Treating Dizziness and Vertigo

Dizziness and vertigo are two of the most common reasons people visit a doctor. And yet they can be complex conditions to identify and resolve, according to functional neurologist Jeremy Schmoe, DC, DACNB, founder and director of the Functional Neurology Center in Minnetonka, Minn. Doctors may have “a hard time coming up with a diagnosis or putting a name on it,” he says. “And then that’s where people get told that maybe this is psychological or maybe it’s just stress induced.”

Even assessing the conditions’ prevalence can be head-spinning: It’s estimated that between 20 and 56 percent of Americans deal with dizziness and vertigo at some time during their lives. And although the terms are often used interchangeably, they describe subtly different sensations. Dizziness is the feeling of being lightheaded or unsteady. Vertigo is an overall spinning sensation.

“At the functional level, it’s about how the system in your brain is integrating things and letting you know where your body is in space,” he explains. “So, when people come in and they’re dizzy, you have to try and figure out what the root cause of that dizziness is.”

The causes can be myriad. They include severe neurological issues, such as a stroke or transient ischemic attack (TIA), or a concussion or traumatic brain injury (TBI).

Functional causes may include:

• Cervicogenic issues, when neck muscles are providing problematic proprioception senses
• Issues with feet proprioceptors
• Loose crystals in the inner ear affecting vestibular functions
• Visual anomalies
• Migraine
• Virus-generated inflammation
• Autoimmunity
• Inflammation from metabolic issues or gut-microbiome imbalances
• Food sensitivities such as gluten intolerance
• Even reactions to mold or flea- or tick-borne diseases

Functional neurology treatments are targeted at root causes. Schmoe uses a variety of therapies and equipment, starting with basic nutrition and marker lab tests as well as eye-movement graphing.

To rehabilitate vestibular or visual functions, he relies on seemingly simple eye and balance exercises. He also uses complex machines, such as the GyroStim, which looks like a NASA spacecraft simulator and can move patients through planes of motion to stimulate their brain’s sense of balance.

Nutrition can also play a key role. Schmoe checks for low thyroid hormone and ample levels of magnesium and vitamins D and B12. Most importantly, keeping blood-sugar levels stable can have a key effect on remedying dizziness.

“We just start pecking away at this, this, and this,” he says. “Maybe working with you neurologically gets you 10 percent better. Structurally working on your neck makes you 30 percent better. Fixing your gut makes you 20 percent better. And that’s what gets you back to where you need to be.”

A Q&A With Functional Neurologist Jeremy Schmoe, DC

We spoke with Schmoe about the various causes of dizziness and vertigo, as well as his treatment approaches.

Experience Life | Can you explain the possible causes of chronic dizziness?

Jeremy Schmoe | When people are dizzy, you have to try and figure out what the root cause of that dizziness is. There are a variety of neurological causes that can cause people to be dizzy, ranging from the most severe, like they’re having a stroke or a TIA [transient ischemic attack] or something like that: You want to be able to rule that stuff out.

But a lot of what I’m seeing are more functional types of dizziness, where people have been to other providers and the doctors say, “Hey, maybe it’s your eyes or maybe it’s your neck or maybe this it’s crystals loose in the inner ear.” But with a lot of the people that we see, it’s really how the system in your brain is integrating and letting you know where your body is in space.

So it could be that they’re getting bad feedback from their neck. This type of cervicogenic dizziness is huge — bad feedback from the proprioceptors of the neck muscles to the brain. When people move their head around, they don’t know where their body is in space and then they feel rocky or floaty or off-center or dizzy. The neck can be a huge component of dizziness.

Or crystals may come loose in your inner ear, which is called BPPV or benign paroxysmal positional vertigo. These natural crystals [known as otoconia] are made of calcium carbonate and sit on a membrane. The crystals can get knocked loose and move into an area of the inner ear where they’re not supposed to be. Then, when people move their head, they’re getting a change in the drag of fluid and their brain perceives that they’re spinning and moving.

This is a really common thing. You might have your head back in a certain position such as when you’re getting your hair done, or they might just come loose when you’re sleeping. There’s a correlation with thyroid problems and low vitamin-D levels, as well as Hashimoto’s and other autoimmunity issues.

The other thing that it could be is you may have a viral infection: There could be neuritis or an infection of the nerve going back into the brain.

Or the issue could be the eyes, how your visual system is taking in information. If that doesn’t match with what your body is telling you, then you get an error — conflicting information — and then it makes people feel off — lightheaded or dizzy.

Your brain does so much to visually map out where your body is in space, and if your eyes aren’t tracking right, or if they have a hard time converging or diverging, or a hard time following objects or moving quickly, then that could be a problem for the brain. Your brain’s got to take that information in, and it has to say similar things to what your neck is saying and what your inner ear is saying. If that doesn’t happen, you get what are called sensory mismatches. And those sensory mismatches lead to people having a perception of dizziness.

Our job then is to try and figure out where the problems are and then develop very specific rehab programs to try and get a person’s brain to know where their body is in space.

EL | Your feet — and, in particular, your big toes — also play a role in your sense of balance, correct?

JS | Your big toe, your ankle proprioceptors — all of that stuff is very important. People who develop neuropathy and lose sensation and feeling in their legs can feel dizzy. We look at everything structural, because if somebody has weak legs, or weak glute-muscle activation, that can to postural problems, which can lead to changes in the neck, and that can make you feel dizzy.

These conditions are called PPPD or “triple-P-D” — which stands for persistent postural-perceptual dizziness. In the past, people have called this stuff psychogenic or psychological. But really what I’m seeing here is that they’re these sensory mismatches, where people’s systems aren’t matching. When they go to get a lot of advanced diagnostic testing done, people really don’t find anything because it’s not just a specific problem with one thing, it’s an integration problem in the brain.

EL | You mentioned that the gut microbiome can also play a role?

JS | Your brain is firing all this information down into your brainstem, and then that’s firing down into your GI system to get it to move and do everything that it needs to do. When you get that infection, you can get inflammation leaking back up into the brain, and it can strongly affect the cerebellum, and then people get nonspecific dizziness.

I often see people where it really seems like there’s an underlying gut-inflammatory problem, and then when you deal with that, then their dizziness improves. So, if they’ve been to somebody and they’ve ruled out a stroke, loose crystals in their inner ear, an inner-ear infection, neck or eye issues, then you’re going to want to start thinking, Is there something metabolic that could be going on here? Maybe they’re anemic. Maybe they’re not getting enough oxygenation to their body and up into their brain and they’re feeling lightheaded and dizzy. You can have other problems like autoimmunity that’s affecting the brain and leading to dizziness.

There are neurons in the cerebellum called prokineticin neurons and inflammation really seems to affect them. People may get all the lab tests and they show that everything’s normal — their iron’s normal, there doesn’t seem to be a huge infection — but there’s just this complex neuro-metabolic web of inflammation that is affecting their nervous system. But if you run some more advanced testing, you might see that they have neurological autoimmunity.

EL | So how do you approach coming up with treatment?

JS | I begin by breaking a patient’s condition down into three main areas:

1. Is it neurological: Is the problem peripheral, meaning is there actually something going on with your ear, or is the problem central, where it’s sensory integration in the brain?
2. Is there a structural problem?
3. Is there a metabolic problem?

Then I go through their history, and we look at their lab tests. Then we just start pecking away at this, this, and this. Maybe working with you neurologically gets you 10 percent better. Structurally working on your neck makes you 30 percent better. Fixing your gut makes you 20 percent better. And that’s what gets you back to where you need to be.

And I think where people fail is where they just get structural care done, because that’s not going to fix a gut infection, or deal with your neurological autoimmunity, or maybe you need to get checked for gluten sensitivity or celiac or look at food sensitivities and do a gut-repair protocol. And things like mold, tick-borne diseases such as Lyme or Babesia, or Bartonella [a flea-borne disease] can cause dizziness too.

So, when you get into this kind of functional dizziness, I think providers need to think that way. And if you do, then you’re probably not going to let as many people slip through the cracks.

EL | So finding the root causes is key to the treatment.

JS | Yes, the functional aspect is the key to the treatment.

Another condition that’s worth looking into is MdDS — mal de débarquement syndrome — where people go on a boat, or they go on a cruise, or maybe they’re on a dock, or even a cross-country trip, or a cross-country flight, and they get off and they still feel like they’re moving.

We’re working to help people re-establish where their body is in space — get them reintroduced to gravity and know where they are.

We deal with their inflammation, get them doing better there, and fix them structurally. And that seems to be the key to getting some of these more complex, multifactorial dizziness cases better.

EL | Can you summarize what the treatments might include?

JS | Just as we seek to specify the root causes of the dizziness, we’re going to try and get specific with our treatments.

So, say if we think that it’s coming from the neck, then we might be doing work on postural rehabilitation with isometric training or [making chiropractic] adjustments to the neck. We do some very specific adjustments called “adjusting to neutral.” It’s a type of adjustment technique where we’re very precise with our feedback into the neck. You have to be careful that you don’t overstimulate people with adjusting them; it can actually make people worse. So, we need to be very specific with the manual care.

And then we do different therapies, such as using a head laser where a patient will be looking at targets and start tracing it with their eyes and neck. We do isometric training with the neck where we’re working on postural stability. We do different types of low-level light therapy on the neck. We do electrical stim with a device called an ARPwave. We do PEMF [pulsed electromagnetic fields therapy].

We have a variety of different things that we do to structurally to try and get your neck more stable. We try and bring stability to the neck because many of the people that we see are hypermobile, so their necks literally feel like they almost have no neck. They just have a head and it’s like loose and feels like a bobblehead. When we bring stability back to the neck, it doesn’t feel all loosey-goosey. It feels like they’re getting good feedback to their brains. That’s huge — just working with the neck in a different way.

If it’s more central vestibular, then we are doing vestibular rehabilitation where we’re having people keep their eyes steady and we’re moving their head in certain ways to try and keep their eyes steady on targets. And then we utilize the GyroStim chair, which is very helpful, where methodically and safely we’re moving them through different planes of motion to try and stimulate their brain in certain ways. We will have graphed their eye movements out and seen that they were drifting, and we might go put them in the chair and move them in specific ways to counteract their eyes from drifting.

If it’s BPPV or loose crystals, we do repositioning maneuvers that are effective in putting those crystals back in place. One of these is the Epley maneuver, where you can put the head in certain positions, and you can actually move those crystals back to where they need to be. It’s very effective and people feel less dizzy instantly.

If things are peripheral and they’ve come from an infection, then we’re doing vestibular rehabilitation where people look at targets and we’re moving their head and we’re trying to get that inner ear to start working better again.

EL | What are the nutritional treatments that you include?

JS | Overall, what we’re trying to do is to nutritionally get people’s neurons more stable. People think about nutrition and what it’s doing for the body, but we’re talking about nutrition for bringing stability to neurons in the brain. You want to relieve neuroinflammation, have good fatty-acid levels, and not have a bunch of inflammatory mediators around from the gut that’s causing inflammation. If your cerebellum is full of unstable neurons, you’re going to feel dizzy.

A huge issue for dizziness is blood-sugar stability. The inner ear responds to fluctuations in blood sugar — the inner ear seems to respond to everything, but blood sugar is huge.

With blood sugar, we begin by asking questions: “If you get hungry and you eat, do you feel better or do you feel worse?” If you eat and you feel way better, then your blood sugar is probably more consistently on the lower end. So, we have to make sure that you’re eating small, frequent meals and working on the most appropriate types of carbs, proteins, and fats to stabilize your blood sugar. That’s been really helpful with people, especially when you have kids with concussion and head injuries and they’re not eating frequently to keep their blood sugar stable; they get dizzy all the time. So, keeping blood sugar stable is No. 1.

No. 2, getting people’s vitamin-D levels optimal is huge.

We then work on gut health. An anti-inflammatory diet is big. We make sure people’s vitamin B12 levels are in the normal range. We want people to get optimal magnesium; we use magnesium threonate, which seems to be very helpful. And we want to get their fatty-acid levels stable.

Those are things that most people have never been told when they have dizziness. We’ll say, “Hey, we should work on your gut health for your dizziness.” And people say, “What?”

If you miss the whole gut piece that could be key to why they’re dizzy. Because that inflammation is probably leaking into the brain and affecting the circuitry that lets you know where your body is in space.

This article originally appeared as “A New Spin on Dizziness” in the July/August 2024 issue of Experience Life.