Vertigo, the perception of spinning or movement where none exists, is usually traced to an issue within the inner ear’s balance system. However, epileptic vertigo is a less common cause, where the sensation of dizziness is itself a form of focal seizure. This means the abnormal electrical activity originates from a specific area of the brain. Because the primary symptom mimics familiar inner ear disorders, epileptic vertigo frequently leads to a delayed or incorrect diagnosis.
Defining Epileptic Vertigo
Epileptic vertigo occurs when there is a sudden, abnormal burst of electrical activity in the brain’s vestibular cortex. This area processes spatial orientation and balance information, making it the focal point for seizure-induced vertigo. The vertigo originates in the brain, distinguishing it from peripheral vertigo caused by inner ear problems.
Seizure activity most commonly originates in the temporal lobe, though electrical disturbances may also arise from the parietal lobe or the temporo-parieto-occipital junction. In these cases, the sensation of spinning is the actual manifestation of the neuronal discharge, not merely an associated symptom.
The vertigo sensation can occur as an isolated event, representing the entire seizure, or it can serve as an aura. When functioning as an aura, the spinning sensation is the patient’s first warning that a more extensive focal or secondary generalized seizure is about to take place.
Clinical Presentation and Associated Symptoms
The defining feature of epileptic vertigo is the brief, sudden rotational sensation experienced by the patient. Episodes are typically short, frequently lasting less than a minute, though some spells can extend for several minutes before resolving spontaneously. Patients describe an abrupt feeling of turning or spinning in a specific direction, which can be highly disorienting.
These episodes are frequently accompanied by other neurological symptoms, providing important clues to their epileptic origin. Associated manifestations can include:
- Auditory hallucinations, such as ringing or buzzing noises.
- Visual disturbances like flashing lights.
- Automatisms, which are involuntary, repetitive movements like lip-smacking.
- Transient cognitive impairment during the spell.
The presence of non-vestibular symptoms helps differentiate this condition from common peripheral causes. Nausea and vomiting may also occur, but these are less specific. When the seizure spreads beyond the vestibular cortex, the brief vertigo can progress into a secondary generalized seizure involving convulsions and loss of consciousness.
Diagnostic Procedures and Differentiation
Diagnosing epileptic vertigo presents a considerable challenge because the core symptom is identical to that of much more prevalent vestibular disorders, such as Benign Paroxysmal Positional Vertigo (BPPV) or Meniere’s disease. The diagnostic process relies on a diagnosis of exclusion. A detailed clinical history is paramount, focusing on the precise duration, frequency, and accompanying symptoms of the spells.
Electroencephalography (EEG) is a primary tool, especially when video-EEG monitoring is used to capture the brain’s electrical activity during a vertiginous episode. Capturing the ictal (during seizure) activity provides concrete evidence of an epileptic focus, most often in the temporal or parietal regions. However, the brief nature of the episodes makes capturing an event difficult and can lead to incomplete diagnostic workups.
Neuroimaging, typically Magnetic Resonance Imaging (MRI), is performed to rule out structural brain lesions that could be the source of focal seizures. Neuro-otologic assessment is also necessary to exclude peripheral vestibular causes. This involves tests like Videonystagmography (VNG), the video Head Impulse Test (vHIT), and Vestibular Evoked Myogenic Potentials (VEMP), which evaluate inner ear function. A diagnosis of epileptic vertigo is strongly considered only when peripheral tests are normal and the clinical history or EEG supports a cerebral origin.
Management Strategies for Epileptic Vertigo
Management focuses entirely on controlling the underlying seizure disorder, rather than treating the vertigo symptom directly. The goal is to stabilize the electrical excitability of the brain’s vestibular cortex. This approach contrasts sharply with treatments for peripheral vertigo, which often involve physical maneuvers or medications targeting the inner ear.
Treatment involves Antiepileptic Drugs (AEDs) selected based on their effectiveness against focal seizures. Common medications used include carbamazepine, levetiracetam, and lamotrigine, often starting with monotherapy to minimize potential side effects. Successful treatment is defined by a reduction in the frequency and severity of the seizures, leading to a significant decrease in vertiginous episodes.
For patients whose seizures remain difficult to control, a combination of AEDs with different mechanisms of action may be employed. If epilepsy is refractory to medication, alternative therapies such as vagus nerve stimulation or epilepsy surgery to remove the focal lesion may be considered.