Vertigo

Vertigo- Bhrama

By Dr Jayagovinda Ukkinadka

Introduction

• Bhrama or Vertigo is a common condition seen in general population.

• Very common in elderly• Major cause of fall in elderly in above 60 age

group.• Vertigo indicates a disease of ear- labrynth or of

Brain- Cerebellum, or Vertibro Basillar artery insuffeciency.

• Vertigo can also be due to postural hypotension.

Vertigo in Ayurveda

• Explained under the heading Bhrama. • But positional and non positional pattern is not

explained.• Relation ship of Bhrama with ear pathology was

not known to our ancients.• But treatment for bhrama on the basis of

doshik involvement is explained in our texts which holds good even in todays practice for vertigo induced due to different causes.

Vertigo in Ayurveda• Rajoguna when joins with vitiated Pitta and

Vata results in Bhrama roga.• No much elaboration is seen.• Here Labrynth fluid, various infectious causes

represent Pitta and Cerebellum, VBI cause represents Vata. Rajo guna one of the feature is moving here and there, where most of vertigo is due to non homogenous distribution of debris in Labrynth, which is also influenced by external movement. AVARANA is the another pathophysiology to be considered.

Need of specific therapy

• In current medical practice none of the system claims better treatment for vertigo induced due to any cause. Present treatment in modern medicine is symptomatic in most of the conditions.

• Knowing the different causes of vertigo we can develop specific treatment for vertigo of different origin or vertigo produced due to different NIDANA.

It is also said that

Means

Relationship between Doshas and ROGA - Susrutha

• Susrutha while discussing about the relationship between Doshas and Disease clearly says that there is no intimate relation or bond between dosha and diseases, if it is the case all living creatures would be a NITYAROGI.

• He further says that many believe that Tridoshas are the root cause for the disease but it is not true, but a disease can not happen without the involvement of dosha is the correct statement.

How doshas and Diseases are related?• In the sky(dosha) one can see lightening(disease)

etc, if any one says that because of sky there is a lightening, the statement is wrong but the truth is sky is must for lightening to occur, but it happens because of specific cause or NIMITTA. Hence for all the disease Nimitta or NIDANA is the important factor, but can understand the process through different symptoms having specific dosha, adhistana, sthananthara, nature of damage considering the Hetu. Hence though we don’t have much elaboration we can plan the treatment to different BHRAMA having different etiology and pathophysiology.

It is also said that

Treating diseases with no name

• Susrutha in another context though says that dosha is a factor to understand the disease, Nimitta is important, while explaining the treatment of unexplained diseases mentions of only dosha and symptom, but Vagbhata corrects his version including the all factors of etiology, pathophysiology as the consideration for planning the treatment.

Hence the advantage is

• Now a days we know the pathophysiology of many diseases causing Bhrama, i.e VIKARA Prkarithi and Ashraya sthana and also we know the etiology of many diseases causing Bhrama. Eg- Vertigo induced by chronic otitis media, over accumulation of endolymph in cochlear duct, Ear wax accumulation etc with the etiology.

TWO FORMS OF VERTIGO

• Peripheral – Pathology will be in middle, inner ear or labrynth

• Central – pathology will be cerebellum, brain stem or 8th cranial nerve.

• VBI where symptoms of both peripheral and central vertigo is seen, because all are supplied by vertebro basilar artery.

IDENTIFYING THE CENTRAL VERTIGO• Gradual onset• Less intense• Associated other neurological signs- may be cerebro

vascular accident, motor ataxia of hand, leg or gait ataxia, imbalance on walking, occipital headache, speech difficulty may co exist.

• Nystamus when iduced* usually starts suddenly and is vertical and by gazing at one point usually precipitated.

• Pattern of nystagmus changes by changing gazing pattern-vertical nystagmus to rotatory and horizontal and sometimes zigzag.

* Nystagmus is induced by Dix-Hallpike maneuver

IDENTIFYING THE PERIPHERAL VERTIGO• Presence of nausea and vomiting• Abrupt onset• Nystagmus when induced* will be usually horizontal

or rotatory, sometimes absent, when done on the affected side-straight, left or right.

• Nystagmus usually starts after few seconds when induced and lasts for less than one minute.

• Pattern of nystagmus does not change by changing the direction of gaze.

• Absence of neurological signs like imbalance, absent motor ataxia of limbs and hands, absence of gait ataxia etc.

Dix-Hallpik maneuver

DIFFERENT CAUSES FOR VERTIGO IN PERCENTAGE.

• Idiopathic pathology (including BPPV) - 39% • Trauma - 21% • Ear diseases - 29% (Otitis media - 9% , Vestibular

neuritis - 7%, Ménière disease - 7%, Otosclerosis - 4%, Sudden sensorineural hearing loss - 2%)

• CNS disease - 11% • Vertebral basilar insufficiency - 9% • Acoustic neuroma - 2% • Cervical vertigo - 2%• Other than these, ingestion of toxic substances, drugs

like alcohol intake, insomnia also induces vertigo.

BENIGN POSITIONAL PARAXISMAL VERTIGO

• Exact cause is not known, but non homogenous distribution of debris in fluid in inner ear which maintains body balance is the cause for giddiness, but exactly which causes this condition is not well understood.

• Main clinical features are-• Positional vertigo-always induced by change in

position• Lasts only for 10-20 seconds. But may start

abruptly and frequently• Usually seen in elders

MÉNIÈRE DISEASE• No single entity is known to be responsible for

Ménière's disease. It is currently thought to be due to overaccumulation of endolymph in the cochlear duct.

Ménière's disease is defined as• recurrent, spontaneous episodic vertigo - Acute attacks

may be accompanied with sudden falls without loss of consciousness. These are termed as drop attacks

• hearing loss; • aural fullness; • tinnitus.Either tinnitus or aural fullness (or both) must be present

on the affected side to make the diagnosis.

How we treat Bhrama in UA• BPPV• Gasinil of Ukkinadkas Ayurveda 25ml twice daily• T. Kamadudha Ras for symptomatic improvement 1

tablet TID or BID• T. Lashunadi Vati 1 tablet twice daily• Gandhaka rasayana 1 tablet three times daily(must in

case of otitis media, otomycosis and labrynthitis)• Otoclean ear drop a product of Ukkinadkas Ayurveda

with very good action in otomycosis, hardened ear wax, and in BPPV, but contraindicated in otitis media.

• Course: from 1.5 to 3 months. • We also advise specific neck exercises - Epley maneuver.

Epley maneuver

MÉNIÈRE DISEASE• Varunadi Gana kwatha and Nimbamrithadi

kwatha with concentration of 25g kwatha churna per day gives tremendous result.

• T Chandraprabha Vati 250mg tablet three times daily

• T Kaishora Guggulu 1g tablet three times daily• T Gandhaka Rasayana250mg, 1 tablet three

times daily.• otoclean ear drop 2 drops twice daily.

OTITIS MEDIA

• 1. Varunadi gana kwatha -25g per day. • 2. Gandhaka rasayana tablet- 1 tid• 3. Kaishora guggulu 1 tid• 4. Naradiya laxmi vilasa ras 40mg tid• 5. sprinkle 1-2 pinch of Tankana bhasma to ear or

use antibiotics if necessary to control otitis media.

• If Allergic rhinitis is the cause for this condition, then treat both condition to avoid recurrence.

OTOMYCOSIS • 1. Varunadi gana kwatha 25 g per day• 2. Gandhaka rasayana 1 tid• 3. Naradiya laxmi vilasa ras 40mg tid• 4. oto clean ear drop 2 drops twice daily• It is very important to ask the patient to plug

the ear with cotton, soaked and squeezed in castor oil before taking head bath for next 3 to 6 months to avoid water entry to ear. This should be followed in otitis media also.

Vertebro Basilar artery insufficiency

• Saraswatharista 25 ml bid• Cholestonorm capsule 1 tid (a special product from Sahasraksha

vaidya shala used as blood thinning agent. This can not be used along with Aspirin, if used induces gastric bleeding or haematuria. We are using this capsule in ischemic strokes in our hospital since more than 6 years, we don’t use any of the modern blood thinning agents since last 6 years. We have done clinical research in clinic level (bleeding time, clotting time and prothrombine time) with satisfactory findings. We have replaced clopidogrel and aspirin in hundreds of patients with ischemic stroke, and in patients with mitral regurgitation with positive result)

• …Contd

• T. Hemoclean (a product of SVS, Ukkinadka, used in atherosclerosis and any fibrosis condition as supportive remedy to rebuild the tissues, the main ingredient is Patola, Ashwatha, Karanja, Putikaranja, Nimba etc.)(can also be used in piles, atopic eczema and urticaria)

• Arjunarista 15 ml bid to improve blood circulation by enhancing the pumping ability of heart. It is always advisable to use Arjunarista in any ischemic condition to get fast result. We have observed such result in many cases.

• This should be continued for very long time. Cholestonorm is for life time in this case.

• Ask the patient to quit smoking, alcohol, excess intake of red or white meat to avoid progression of pathology.

• CNS causes like cerebellar lesions, cerebellar ischemic strokes(postero inferior cerebellar artery ischemia), mid brain ischemia.

• Here the condition should be treated as if we treat ischemic stroke.

Conclusion

• Bhrama or vertigo is a very common condition among the elderly people. Considering the treatment options in Ayurveda, we can improve the treatment technique still better.

• In our experience we have successfully treated hundreds of vertigo including BPPV, Menier’s disease etc, where many of them came after failure with modern medicine.

… Conclusion• Even in case of vertigo due to chronic otitis

media where the common triggering cause is allergic rhinitis, we have better treatment option in comparison with the modern medicine.

• In case of central vertigo we have to consider Avarana, Srothorodha, sthana, Nidana etc while planning the treatment.

THANK YOU