What is Post-Concussive Vertigo?
Post-Concussive Vertigo
Vertigo is a false sense of motion. It can make you feel like you’re moving when you’re standing still, or like the world is moving when it isn’t. Post-concussive vertigo is vertigo that develops after a concussion or traumatic brain injury.
After any head injury, get emergency care right away for a headache that keeps getting worse, repeated vomiting, confusion, unusual drowsiness, slurred speech, weakness or numbness, a seizure, or one pupil larger than the other. If you are having thoughts of harming yourself, call or text 988 to reach the 988 Suicide & Crisis Lifeline, or call 911.
How Common Is Post-Concussive Vertigo?
An estimated 1.8 to 3.8 million concussions happen each year in the U.S. Research estimates that 40% to 60% of people with a traumatic brain injury have some degree of vertigo afterward (1). It may come in short, occasional episodes, or it may last for years after the injury.
What Causes Post-Concussive Vertigo?
The vestibular system tells your brain where your head is in relation to your body and to gravity. Post-concussive vertigo can come from an injury to the inner ear itself (the peripheral vestibular system) or to the brain and brainstem areas that process balance information (the central vestibular system).
There are several types of post-concussive vertigo, each with different causes. Many people have more than one type after a concussion, often at the same time.
Benign paroxysmal positional vertigo (BPPV). BPPV is one of the most common causes of post-concussive vertigo (2). The inner ear has two kinds of balance sensors: the otoliths, which sense head tilt relative to gravity and straight-line movement like up, down and side to side, and the semicircular canals, which sense head rotation. The otoliths rely on tiny calcium crystals called otoconia to work.
In BPPV, some of these crystals come loose and drift into one of the canals. The canals are fluid-filled tubes with hair cells that sense movement. When your head turns, the fluid lags behind for a moment, bending the hair cells and telling your brain which way your head is turning. In BPPV, when the affected canal is tipped into a vertical position, the loose crystals sink and drag the fluid with them, bending the hair cells even though your head isn’t turning. The canal sends the wrong signal to the brainstem, creating a sensory mismatch and vertigo.
BPPV is very common after head trauma, since whiplash and blows to the head can knock the crystals loose (3), and BPPV involving more than one canal is also common after an injury. BPPV is often treated effectively with the Epley maneuver and other canalith repositioning maneuvers, which move the head through a series of positions that guide the crystals back where they belong. We have extensive experience treating complex BPPV involving more than one canal.
Central vestibular disorders. Dizziness and vertigo can come from problems in the inner ear itself, or from problems in the cerebellum, brainstem and brain pathways that process balance information (4). These systems combine inner ear input with information from your eyes and from your muscles and joints to create a clear picture of where your body is and how it’s moving.
Certain test findings can point to a central problem, such as changing patterns of involuntary eye movements called nystagmus, or trouble following a moving target with your eyes (5). Central disorders are generally considered harder to treat than peripheral ones, and they are a major focus of our work.
Cervicogenic dizziness. Cervicogenic dizziness comes from injuries to the neck. Neck injuries and cervicogenic dizziness are common after concussions and other brain injuries (6). Neck injuries can create significant mismatches between the position sensors in the neck and the vestibular and visual systems. Many people have injuries to all of these systems at once, and complex cases often need rehabilitation strategies applied in a specific order (7).
What Are the Symptoms of Post-Concussive Vertigo?
Post-concussive vertigo can feel like falling, tilting, swaying, being pulled in one or more directions, or being generally unstable. In busy or complicated environments, it can also show up as anxiety, panic or a feeling of being detached from yourself or your surroundings.
How Does Post-Concussive Vertigo Affect Your Life?
A concussion can affect every part of your life. Simple tasks like reading can become exhausting and set off headaches and dizziness. Following a conversation or doing basic mental tasks can wear you out. A trip to the grocery store can feel overwhelming. Driving or riding in a car can trigger headaches, dizziness and panic. Screens and computer work can make every symptom worse. After a concussion, even the simplest tasks can feel impossible.
Depression, anxiety, post-traumatic stress disorder and emotional distress are common long-term effects of concussion, and rates of substance use problems are higher after a concussion (8).
Sleep problems (9) and chronic pain (10) are also common long-term effects. Job and school performance often suffer, leading to lost wages and higher rates of unemployment (11). Tragically, concussions also raise the risk of suicide (12), which is why getting support matters.
What Happens in the Brain With Post-Concussive Vertigo?
Your brain is made up of several types of cells. The ones most people think of as “brain cells” are neurons, which carry the brain’s electrical signals. You have billions of them, constantly sending messages to each other. Your brain also has supporting cells called glia, which do everything from helping neurons communicate efficiently to clearing away waste.
Neurons have a cell body, branches called dendrites that receive signals from other neurons, and long, thin fibers called axons that send signals. Most cell bodies are in the brain’s outer layer, the cerebral cortex, also called gray matter. Much of the rest of the brain is white matter, made up of axons running between neurons. Axons can be very short or several inches long. Because they are long, thin extensions of a single cell, they are fragile and easily damaged by stretching and shearing.
When the brain is hit or twisted quickly, or both, axons can be damaged. Depending on the injury, this may affect one group of axons or cause widespread injury across many brain regions and pathways, called diffuse axonal injury. Neurons in these pathways may work less efficiently or be lost.
When brain cells are injured, immune cells in the brain called microglia become active and start an inflammatory response to help heal the damaged tissue. Sometimes this response is stronger than it should be, which may cause additional damage. Injured neurons may also have trouble getting the oxygen, nutrients and blood sugar they need, which can add to the injury (13).
As the brain heals, the remaining neurons have to take over for those that were damaged or lost. Depending on the extent of the injury, this may be easy or very hard. Unlike muscles, which get stronger when you push them to the point of failure, injured brain pathways can be set back when pushed too far past their limits. In post-concussion syndrome, pathways may tire quickly because they’re doing their own job and also covering for injured cells. That’s why knowing when to push and when to rest matters so much in concussion recovery.
The neurons involved in post-concussive vertigo are part of the major systems your brain uses to figure out where you are in space: the vestibular system, the visual system and the body-position system. These systems come together in the brainstem, which can be injured in a concussion. An injury to any of these systems can create a sensory mismatch that causes vertigo and dizziness.
How Is Post-Concussive Vertigo Usually Treated?
Dizziness and vertigo are often treated with medications, such as vestibular suppressants, anti-nausea medications or medications for anxiety, and sometimes antidepressants. These can help reduce symptoms, especially in the short term (14).
Many people are also referred to physical therapists for vestibular rehabilitation. Many programs use habituation, which helps the brain gradually get used to movements that trigger symptoms. This can be very helpful for many people (15).
How the NeuroRescue Program Can Help
Our care is designed to work alongside your physician and other providers, never in place of them. Please don’t change or stop any medication without talking with your prescriber.
One of the brain’s most important jobs is figuring out where you are in the world. It uses your inner ear to sense where your head is in relation to gravity and how it’s moving, your muscles and joints to sense where your body is and what it’s doing, and your eyes to sense where you are in relation to everything around you. Your brain combines all of this into a picture of where you are, so you can respond to the world around you.
A concussion is rarely just an injury to the eyes, the inner ear or the neck alone. It often affects how well these systems work together. That’s why we look at all of these systems together, and at how they work as a team.
Depending on your needs and test results, your program may include eye exercises to improve gaze stability (16) and the accuracy of your eye movements (17); exercises for reflexes involving your inner ear, neck or both (18); balance training under specific conditions and vision training that combines several types of input at once (19); care for the muscles and joints of your neck, including chiropractic adjustments when appropriate; electrical stimulation (20); and exercises in a virtual reality environment (21). Transcranial magnetic stimulation (TMS) has been studied for symptoms after brain injury (22). At our clinic, TMS is provided by our psychiatric mental health nurse practitioner, who will evaluate whether it may be appropriate for you. Your program may also include computerized cognitive training to support attention, memory and processing speed. A randomized trial in people with ongoing symptoms after mild traumatic brain injury found that a computerized, brain plasticity-based training program improved overall thinking skills more than ordinary computer games (23).
Studies of approaches that combine several of these therapies after brain injury have reported improvements in symptoms, in some cases lasting over time (24, 25, 26). The therapies we recommend are always chosen based on your testing and exam findings.
How the NeuroRescue Program Works
Your NeuroRescue Program begins with your Discovery Day. We start with a detailed history of your condition and your life on a timeline. This helps us understand the factors that may have contributed to where you are now, and identify related conditions that may be making it harder to move forward.
We measure how your visual, vestibular and balance systems are working through computerized analysis of your eye movements, inner ear reflexes and balance under different conditions. Our testing includes videonystagmography and saccadometry to measure several types of eye movements, the video head impulse test to measure how each semicircular canal is working, and CAPS computerized posturography to assess your balance under different sensory conditions. We also use NeuroSensoryMotor Integration testing to evaluate hand-eye coordination and cognition, and Virtualis testing to assess dynamic eye tracking and your perception of vertical in a virtual reality environment.
We combine this with a thorough physical and neurological exam of your sensory, motor, autonomic and cognitive systems. We also review any relevant lab work, imaging and prior testing, and integrate it with our findings.
Together, this helps us understand which parts of your nervous system are working well, which are struggling, and how quickly they tire. We use that information to design your personal NeuroRescue Program, aimed at improving function in the systems that need support and helping them work together. Our testing also helps us decide when to push and when to let you rest.
Our goal is to help the world feel steady again, so you can read, drive, shop and get back to more of the things you enjoy.
Your Next Step
Living with vertigo after a concussion can be exhausting and isolating, especially when people can’t see what you’re going through. You don’t have to keep figuring it out alone. To find out if the NeuroRescue Program is right for you, contact one of our patient care coordinators to schedule your Discovery Day.
It’s never too late to take the next step.
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