Vertigo & Head Injuries: An Essential Guide to Maneuvering Dizziness after a Concussion or Traumatic Brain Injury (TBI)

Concussions also known as mild traumatic brain injuries (mTBI) are commonly talked about among the media nowadays with football players and other professional athletes bringing chronic traumatic encephalopathy (CTE) to light. About 5% of the population annually will experience some kind of head injury and dizziness is a common symptom that comes along with it. Some people can experience mTBI and TBI symptoms without a head injury and with just whiplash. There does not need to be a direct impact to the head for you to experience a head injury. About 1.5m TBI’s occur each year and affect females more often than males.1,2 Post-traumatic vertigo is dizziness following some kind of neck or head injury. About 30 to 65% of people with a traumatic brain injury (TBI) will experience some kind of dizziness or equilibrium issues (feeling off balance).3

Can a concussion or TBI cause vertigo? How does it happen?

Due to the shearing and torqueing nature of a head injury, all midline structures in the brainstem will be affected alongside the cortex. This force can impact central and peripheral structures associated with your vestibular system. Your vestibular system is what keeps you balanced and stabilizes you like if you were on a boat. The otoconia (small calcium carbonate crystals in your inner ear) can be shaken out of place and migrate to other parts of the semicircular canal causing you to feel dizziness. In a study done by Knoll et al (2019), damage throughout the vestibular structures were equal in post-mortem autopsies that had complaints of dizziness and a history of head trauma.4 There are three types of vestibular impairments that are commonly associated with a mTBI or TBI.

Benign Paroxysmal Positional Vertigo (BPPV)

BPPV is a type of vertigo caused by small crystals of calcium moving in your inner ear semicircular canals. These small crystals moving out of place can cause you to feel dizziness and like the world is spinning around you. As the name suggests, it is considered a benign condition caused by positional changes with your head.

BPPV most commonly affects those over the age of 50 and typically affects women more so than men. However, younger individuals can experience BPPV as well but typically have a preceding head trauma. Head trauma is also the most common cause of bilateral BPPV.6 About 28% of people with post-traumatic vertigo will experience BPPV.7

Labyrinthine Concussion

Labyrinthine concussion is a condition where cranial nerve 8 of your brainstem becomes damaged leading to vertigo and disequilibrium issues. It is difficult to diagnose this as there are a few other conditions that are in the same area that can mimic these symptoms. Any traction causing a stretch injury of the 8th cranial nerve can cause this as well as the tracts in the brainstem that integrate into the area where the 8th cranial nerve lives and the nuclei it interacts with can cause vertigo symptoms.

Traumatic Endolymphatic Hydrops

Traumatic endolymphatic hydrops also known as post-traumatic Meniere’s syndrome is defined as an imbalance of fluid in the inner ear causing dizziness for up to a year. Some other common symptoms associated with this can be a fullness feeling in the ear, tinnitus (ringing in the ears), and hearing loss.

Other Central Vestibulopathies

Cerebellum Trauma – The cerebellum is another area that can be directly affected in a head injury. Your cerebellum is in control of coordination, balance and equilibrium and also integrates with your vestibular system. Any trauma to this part of your brain can cause non-positional vertigo, disequilibrium and nausea. It’s important to correlate these symptoms with cerebellum-specific testing in order to pinpoint what part was affected during the head injury.

Parieto-insular Vestibular Cortex (PIVC) Trauma – The PIVC is a part of your brain that helps in the perception of visual motion in regards to gravity as well as the processing of vestibular inputs and self motion. Due to this, it can be a central part of why you are experiencing dizziness following a head injury. This area can influence things like anxiety as well which has been noted as being higher with people who experience dizziness that’s generated from the PIVC.9

Cervicogenic Dizziness (CGD) – Typically occurs due to whiplash in the neck. This condition can cause migraines as well as dizziness. CGD has been associated with inflammatory, degenerative, or mechanical dysfunctions of the cervical spine. There are possible reasons as to why CGD causes dizziness as there may be abnormal afferent signals from the cervical spine to the vestibular nucleus that orient your head and neck in space. There also may be some abnormal signaling due to pain in the region as well.10

Positional Orthostatic Tachycardia Syndrome – Positional orthostatic tachycardia syndrome (POTS) can occur following a head injury. POTS is a condition where your heart rate will spike when changing from different positions such as seated to standing. This increased heart rate can cause you to feel dizziness or lightheadedness. About 1 – 3 million people suffer from POTS yearly.11

How are mTBI’s and TBI’s diagnosed? What other testing should I do if I have vertigo?

The initial testing done by a medical professional usually involves a computerized tomography (CT) scan or a magnetic resonance imaging (MRI) scan. Usually this is based on how recent the head injury was and the severity. Some might not opt to do any diagnostic imaging if they believe the injury is mild. Typically in concussions you won’t be able to find anything on the MRI as it’s used more to detect any bleeding and or visible structural brain abnormalities. However, there are more tests that can be performed to further assist in diagnosing a mTBI and TBI. In some clinics like ours they will utilize a thorough neurological bedside test, balance testing, videonystagmography (eye tracking software) as well as any blood work to help with figuring out why you are still experiencing symptoms like vertigo. It’s important to be thorough with testing as there are many areas where vertigo symptoms can be generated from as discussed above. We suggest getting checked out or scheduled for an initial consultation here if you’d like more insight as to why you still might be experiencing vertigo after a head injury.

How long will I feel these symptoms?

Typically symptoms should resolve within 6 weeks, however some people may experience symptoms for years following a head trauma. Some studies state that on average people recover in about 10 days while other studies stated that there was a recovery within a year.12,13 About 15% of people who experience a TBI will experience long lasting symptoms (CITE). Why some people experience symptoms longer than others depends on a variety of factors and depending on your situation you may end up in a negative feedback loop. People who have repetitive head injuries or persistent symptoms past 4-6 months are less likely to recover on their own without rehabilitation. Unfortunately with vertigo and disequilibrium symptoms especially, you’re at a much higher risk for falling and hitting your head again. It begins to snowball and your symptoms may become even worse and oftentimes it can be difficult to improve without being looked at by a healthcare professional that specializes in mTBI and TBI rehabilitation.

Who’s most affected by this?

mTBI’s and TBI’s tend to be very common among athletes as well as the geriatric population. Athlete’s in high impact sports naturally have more opportunities to hit their head and suffer an injury. While the geriatric population generally has a higher incidence of falls which can be due to underlying vestibular conditions that have gone undiagnosed. This leaves them at a very high risk for hitting their head and suffering from a TBI. However the severity of symptoms can vary based on the individual. Some may have severe symptoms that last long term while some may have mild symptoms that recover immediately. Generally as you age, your brain declines overall and its ability to heal from injuries decreases.

Treatment for Vertigo after a head injury?

There are different avenues that a clinician can take when treating vertigo related to mTBI and TBI. It’s absolutely essential that your doctor does a thorough job of testing so that they can figure out what mechanism may be contributing to your vertigo. Depending on if it is peripherally based or central will change how your healthcare professional should approach your care plan. At our clinic we approach head injuries and vertigo from three different aspects: neurological, metabolic and structural. It’s essential for all three of those to be addressed as if you only focus on one, you may be missing out on something that could be indirectly blocking your healing process. For example, let’s say you hit your head and experience persistent vertigo in the following days. Your doctor puts your on meds for the vertigo but doesn’t touch address the dysfunction in your neck. Although you may be putting a lot of time and effort into doing different vestibular and neuro rehab, your neck may be producing abnormal afferent signals to your brain causing you to still experience vertigo. This situation is not uncommon and many times we see people that have gone to many different doctors but still haven’t found relief for their vertigo or the other symptoms related to their head injury. It’s absolutely pivotal that you approach mTBI/TBI from multiple facets as it can get quite complicated.

What should I do if it doesn’t go away?

If your vertigo symptoms persist and you are not improving, please contact a healthcare professional. You may need a more in depth look at what your options are for treatment and why you may not be recovering. If you would like to schedule a free consultation with our clinic, please contact us here. We see patients from all around the country as well as locally. We are here to help you and look forward to working with you!

References

1. “Report to Congress: Traumatic Brain Injury in the United States.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 22 Jan. 2016, www.cdc.gov/traumaticbraininjury/pubs/tbi_report_to_congress.html.
2. Mollayeva, Tatyana et al. “Sex & gender considerations in concussion research.” Concussion (London, England) vol. 3,1 CNC51. 18 Jan. 2018, doi:10.2217/cnc-2017-0015
3. Peterson, Michelle, and Brian d Greenwald. “Balance Problems after Traumatic Brain Injury.” Balance Problems after Traumatic Brain Injury | Model Systems Knowledge Translation Center (MSKTC), https://msktc.org/tbi/factsheets/balance-problems-after-traumatic-brain-injury.
4. Knoll, Renata M et al. “Peripheral Vestibular Organ Degeneration After Temporal Bone Fracture: A Human Otopathology Study.” The Laryngoscope vol. 130,3 (2020): 752-760. doi:10.1002/lary.28010
5. Treleaven, Julia. (2017). Dizziness, Unsteadiness, Visual Disturbances, and Sensorimotor Control in Traumatic Neck Pain. Journal of Orthopaedic & Sports Physical Therapy. 47. 1-25. 10.2519/jospt.2017.7052.
6. Haripriya, G R et al. “Incidence and Treatment Outcomes of Post Traumatic BPPV in Traumatic Brain Injury Patients.” Indian journal of otolaryngology and head and neck surgery : official publication of the Association of Otolaryngologists of India vol. 70,3 (2018): 337-341. doi:10.1007/s12070-018-1329-0
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9. Indovina, Iole et al. “Role of the Insula and Vestibular System in Patients with Chronic Subjective Dizziness: An fMRI Study Using Sound-Evoked Vestibular Stimulation.” Frontiers in behavioral neuroscience vol. 9 334. 9 Dec. 2015, doi:10.3389/fnbeh.2015.00334
10. Reiley, Alexander S et al. “How to diagnose cervicogenic dizziness.” Archives of physiotherapy vol. 7 12. 12 Sep. 2017, doi:10.1186/s40945-017-0040-x
11. Mar, Philip L et al. “Neuronal and hormonal perturbations in postural tachycardia syndrome.” Frontiers in physiology vol. 5 220. 16 Jun. 2014, doi:10.3389/fphys.2014.00220
12. Radanov, B P et al. “Cognitive deficits in patients after soft tissue injury of the cervical spine.” Spine vol. 17,2 (1992): 127-31. doi:10.1097/00007632-199202000-00001
13. Peterson, Connie L et al. “Evaluation of neuropsychological domain scores and postural stability following cerebral concussion in sports.” Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine vol. 13,4 (2003): 230-7. doi:10.1097/00042752-200307000-00006
14. Balatsouras, D G et al. “Benign paroxysmal positional vertigo in the elderly: current insights.” Clinical interventions in aging vol. 13 2251-2266. 5 Nov. 2018, doi:10.2147/CIA.S144134
15. Samy, H M et al. “Dizziness, Vertigo, and Imbalance: Background, Etiology, Epidemiology.” Retrieved from https://emedicine.medscape.com/article/2149881-overview. 11 Nov 2019.
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