Swaying, drowsiness, fatigue

Dizziness with and without physical findings

Dizziness, that means a disorientation in space. There is hardly anything that is as unsettling and causes fear, even panic, as this sensation.

For some types of vertigo there are clear findings, e.g. an impairment of the inner ear. An example would be benign positional vertigo, the most common type of vertigo.

But sometimes there are no physical findings at all. Often it is more a feeling of dizziness, a feeling like being drunk or having absorbent cotton in the head. Usually it is coupled with strong exhaustion, sleep disturbances and numerous further complaints. Then the insecurity is twofold: Once by the discomfort and then still by the lack of clarity, what then causes this discomfort.

These pages are about dizziness with and without physical findings. What is it? How does it occur? What to do about it?

New: After a very long preparation time, we can now make our dizziness self-help app available. More details on our online therapy pages.

Basis

Orientation in space

Knowing where up and down is, and where we are in space, is as natural to healthy people as water is to fish. No one worries about balance as long as everything is in kilter.

But for those who suffer from vertigo, a basic orientation is lost. Suddenly it becomes clear that orientation in space is a prerequisite for any action. The loss of balance is massively limiting and often associated with great anxiety.

The organ of balance is a puzzling and often misunderstood human sensory organ. Evolutionarily, it is one of the oldest senses and arose far before the sense of hearing. The misunderstandings begin with the name. What sits in the inner ear next to the sense of hearing is actually not a balance organ but an acceleration organ. It measures different types of speed changes.

Complex perception - complex calculation

Humans do not have a single organ of balance, but multiple sources of spatial orientation. The feeling of down and up then arises from the integration of the different impressions in the brain. Several sources contribute to this feeling:

The vestibular organ in the inner ear
The eyes
The body perception (med. proprioception) i.e. information from the skin, muscles and joints.
The hearing

The feeling of balance is therefore the result of complex perceptions and equally complex processing in the brain. It is one of the most difficult tasks we have to perform on a daily basis. This is why it takes a correspondingly long time for a child to be able to balance over a tree trunk.

If, in the end, a person is able to coherently combine the abundance of data into an overall impression, he or she has the impression of having both feet firmly on the ground. But if this is not successful, if there are contradictions between the sources of information, uncertainty, dizziness and vertigo arise.

Example seasickness

Such discrepancies can be experienced very impressively in a ship when the sea is moving. If you then go inside the ship to avoid the sight of the waves, your eyes will make you believe that you are apparently calm. At the same time, the inner ear and body convey considerable motion. Disorientation, dizziness and nausea is the result, which in this case is called seasickness.

Irritation can also occur when leaving a ship. The balance is out of joint. The ground pretends to sway like a ship. "Mal de debarquement," the disease of disembarkation, is the name given to the phenomenon. It is a complaint that not only affects old sea dogs, who, as is well known, only feel really secure on their feet when they are at sea.

Complicated name: The Reafference Principle

Equilibrium is based on the fusion of numerous information without conflict. Various factors like fear, avoidance and also excessive attention worsen it. But there are other essential influencing factors.

With every movement, even minimal fluctuations of the body, the image on the retina of the eye changes, no different than if the environment were moving. But how can we know who is actually moving.

In science, it is assumed that with every planned muscle movement, a copy of this plan simultaneously goes to the centers that will subsequently register the movement. So something like this: "Attention visual cortex, eyes are about to move 10° to the right, don't be surprised if visual impressions change by 10°." Or, "Attention postcentral gyrus (a brain region), I am about to give the command to raise the arm, move the hand and fingers to turn the page! So if there are any impulses coming from this region, it's nothing to worry about."

Then, if the eyes have moved and the transmitted image has changed as expected, the impression is that the environment remains constant, while the direction of gaze has changed. Thus, if the change is as expected, it is internally checked off, it is uninteresting. The same is true for turning the page of a book.

This consideration is called the "Reafference Principle" and is apparently based on a broad body of experience. In the course of development, every human being must learn in all conceivable situations how movement affects perception in order to avoid disorientation and dizziness. Ultimately, the effect of all actions on the various senses must be anticipated in order to act sensibly.

Forward and reverse model

Benign paroxysmal positional vertigo (BPPV)

Benign positional vertigo

Benign positional vertigo is the most common type of vertigo. It is said that one in three people suffers from it at least once at some point in their lives. It is a complaint predominantly of the older age, whereby women are affected somewhat more frequently. In addition to age and the female sex, injuries, accidents, inflammations, migraine, osteoporosis and long bed rest favor the occurrence of this vertigo.

Symptomatology

Positional vertigo is actually not difficult to diagnose. The symptoms are extremely typical. Especially the following characteristics indicate it:

Sudden onset after a change in position or head movement (often obliquely upward).
Short duration (< 1 minute)
Largely symptom-free between seizures
Provocation of the symptoms by appropriate positioning
Dizziness subsiding after repeated provocation, when the otoliths have left their wrong place and are no longer a nuisance

Typical eye movements

During the positioning test, not only dizziness but also a typical eye movement occurs, which is called nystagmus.

Test posterior archway

You can provoke the typical dizziness yourself with a simple positioning exercise. Although this is not pleasant, it provides a quick diagnostic indication. Whereby it is useful that you do not perform this test alone and, if necessary, immediately follow the freeing maneuver.

Test horizontal arcade

Therapy: Short but intense

The therapy of benign positional vertigo can be easily deduced from its origin: The stones must be removed from the arcades! This does not require any surgical intervention, but only a skillful movement sequence, during which the arcades are freed from the unwanted "settlers". This is why the exercise is also called a "liberation maneuver". Although this is uncomplicated and harmless, it still takes some effort, since dizziness will inevitably occur during the exercise and a certain degree of gait insecurity may persist shortly afterwards. Therefore, you should not perform the exercises alone and should not drive yourself afterwards.

Liberation maneuver of the rear archway to Semont

Liberation maneuver rear right archway to Epley

Liberation maneuver rear left arch to Epley

Liberation maneuver horizontal arcade (barbecue method)

Fashioned diagnosis and rescue maneuver horizontal arcade

Morbus Menière

Dizziness, ringing in the ears and hearing loss

Meniere's disease - like positional vertigo - is one of the common vertigo disorders. It occurs mostly in people in middle age. Men suffer from it somewhat more frequently. Despite extensive research, the causes are only partially understood. What is known is that in this disease there is too much fluid (endolymph) in the inner ear. This fluid is either produced in excess or is insufficiently removed. The vestibular canal and the cochlea are connected, and the same endolymph flows through both. Therefore, in case of overpressure, both balance and hearing are affected. As overpressure increases, the fine skin surrounding the inner ear tears. Then the endolymph mixes with the tissue fluid (perilymph) outside.

The electrolyte composition of the perilymph differs from that of the endolymph and therefore now irritates the nerve fibers of the inner ear. The brain interprets the irritation of the vestibular organ as movement, and the auditory cochlea interprets it as noise. Fortunately, the tear closes again, and after some time the conditions return to normal. The complaints subside.

If such attacks remain the exception, the damage is also limited. Hearing and balance function completely normally again after an attack. However, the more frequently such attacks occur, the more severely the organ is damaged. This can result in a permanent reduction in hearing and tinnitus (also between attacks).

Specialists base their diagnosis on the classic triad of dizziness, ringing in the ears and hearing loss, sometimes accompanied by a feeling of pressure in the ear and nausea. Additional clinical and technical examinations then bring final clarity.

The seizure itself subsides on its own with or without therapy. However, the nausea may be so severe that a drug (such as dimenhydrinate suppositories) is needed to provide the patient with relief. Tranquilizers can also relieve anxiety or panic for a short time (e.g. diazepam). These preparations do not really improve the dizziness as such, but they make it easier to bear.

Vestibular neuritis

It starts with an acute spinning dizziness. Everything seems to go round in circles, nausea or vomiting are the result. When walking, the affected person experiences an uncontrollable gait deviation and a tendency to fall in the direction of the affected ear. Patients feel very ill, are forced to lie down, avoid any movement and keep their eyes closed as much as possible. Even the slightest movements intensify the dizziness, which can persist even when the patient is lying still. During the ENT medical examination, in addition to the insecurity of movement, a conspicuousness of eye movement (nystagmus) can be detected with a jerky rotation of the head. Further technical examinations then confirm the diagnosis.

Migraine dizziness

The combination of migraine-like headache and dizziness is usually called "vestibular migraine". Sometimes it also goes by names such as "migrainous vertigo," "migraine-associated vertigo," "vertiginous migraine" or simply "migraine vertigo." It affects about 1 percent of the population. The correct diagnosis is only made in 20 percent of cases, since there is no typical form of vertigo, but ultimately all types of vertigo (such as spinning vertigo, staggering vertigo, elevation vertigo) can occur together with migraine.

Diagnostically, it can sometimes be even more difficult, namely when headaches are completely absent. Then other migraine symptoms, especially the high sensitivity to stimuli, lead the examining physician on the right track.

Vestibulopathy

Bilateral (both sides) vestibulopathy

Older people sometimes experience a peculiar change in their sense of balance. They feel unsteady in the dark or on uneven terrain and, when on the move, can no longer see faces, signs or writing clearly. The environment seems to make strange movements for them, for example during a walk. Dizziness or spinning dizziness and a disturbance of spatial orientation are also present. In some patients, hearing is also impaired.

At rest, the spook is over: faces are recognized, signs can be read, and there is no longer any trace of apparent movements.

Core symptoms of the usually bilateral vestibulopathy, the usually bilateral disease of the vestibular organ:
Gait unsteadiness, visual disturbances and perception of "illusory movements" when walking.
Motion-dependent vertigo
Disturbances of spatial orientation
Improvement at rest

Vestibular paroxysm

Nightmare with second cycle

In the case of so-called vestibular paroxysmia (meaning: seizure-like disturbance of the vestibular nerve), there is an abrupt onset of vertigo that usually lasts only seconds and rarely longer than one or several minutes. The disorder usually occurs as spinning dizziness, more rarely in the form of staggering dizziness. Afterwards, there is complete freedom from symptoms. Sometimes the vertigo is accompanied by a slight ringing in the ears. Certain head movements - especially upwards - can also trigger the symptoms. For those affected, some head positions are unbearable even during sleep.

Dizziness of the elderly and the risk of falls

The older we get, the greater our problems with balance become. As they enter their well-deserved retirement years, 20 percent of all seniors complain of dizziness. Ten years later, it's already 30 percent, and of those in their 80s, it's one in two. This puts dizziness in first place among the most common symptoms that very old people complain about to their doctors.

Avoiding and risk of falling

Dizziness often causes older people to lose their balance and fall. This in turn triggers the fear of another fall: a vicious circle is created. 25-50 percent of all seniors are said to suffer from such fears. And as is so often the case, this fear causes avoidance behavior. In order to avoid falling, those affected avoid active movement. Riding a bicycle is abandoned, sporting activities are limited, and a cane is preferred for walking. Even when walking within their own four walls, they look for support. The safest place seems to be the comfortable armchair.

Such avoidance behavior almost inevitably ends in a downward spiral: coordination, balance and strength decline - and with them the real risk of falling increases. Scientists speak of a declining "fall-associated self-efficacy expectation." In other words, older people are less and less confident in their ability to master difficult motor situations (steep, uneven paths and such or stairs without railings) in everyday life on their own.

Vertigo, the atlas and the cervical spine

Highly controversial

Hardly any dizziness is as controversial as so-called cervicogenic, i.e., dizziness caused by the cervical spine. In general, orthopedists consider this to be a significant cause of vertigo, while neurologists or ENT physicians not infrequently speak of a "myth" in this context.

Dizziness due to medication

If you suffer from dizziness and take medication regularly at the same time, I recommend that you first take a look at the package insert. Can you find "dizziness" in the list of side effects listed there? This is especially important if you are elderly or have been prescribed several medications at the same time, perhaps by different doctors.

Phobic postural vertigo PPPD

Overdiagnosed, misunderstood and left alone

This is the form of vertigo we treat most often. It is usually not a spinning dizziness but a feeling of drowsiness, a sensation like being drunk, having absorbent cotton in your head or being beside yourself.

At the same time, those affected usually suffer from head pressure, shortness of breath, palpitations and pronounced exhaustion. In rooms with many people (department stores, bus, train, airplane) and under stress, everything gets worse. Anxiety, feelings of panic or even panic attacks can occur. For those affected, the worst thing is often that no cause can be found for all these symptoms.

Usually, a psychological cause is suspected, but psychotherapy and psychotropic drugs usually do not show any resounding success.

What kind of disease is this?

We have extensively researched this clinical picture and can now present well-founded knowledge and a clear therapy concept.

Dizziness and lightheadedness

Onset of symptoms

The fluctuating vertigo usually occurs in stressful situations. Most common:

Stress/overload
Organic vertigo
Panic feelings/panic attacks

Sufferers reported feeling "as if drunk" or having the sensation of "absorbent cotton in the head." Some patients also report that the feeling resembles a slight swaying, like on a boat. Less common are other vertigo sensations, such as feeling pulled to one side or forward/backward, spinning vertigo as if on a merry-go-round, or even elevator vertigo. As always, when they do not have a secure orientation in space, the affected person is seized with fear up to panic.

This is almost always accompanied by physical symptoms. Mostly these are palpitations, irregular heartbeat, palpitations, increase in blood pressure or even a blood pressure crisis. Sweating, inner restlessness and trembling are also evidence of the enormous stress associated with the symptoms.

Those affected usually go immediately to a doctor or to the emergency room of a hospital. The most common suspected diagnoses are heart attack and stroke. Many patients are immediately admitted to an intensive care unit, where they first undergo a thorough physical checkup. Blood analyses, ECG, ultrasound examinations, CT and/or MRI are usually part of this routine. But the result after a short time is: Everything is fine, no pathological findings can be detected!

Anyone who just thought they were suffering from a serious, life-threatening illness will, of course, be relieved at first by the good news. But the relief does not last long. For now the person suffering from vertigo is faced with the pressing question: If there is nothing wrong with me, where did my complaints come from?

The answers to this question are usually less enlightening. Patients are usually told that their symptoms are somehow related to excitement or stress, and that it would be a good idea to consult their family doctor or, even better, a psychotherapist. For those affected, such sentences often come as a surprise. Yes, they have had stress lately. But where does this dreadful dizziness come from? Why do I feel so dizzy? Why do I find it so difficult to concentrate? What's going on with my head?

Fatigue and exhaustion

Worn out and tense

If the symptoms of the patients last not only a few weeks, but months or even years, there are almost always additional impairments: above all, an agonizing feeling of exhaustion, a mental paralysis that is difficult to describe, as if they had the proverbial "board in front of their head". The ability to concentrate decreases, when reading articles and books it is difficult for those affected to remember what they have read, and in many cases their professional activities become difficult or even impossible.

Physical causes for the exhaustion can be found just as little. And visits to naturopaths or alternative practitioners rarely lead to success. Their diagnoses read for example: "load with heavy metals or environmental poisons", "chronic Borreliose", "lack of trace elements", "food incompatibility", "overacidification of the organism" or "problems with the first neck vertebra". However, the remedies prescribed, often by the dozen, or even the adjusting, only have a very short-term effect - if any at all - on reducing the complaints.

The exhaustion complaints can then become so pronounced that there are transitions to "burnout", exhaustion syndromes or CFS (chronic fatigue). Typical: an incredible need for rest and constant inner restlessness.

Feelings of panic and anxiety

Virtually all dizziness patients experience an acute worsening of their symptoms when they are in confined spaces with many people. It is particularly unpleasant when they have to stand in line at the checkout in a crowded supermarket or when they have to wade through the masses in a busy department store. Then they are overcome by a real sense of claustrophobia. "Get out, I'm suffocating!" her body must want to scream.

Even in the car, the drowsiness often increases. It becomes downright unbearable when several people have squeezed into a narrow vehicle at the same time with the ventilation turned off. In this case, the affected person feels suffocated within a few minutes, while the other passengers hardly seem to notice the distressing situation. Long tunnel journeys become in such a way the agony!

If they have been crammed into a packed vacation plane, dizziness sufferers often experience the same feeling of panic after the plane doors have closed. Looking forward to the best weeks of the year then becomes an impossibility. The feeling of constriction, anxiety and shortness of breath is too strong. For the next vacations, a flight is often no longer an option.

Those affected were not necessarily real daredevils in the past. But so many concerns and restrictions, such as fear of flying, tunnel anxiety or social anxiety, were foreign to them. The end of the story: Some of them hardly dare to leave the house. Going shopping alone, taking public transportation or attending an event are all associated with (too) much fear for them. Of course, regular attendance at their workplace is no longer an option.

Constantly "beside himself

Derealization" is a feeling in which the outside world seems strange and unreal. The self-evidence of inside and outside is lost, the affected person feels as if he/she has been "taken away".

"Depersonalization" is the related sensation of having become a stranger to oneself, such as the feeling of going through life like a robot. One's own body, feelings and thoughts do not seem to belong to one's own person (anymore).

Those affected often describe their condition as follows: "I feel as if I am cut off from my surroundings, as if a veil hangs between me and the outside world. Out of the blue, I feel alien, as if I am not real."

Often the complaining is described as if the knock is in clouds, foggy and unclear.

New insight: dizziness and breath

Can this be the result of incorrect breathing?

In our search for the causes, we were able to identify a regular pattern:

Based on a certain personality structure with high sensitivity and high willingness to perform, excessive demands in life - stress - trigger physical reactions. One of these is the unconscious acceleration of breathing, i.e. mild or chronic hyperventilation.

The result: dizziness, palpitations, shortness of breath, feelings of tightness. As a rule, those affected are not aware of this breathing, since breathing is normally blanked out.

But for the therapy this realization is central!

More about breathing disorders

Visual vertigo

Mal de Debarquement Syndrom

If you have ever been on a ship for a long time, you know the strange feeling when you have solid ground under your feet again: The ground seems to sway similar to a ship.

As a rule, this disappears after a few minutes or hours. If someone was on a longer cruise, it can take until the next morning for the world to get back on track.

About ¾ of all seafarers reported a feeling of swaying (forward/backward, up/down, sideways), according to one publication, but this dissipates after about 24 hours in the vast majority. In one study, even more than 90% were affected.

In addition to a sea voyage, flights, train journeys or other irritating movement experiences can also be at the beginning. Very often a combination of movement and uncertainty is found.

In a few people, the symptoms persist for weeks, months or even years. There are no clear figures about the frequency of the symptoms, it is suspected that it may be more common than is known in everyday medical practice. This condition is called Mal de Debarquement. This is derived from the French Mal = disease and Debarquement = to leave a ship. In English, it is referred to as Mal de Debarquement Syndrome (MdDS).

Lice and fleas

In a larger proportion of all patients with organic vertigo, additional psychosomatic vertigo ("secondary somatoform vertigo") develops as a result of their severe uncertainty in the further course. This most frequently occurs after vestibular migraine, Meniere's disease, neuritis vestibularis or benign positional vertigo.

In connection with the respective initial problem, this leads to confusingly complex manifestations in the symptomatology. Then, in addition to the possibly specific treatment measures, general training for balance and respiratory regulation is therapeutically necessary.

Note the general instructions for all videos

Drug therapy

Antihistamines etc

The focus is on one active substance: diphenhydramine (trade names: Emesan®, Betadorm®, Dolestan® and others).

It acts primarily as an antihistamine at the so-called H1 receptors. Therefore it is used against various allergies.
It also makes people tired and is therefore sold as a sleeping pill.
It is also used as a sedative.
Finally, it is effective against nausea and seasickness (e.g. travel tablets).

It isnot a remedy to improve balance!

In acute dizziness (e.g.,neuritis vestibularis), its use for a few days is quite helpful. However, prolonged administration is not advisable. In particular, continuous use should be avoided in the case of complaints such as"senile vertigo". The depressant effect (sleeping pills!) is then in massive contrast to the actual therapy goal: relearning balance.

Questionable usefulness

In order to reduce fatigue as a result of taking diphenhydramine, it is also offered in combination with substances that tend to stimulate. For example, with theophylline an asthma drug (trade name Vomex®, Vertigo-Vomex®, Reisegold®, Emedyl® and others). Theophylline is related to caffeine.

Whether this combination is useful is a matter of great controversy. Not least because the stimulating substances can be addictive. It's kind of like when you dissolve sleeping pills in espresso. Furthermore, the stimulant components can be addictive.

Betahistine (trade names: Aequamen®, Vasomotal® and others), is approved in Germany for the treatment of vertigo in Meniere's disease. In a sensationalstudy, however, it was shown that the effect of the preparation in Meniere's disease did not differ from that of a placebo.

Scopolamine is also available as a patch for motion sickness. There are only small studies on its efficacy with a small number of participants. Sulpiride, a drug for psychosis and depression, is also not recommended for vertigo.

A number of other preparations (e.g., ginkgo biloba, pentoxifylline, dextrane) were once commonly used and are still used occasionally. They are said to promote blood flow to the brain. This effect is doubted today. Nerve blocks with the help of local anesthetics are equally useless.

Homeopathy

Perhaps, after reading this, you may have doubts as to whether a preparation consisting mainly of water can achieve what no other chemical remedy can. Homeopathy, unfortunately, is anything but safe in case of vertigo!

However, if you respond well to placebos, then at least taking it is not dangerous!

Ginger

Ginger actually has verifiable effects against nausea, but the effectiveness is lower than that of antihistamines. However, the side effects (in reasonable doses) are negligible, and in addition, the slightly spicy tuber tastes simply excellent. So ginger is always worth a try. To do this, you can peel a 2-3 centimeter piece of ginger, cut it into small pieces (or grate it) and boil it with some water for a few minutes. There are also ready-prepared ginger drops in vials to take home.

Non pharmacological therapy

Intensive Therapy

The most effective is intensive therapy, which we perform in our practice clinic. It lasts between 1-4 weeks (most often 2 weeks).

Depending on the symptoms, the following elements are used:

Various dizziness exercises
Breathing therapy
Physiotherapy
Massages
Heat/cold chamber
Exercise therapy
Nutritional counseling and change
Relaxation procedures
Targeted psychotherapy or coaching

The central point is the guidance to self-help. In the end, our patients should know what they can do at home without us. To this end, we also equip them with the appropriate aids.

Book

We have compiled 53 exercises for training at home in a book. You will also find the instructions on how to perform each of the exercises step by step and what you should pay attention to.

Online App Dizziness

Even though we have tried to illustrate the exercises with many photos, it is easier with films where you can directly follow along. Therefore, there is also an online program that you can easily follow along with that specifically addresses your vertigo symptoms. These exercises are especially helpful for the organic types of vertigo.

Online App Breathing

For non-organic dizziness, which is characterized by lightheadedness, feelings of absorbent cotton and exhaustion, the breathing exercises that you will find in a comprehensive app are particularly useful. We also offer online coaching for this purpose.