’re only temporary feelings which will pass in due course, things become much easier.

2. Feeling bad about feeling bad.

We start to have thoughts such as “I’m going to die or go crazy,” “This’ll never end,” and “I hate that I can’t enjoy life like other people; I feel utterly miserable.”

Our mind starts to add new fears and negative emotions to the depression we already have. And, as I saw for myself, these fears and feelings end up constituting the main part of our condition.

It’s actually your mind, not the depression and panic themselves, which makes each episode so unbearable.

If you don’t believe me, try this experiment: The next time you’re overwhelmed by an attack, try to simply observe it without getting caught up in or assessing it in any way. Just watch it in its pure form, without any thoughts. Try to notice which parts of your body you feel it in and how it comes and goes.

In this way, you’ll remove your mind from the formula of your distress. You’ll notice how much weaker the attacks become when they’re no longer supported by your thought processes. Give it a try, making notes of the results if you like. Would it be true to say that it’s not all as terrifying and dreadful as it seemed at first?

When you stop feeding your depression with fears and thoughts it becomes much easier to shake off.

3. Comparing.

“Everything was so good when I wasn’t depressed! What an amazing time it was, and how awful it is now. Why can’t I go back?!” These are the kinds of things many people think, me included, but such thoughts bring nothing but harm.

If you want to beat depression or panic, you have to stop comparing. Forget that there’s a past and future. What’s happened has happened. Don’t dwell on it, and instead live in the here and now.

Start with what you have, and don’t think about how it all was before. Learning how to live in the present moment will make your depression or panic much more bearable.

4. Asking pointless questions.

Many people spend hours asking themselves all kinds of questions: “When will this end?” “Why me?” and “What have I done to deserve this?”

To make use of a well-known Buddhist parable, these questions are as much use as trying to figure out the source of the arrow which blinded you: it’s just not that important. What you need to know is how to pull the arrow out.

Questions of the “Why me?” ilk just make your condition worse, forcing you as they do to complain and be upset about something that’s already happened. Focus on what will help you get past your depression and don’t bother with questions which don’t serve this purpose.

5. Believing your fears.

We think that because we experience such fear at the idea of going outside, meeting people, or going on the underground, it means that something bad is going to happen. There’s nothing surprising in this, because nature has made fear in order to warn us of danger. We’re made in such a way that we instinctively believe this fear and respond to it.

But our fear hardly ever arises due to a real threat. For example, the fear of losing your mind or suffocating during a panic attack is simply fallacious. Stop believing this fear. Whatever it is you’re afraid of at these times isn’t going to happen.

Fear is nothing more than a feeling, a chemical reaction in your head. If you’re overcome with terror when you go down into the underground, it doesn’t mean that something horrific is laying in wait there. It’s like a malfunctioning fire alarm—just because it’s going off doesn’t mean there’s actually a fire.

So stop listening to your “inner alarm” every time it goes off. Don’t pay it any heed: go out, meet your friends, get on a plane, and let the alarm keep ringing. Nor should you try to “switch it off,” as this doesn’t always work. Just ignore it. In other words, stop taking your fear as something real.

6. Seeking reasons for your depression in the outside world.

This is another mistake I made myself. I thought that my malaise was linked solely to the way my life and work were going. I believed that if I could just change that, I’d be happy.

But then, with meditation, I realized that everything I needed to be happy was inside me, and likewise what was causing me to suffer!

I was so edgy, anxious, feeble, caught up in bad habits, undisciplined, and irresponsible that even if I’d succeeded in changing the external circumstances of my life, the traits that had given rise to my depression would still be there.

In order to get rid of my depression, I had to get rid of the internal reasons that had caused it.

So don’t keep telling yourself, “If I get a new job, everything’ll be smooth sailing,” or “If I get rid of everything I’m scared of, there won’t be anything to be afraid of any more.” Your depression and fears reside inside you, so wherever you are, they will be too, projected onto the outside world.

Of course, this doesn’t mean that you shouldn’t strive to improve your life. First of all, though, you need to direct your efforts inwards.

Conclusion: Acting Against What Feels Like Common Sense

Now, when I look at these mistakes and remember making them myself, I can see the one thing that unites them.

The reason we make them is that when depression or panic pounces on us, we start to think and act in the way our instincts and gut feelings tell to us. “Be afraid, run away, resist, danger awaits you everywhere, you’re trapped,” they whisper.

Tuning in to this during a bout of depression aggravates our situation. This is because our mind, emotions, and instincts are strongly conditioned by depression, so listening to them is like listening to the voice of a malicious, invisible demon intent on leading you to ruin.

To free yourself from depression once and for all you have to drop all your notions of common sense; abandoning your sense of reason, you must act against them.

Don’t resist your depression, accept your fears and allow them to simply pass; don’t get caught up in them and don’t believe them; don’t compare your current situation to how it was before—all things that feel illogical when you’re in a state of terror or intense depression.

What I’m advising may seem to be the polar opposite of what your gut encourages you to do. But it’s precisely because people continue to give credence to and obey these feelings that depression is such a widespread complaint. You need to act somewhat paradoxically to get rid of it.

My own experience has convinced me of this. The understanding I reached allowed me to come through my difficult situation and continues to help me cope with challenges I encounter on my journey.

Avatar of Nikolay Perov
About Nikolay Perov

Nikolay Perov formerly suffered from depression, panic attacks, addictions, laziness and communication problems. He coped with the help of meditation. His blog (also available in English) became popular in Russia, his native country. It has helped a lot of people get rid of depression, nervousness and alcohol problems and discover the new meaning of life. Read him on nperov.com!