What causes vertigo in MS?

Dizziness and Vertigo

Dizziness, a feeling of being off balance or lightheaded, is a common symptom in people with MS. A less common symptom for people with MS is vertigo, which causes the sensation that they or their surroundings are spinning or that the ground suddenly rushes upwards. Vertigo can be exacerbated by lying down or inclining one’s head or in situations where vision cannot be used, such as in a darkened room.

Causes of dizziness and vertigo

The symptoms of dizziness and vertigo result from lesions (damaged areas) on the nerve pathways responsible for transmitting input from the inner ear to the brain for the purpose of maintaining balance or equilibrium. Damage to the eighth cranial nerve, which serves both the balance (vestibular) and acoustic processes of the ear, can cause dizziness or vertigo.

Are there effective treatments for dizziness?

If dizziness or vertigo become significant problems for you or continue for a long time, your doctor may be able to give you a medication to help resolve the symptom.

Medications for treating motion sickness, including antihistamines such as Antivert® (meclizine), Dramamine® (dimenhydrinate), and Benadryl (diphenhydramine), may be useful, as well as select drugs in the benzodiazepine family, including Valium (diazepam), Klonopin (clonazepam), Ativan (lorazepam), and Xanax (alprazolam). A drawback with both antihistamine and benzodiazepine medications is that they can make you feel drowsy. So, you should work with your doctor to find the lowest dosage that resolves your symptoms.

In some cases, niacin, an essential nutrient part of the B vitamin complex that causes blood vessels to dilate, may provide relief from dizziness and vertigo.

In cases where dizziness and vertigo are very severe and vomiting won’t allow use of oral medications, high-dose corticosteroids given with IV fluids may be used to treat the CNS inflammation causing the symptom.

If dizziness or vertigo is linked to specific changes in body position, a physical therapist may be able to offer instruction on exercises for building tolerance and comfort with those position changes.

Since dizziness can result from the flu, treating muscle aches, fever, and other flu symptoms with aspirin and other medications may help to resolve dizziness which is related to the flu.

If You Are Experiencing Dizziness

First, remain calm. If you have a family member or friend nearby, make sure they are with you now. If this is a new problem for you, the key question is whether you should call 911 and go immediately to the emergency room.

If you are dizzy right now and have any of the following neurological symptoms along with your dizziness or vertigo, call 911 immediately:

  • New confusion or trouble speaking or understanding speech
  • New slurred speech or hoarseness of voice
  • New numbness or weakness of the face, arm, or leg
  • New clumsiness or tremor (shaking) of the arms or legs
  • New trouble seeing out of one or both eyes, or to one side
  • New double vision or inability to move one or both eyes
  • New unequal pupils or drooping eyelid on one side
  • New inability to stand even when holding onto something firm
  • Sudden severe vomiting with no known cause
  • Sudden severe headache or neck pain with no known cause

Dizziness, Stroke and TIA

Even if you don’t have any of the symptoms above, you could still be having a stroke or have suffered a recent pre-stroke (transient ischemic attack or TIA). A stroke or TIA is more likely if you are older or have known stroke risk factors (such as smoking, high blood pressure, high cholesterol, diabetes, atrial fibrillation, sickle cell disease, or a personal or family history of stroke or heart attacks).

But even young people with none of these traditional stroke risk factors can still suffer a stroke. Furthermore, there are dangerous heart conditions (heart attack or cardiac arrhythmia) that can also cause dizziness or vertigo. If you do not already know the cause of your new dizziness or vertigo, call your doctor right away or go to the emergency room to be assessed.

The only definite way to know you have not suffered a stroke or TIA is to be sure that you know that your dizziness or vertigo is due to something less serious. The most common conditions are benign paroxysmal positional vertigo (BPPV), vestibular migraine, Menière’s disease and vestibular neuritis/labyrinthitis. Unfortunately, each of these conditions can produce symptoms very similar to those of stroke or TIA, so careful attention to symptom details is required.

Benign Paroxysmal Positional Vertigo (BPPV)

If the dizziness or vertigo symptoms follow any of the following patterns, the cause is likely BPPV: (1) symptoms are intermittent; (2) symptoms occur only when the head is tipped or moved in a particular direction (especially when rolling over in bed to one side); (3) symptoms last for less than a minute after the head position change as long as the head is held still and (4) there is no vomiting, hearing loss or neurological symptoms.

Although rare exceptions do occur, people with these symptom patterns usually do not have strokes. People experiencing these symptoms should contact their primary physician for advice.

Vestibular Migraine and Menière’s Disease

If the dizziness or vertigo comes in episodes that last for minutes to hours, it could be due to vestibular migraine (usually without hearing symptoms) or Menière’s disease (usually with hearing symptoms), but it also can be the result of a pre-stroke (transient ischemic attack, or TIA). Those who have had such symptoms repeatedly over many years usually do not have TIA, but when the first episode occurs, it is advisable to seek medical care right away to assess your immediate risk for stroke.

If there are obvious neurological symptoms (described in detail above), call 911 or proceed immediately to the emergency room. If there are no obvious neurological symptoms, it is reasonable for patients to contact their primary physician for advice.

Vestibular Neuritis and Labyrinthitis

If the dizziness or vertigo is new, severe and persists for hours to days; has not stopped; and is associated with vomiting and trouble walking, it could be due to vestibular neuritis (usually without hearing symptoms) or labyrinthitis (usually with hearing symptoms). This symptom complex is identical to the symptoms seen with strokes in the balance part of the brain (brainstem or cerebellum), and it is impossible to exclude stroke without careful examination of the patient’s eye movements.

Even without neurological symptoms, patients with this symptom complex should generally call 911 or proceed directly to the emergency room to get immediate help. There, patients with this acute vestibular syndrome should expect the examiner to carefully inspect their eyes, including performing a test with a rapid head turn to either side while the patient looks straight ahead (head impulse test). This test can be performed with or without a special diagnostic device (quantitative video-oculography) sometimes referred to as “stroke goggles.”

When performed properly and combined with two other eye exams (together called “HINTS”), this exam can confirm vestibular neuritis rather than stroke. This approach has been shown to be more accurate than brain imaging in several scientific studies. Although it is common for patients to undergo CT scan of the brain in this setting, CT is generally unhelpful and risks radiation exposure. If neuroimaging is required, this should generally be by MRI scan of the brain.

Vestibular Neuritis: Angela’s Story

Suddenly stricken with severe dizziness that left her unable to move with no known cause, Angela sought out help from the Johns Hopkins Vestibular Clinic. Learn how an accurate diagnosis and treatment got her back on her feet.

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Vertigo, or the sensation of “spinning,” may occur as the result of lesions in the brain areas that coordinate balance.

Non-Pharmacologic Management

Physical Therapy

If changes in head position are a component of vertigo, a physical therapist can develop an exercise program that will help to reduce the effects of these positional changes.

Pharmacologic Management

including Benadryl® (diphenhydramine), Antivert® (meclizine), and Dramamine® (dimenhydrinate)

Mild vertigo may be controlled with these agents, originally used to treat vertigo associated with motion sickness. Dose is usually 25-50 mg every eight hours.

Side effects include drowsiness, blurred vision, constipation, and dryness of the mouth.

Scopolamine Transdermal Patch

This is an anticholinergic agent, meaning that it acts on neurons that use acetylcholine as their transmitter. One of its main uses is the treatment of motion sickness and its associated vertigo.

Side effects are similar to the antihistamines, listed above.

Benzodiazepines including Valium® (diazepam), Klonopin® (clonazepam), and Serax® (oxazepam)

These medications decrease activity in the areas of the nervous system that control the inner ear.

Please refer to the Spasticity and Anxiety sections for details on these drugs.

► Go to Introduction to Multiple Sclerosis Symptom Management

► Go to Multiple Sclerosis Symptom Listing

► Go to Multiple Sclerosis Symptom Medications

What are the early signs of MS?

Most people with MS experience their first symptoms in their 20s or 30s. Some of the most common early indications include:

Vision changes

Share on PinterestEarly signs and symptoms of MS can include fatigue, weakness, dizziness, and emotional changes.

The National Institute of Neurological Disorders and Stroke in the United States report that vision problems are often the initial symptom of MS. Inflammation disrupts the vision when it affects the optic nerves.

Possible vision changes include:

  • blurred vision
  • double vision
  • red-green color distortion
  • loss of vision
  • pain when looking up or to the side

Fatigue and weakness

Most people with MS experience fatigue and weakness. Nerve damage in the spine results in long-term, or chronic, fatigue.

Weakness most commonly affects the legs before extending to other body parts. The symptom may come and go or last for several weeks at a time.

Tingling and numbness

Tingling and numbness are other common early warning signs of MS. These symptoms most often occur in the:

  • arms
  • face
  • fingers
  • legs

Initially, numbness and tingling may be mild, but they can become more severe over time. Most of the time, these symptoms are not disabling and will come and go without the need for treatment.

Pain and spasms

Up to two-thirds of people with MS worldwide report related pain. A person may experience short- or long-term pain.

Examples of short-term pain include:

  • stabbing pain in the face (trigeminal neuralgia)
  • a brief, electric shock-like sensation from the back of the head down the spine (Lhermitte’s sign)
  • burning or stabbing sensations around the body (neuropathic pain)

Chronic pain causes burning, aching, or “pins and needles” sensations. Muscle spasms — sharp, jerking movements of the legs and arms — are also common.

Dizziness and loss of balance

Dizziness and balance problems affect many people with MS. They may experience:

  • faintness
  • lightheadedness
  • nausea
  • weakness

These symptoms can cause people to lose their balance, be clumsy, or struggle to walk.

Less commonly, people with MS experience vertigo, which is the sensation that the surroundings are spinning. This occurs when lesions affect the parts of the brain that maintain balance.

Bladder and bowel issues

The majority of people with MS experience some degree of bladder dysfunction. Bladder issues occur when lesions affect nerve signals that control the bladder and urinary function.

Symptoms typically include:

  • increased urinary frequency
  • urinary urgency
  • difficulty starting urination
  • night-time urination (nocturia)
  • incontinence
  • difficulty completely emptying the bladder

Bowel issues are less common than bladder problems in people with MS, although some experience diarrhea, constipation, or loss of bowel control.

Sexual problems

Sexual arousal begins in the central nervous system, when the brain sends messages to the sexual organs.

Damage to these nerves causes some people with MS to notice changes in their levels of sexual desire, sexual activity, and ability to orgasm.

Other symptoms of MS, such as fatigue and pain, may also reduce sexual desire.

Cognitive and emotional changes

Approximately half of all people with MS will notice cognitive changes that affect their:

  • ability to concentrate
  • abstract reasoning
  • attention span
  • memory
  • problem-solving skills
  • speed of information processing

Emotional health problems are also common, including depression, stress, and anxiety. These issues can arise as people manage their symptoms and the impact of MS on their lives.

Other symptoms

Other symptoms that affect people with MS include:

  • breathing difficulties
  • headaches
  • hearing loss
  • itching
  • seizures
  • speech problems
  • tremors
  • trouble swallowing
  • walking difficulties

Dizziness and Multiple Sclerosis (MS)

Timothy C. Hain, MD Page last modified: January 6, 2019

While many persons with dizziness are very anxious about having MS, practically it is very uncommon to diagnose MS in a person with vertigo or unsteadiness. The reason for this is that MS is an uncommon disease, far less common than inner ear conditions such as BPPV, or common neurological disorders such as migraine.

On the other hand, MS can sometimes be a devastating neurological illness, and treatments are gradually becoming available. Thus, thought is that although MS is uncommon, it is worthwhile to look a bit harder for MS than more benign disorders, or equally devastating ones in which there is no effective treatment (such as PSP).

Perhaps the biggest problem with diagnosis of MS is that it common to confuse an MRI with lots of white matter lesions with MS. To have MS, one needs to have objective signs of MS. More about this is on this page concerning white matter lesions in Migraine, which is massively more common than MS, and often has plenty of white matter lesions as well.

Typical presentations

Patients with MS generally do NOT present with vertigo or hearing loss, but in the context of our dizziness specialty clinic, much more commonly present with a cerebellar syndrome. Like all dizzy patients, they are unsteady on tandem Romberg testing. In addition to this, there are generally specific oculomotor findings such as an internuclear ophthalmoplegia (see figure below), extreme impairment of smooth pursuit, rebound nystagmus, and ocular dysmetria. In fact, without objective signs of CNS lesions, one really cannot make the diagnosis of MS.

The general neurological examination is particularly important in MS, as opposed to other types of dizziness, as one is looking for multiple neurological lesions. Reflex asymmetry, upgoing toes (Babinski sign), unilateral sensory disturbances, spasticity, and evidence of optic neuritis (pale disk or Marcus-Gunn pupil) are all common.

Large MS plaque in 8th nerve root entry zone in brainstem. MS plaque similarly disposed in the middle cerebellar peduncle. Two MS plaques in cerebellar white matter.

Diagnostic testing for MS in persons with Dizziness or ataxia as the main presenting symptom.

Screening for MS is generally easy, because MRI scanning as well as the general neurological examination is very sensitive to MS. One looks for multiple white matter lesions separated in time and space. On the MRI, when there are “innumerable” white matter lesions, scattered throughout the brain and spinal cord, MS is possible (see MRI’s below). That being said, it is important to emphasize that an MRI showing multiple white matter lesions is not equivalent to MS (Brownlee et al, 2018). Migraine is a very common disorder that can have many white matter lesions. In migraine, there are no objective neurologic finding, and the spinal tap is also normal. There are far more persons with white matter lesions due to migraine than due to MS, because about 14% of the entire population has migraine — i.e. 1/7 people. This far exceeds the prevalence of MS (about 1.5/1000). So MRI scans can suggest MS, but actually their main utility is to rule it out (with a normal scan).

When there are just a few white matter lesions, the differential diagnosis is wide — depending on the clinical situation, one may attribute them to “small vessel disease” (tiny strokes), the ravages of age, and of course, our ever present migraine. Tumors can usually (but not always) be distinguished from MS because they are “space occupying”, meaning that they push surrounding brain tissue to the side. Neurosarcoidosis is distinguished from MS mainly through discovery of lesions elsewhere in the body. Neurosarcoid is exceedingly rare as well.

Multiple MS plaques in white matter just above ventricles Dawson’s “fingers” extending from the ventricles seen in this woman with longstanding and classic MS. Another illustration of Dawson’s fingers, just above the lateral ventricle, seen on this sagittal view.

Peculiarly, although MRI scans are widely available, in our setting in Chicago Illinois, as of 2019, the cost of MRI’s has been rising very rapidly. We have seen hospitals charge as much as $7000/scan billed to insurance. As just a year ago, MRI scans were much cheaper, and one would think that costs should be coming down, comparison shopping is recommended. Our thought is that a “reasonable” price for an MRI is $700 or less.

We recommend that someone having a scan for MS select a closed unit (i.e. no “open” MRI’s), a high-field scanner (1.5 Tesla or more -3T is preferable), and be sure that T1, T2, gadolinium contrast, and flair sequences are included in the study. This is very routine, and one generally only gets something different if one goes to an “open MRI” facility. The radiological diagnosis of MS is not “rocket science”, and except in very complex cases, a neurologist should be able to tell you to a high degree of reliability whether or not your MRI and clinical picture is compatable with MS. If your MRI is normal, MS is very unlikely. If it shows lots of white spots, more consideration is needed.

Certain patterns of lesions are “classic” for MS. Dawson’s fingers are projections from the ventricles (see above).

CT scans of the brain or spinal cord are not very good for diagnosing MS, because they do not show MS plaques very clearly, and they are used only when an MRI is not possible. This might be due to a person having a pacemaker or metal objects of some kind in their head.

Increased signal in periaqueductal gray region (no obvious signs or symptoms due to this).

Occasionally a lumbar puncture (spinal tap) is used to provide additional information. Here one looks mainly for increased gamma-globulin and an increased number of oligoclonal bands. The procedure also has some value in excluding other conditions such as meningitis or disseminated tumor. In the author’s clinical practice, a lumbar puncture is rarely performed, but instead a watchful-waiting strategy of getting repeat MRI scans at roughly one year intervals for a few years is used. If there is no change in exam or scan, then I stop scanning.

Oculomotor testing documents an in INO (internuclear ophthalmoplegia) individual with MS. Also see the accompanying movie. INO’s are common in MS, and rare in nearly every other disorder involving dizziness.

Audiological testing and MS.

Otologic testing for MS is generally normal. Hearing testing should be normal, as should be caloric testing and OAE’s. The oculomotor parts of the ENG or rotatory chair test can be diagnostic, as in the figure above illustrating an INO, but see the next paragraph for the pitfalls. Brainstem auditory evoked responses (ABR) are also, generally speaking, normal. It is too soon to say whether VEMP’s are helpful, but it seems likely that they will generally not be useful, because of the multifocal nature of MS. If you can get a reasonably priced MRI, we see little reason for bothering with a ABR, as the MRI covers all of the disease processes that might be diagnosed by a ABR, as well as many others.

While the ENG battery has some testing aimed at diagnosis of central lesions, the ability of audiologists who generally perform these tests is variable, with false positives and false negatives abounding. The problem is that because MS is such a rare source of dizziness, the people who usually do the testing and interpretation (audiologists), have very little experience in recognizing it. Our suggestion – -if an audiologist reads your ENG as showing “central signs”, show it to a neurologist who is familiar with these things. On the other hand, if there is good evidence for MS on your clinical examination, and your ENG is read as normal, again show it to someone who is familiar with both MS and ENGs — this is usually an otoneurologist. Otolaryngologists, like audiologists, are generally unfamiliar with MS. In our opinion, the optimal testing arrangement is one in which an experienced individual performs the ENG, and an experienced otoneurologist reads it.

Another difficulty with ENG’s oculomotor testing is that they may not use large enough eye displacements to detect an INO. One should ideally use 40 degree saccades. It is common for newer ENG’s to use 15 degree displacements or even less to avoid nonlinear artifact. This means that the bedside examination may be more sensitive than recordings (sadly enough).

Treatment of dizziness accompanying MS

There are presently many immunological treatments of MS, largely involving use of interferon or other immunosuppressants. We will not cover this in any detail, but this is the reason why it is worthwhile spending some effort on diagnosing MS.

Otherwise, treatment of dizziness accompanying MS follows the general strategy as treatment for central vertigo. The most useful medications are benzodiazepines (see article on drug treatment of dizziness). Vestibular rehabilitation is usually worth trying.

Treatment of tinnitus accompanying MS also generally follows the same strategies as for tinnitus in other contexts.

  • Brownlee WJ. Misdiagnosis of multiple sclerosis. If you have a hammer, everything looks like a nail ? Editorial. Neurology, 2019;92:15-16.

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