Multiple Sclerosis (MS) is a chronic autoimmune disease where the immune system attacks myelin, the protective covering of nerve fibers within the central nervous system (CNS). This damage creates lesions that interfere with the flow of information between the brain and the body. Vertigo is the sensation of spinning or whirling, often described as feeling like the person or the room is moving when no movement is occurring. When vertigo arises from CNS damage, it is recognized as a potential manifestation of MS.
The Connection Between Multiple Sclerosis and Vertigo
Vertigo can be a sign of Multiple Sclerosis, sometimes presenting as one of the initial symptoms leading to diagnosis. Dizziness and balance issues are common in MS; nearly half of all patients experience some form of dizziness during their disease course. True rotational vertigo—the intense feeling of spinning—is estimated to affect about 20% of people with MS.
This symptom usually results from new inflammatory activity or the enlargement of an existing lesion in specific brain areas. The onset of vertigo often signals an MS relapse, which is a period of new neurological dysfunction. It is important to distinguish true vertigo from chronic disequilibrium, which is a persistent feeling of unsteadiness or being off-balance. Disequilibrium is more common in MS and relates to poor coordination and muscle weakness rather than a specific central vestibular event.
Neurological Pathways Affected by MS Lesions
The balance system relies on complex integration between sensory input and processing centers, known as the central vestibular system. Lesions in areas responsible for processing balance signals can directly cause vertigo. These areas include the brainstem and the cerebellum, which coordinate posture and movement.
The brainstem contains the vestibular nuclei, which receive signals about head position and movement from the inner ear. Demyelination in these nuclei disrupts nerve signals, leading to “central vertigo.” Damage to the cerebellum, situated above the brainstem, also impairs movement coordination and spatial orientation, often resulting in severe imbalance.
Lesions are frequently found in the pons, a section of the brainstem. Demyelination in the medial vestibular nucleus is a common location linked to vertigo. Central vertigo is distinct from inner ear causes because it originates from a breakdown in the brain’s processing center. This type of vertigo can be persistent and is often accompanied by other neurological signs due to the close proximity of nerve pathways in the brainstem.
Differentiating MS-Related Vertigo from Inner Ear Causes
Vertigo can arise from many conditions, categorized as peripheral (inner ear) or central (brain-related). Clinicians must determine the source for appropriate treatment, as most cases are peripheral, such as Benign Paroxysmal Positional Vertigo (BPPV). Central vertigo, the type associated with MS, often presents with a less intense spinning sensation than peripheral vertigo, but tends to be more constant and longer-lasting.
A key difference is the presence of associated symptoms. Peripheral vertigo is frequently accompanied by auditory symptoms like hearing loss or ringing in the ears (tinnitus). In contrast, central vertigo caused by MS is rarely associated with hearing problems, but often occurs alongside other neurological deficits. These co-occurring signs can include double vision (diplopia), slurred speech, or weakness in the limbs, pointing directly to brainstem involvement.
Diagnostic testing confirms the origin of the dizziness. Specialized balance testing can reveal involuntary eye movement, called nystagmus, suggesting a central cause. The nystagmus in MS-related vertigo is multi-directional and does not stop when the patient focuses their gaze. Magnetic Resonance Imaging (MRI) is the most definitive tool for distinguishing central from peripheral causes, as it visualizes the inflammatory lesions characteristic of MS in the brainstem or cerebellum.
Treatment Strategies for Central Vertigo
Management of central vertigo involves addressing both the acute symptom and the underlying disease activity. For immediate relief, anti-nausea medications or vestibular suppressant drugs may be prescribed to temporarily alleviate the spinning sensation. These medications are used cautiously and for short periods, as prolonged use can hinder the brain’s ability to adapt to the balance disruption.
When vertigo is part of an MS relapse, a short course of high-dose corticosteroids may be administered to reduce inflammation in the CNS lesions. Reducing inflammation helps resolve the acute episode of vertigo and other relapse symptoms. The long-term strategy for preventing future episodes involves Disease-Modifying Therapies (DMTs), which aim to reduce the frequency of relapses and the formation of new lesions.
A cornerstone of ongoing management is Vestibular Rehabilitation Therapy (VRT), a specialized form of physical therapy. VRT uses specific exercises to help the brain compensate for inaccurate signals from damaged vestibular pathways. This approach promotes central nervous system compensation and helps improve balance, coordination, and gaze stability.