What are the main types of dizziness. How can doctors diagnose the underlying cause of dizziness. What are effective treatments for different forms of dizziness.

Understanding the Four Main Types of Dizziness

Dizziness is a common complaint that accounts for approximately 5% of primary care visits. To properly diagnose and treat dizziness, it’s crucial to first understand the four main categories:

• Vertigo: A false sense of motion or spinning sensation
• Disequilibrium: Feeling off-balance or unsteady
• Presyncope: A feeling of nearly losing consciousness
• Lightheadedness: Vague symptoms of feeling disconnected from one’s environment

Each type of dizziness has distinct characteristics and potential causes. By accurately categorizing a patient’s symptoms, healthcare providers can narrow down the possible diagnoses and determine the most appropriate treatment approach.

Common Causes of Vertigo and Their Prevalence

Vertigo, characterized by a spinning sensation, is the most common form of dizziness, affecting 45-54% of patients with dizziness complaints. The main causes of vertigo include:

• Benign Paroxysmal Positional Vertigo (BPPV)
• Meniere’s Disease
• Vestibular Neuritis
• Labyrinthitis

BPPV is particularly prevalent, accounting for a significant portion of vertigo cases. It occurs when small crystals in the inner ear become dislodged, causing brief episodes of intense dizziness with certain head movements.

Can BPPV be diagnosed with a simple physical examination test?

Yes, BPPV can often be diagnosed using the Dix-Hallpike maneuver. This test involves rapidly moving the patient from a sitting to a lying position with the head turned to one side. A positive result, indicated by the onset of vertigo and characteristic eye movements (nystagmus), strongly suggests BPPV.

The Role of Medications in Causing Dizziness

Many medications can contribute to dizziness, particularly by causing presyncope or orthostatic hypotension. Some common culprits include:

• Alpha blockers (e.g., doxazosin, terazosin)
• Beta blockers
• Diuretics
• Antidepressants
• Antihypertensives

When evaluating a patient with dizziness, it’s crucial to perform a thorough medication review. In some cases, adjusting medication regimens can significantly alleviate symptoms.

How can orthostatic hypotension be diagnosed in a clinical setting?

Orthostatic hypotension can be diagnosed through orthostatic blood pressure testing. This involves measuring the patient’s blood pressure while lying down, then again after standing up. A significant drop in blood pressure upon standing (typically a decrease of 20 mmHg systolic or 10 mmHg diastolic) indicates orthostatic hypotension.

Neurological and Systemic Causes of Disequilibrium

Disequilibrium, characterized by a feeling of unsteadiness or imbalance, can have various underlying causes. Two important conditions to consider are:

1. Parkinson’s Disease: This progressive neurological disorder can affect balance and coordination, leading to disequilibrium.
2. Diabetic Neuropathy: Nerve damage resulting from long-term diabetes can impair proprioception and balance.

Other potential causes of disequilibrium include cerebellar disorders, multiple sclerosis, and certain medications. A thorough neurological examination is often necessary to identify the underlying cause.

Psychiatric Disorders and Lightheadedness

Vague lightheadedness can sometimes be attributed to psychiatric conditions, including:

• Depression
• Anxiety disorders
• Hyperventilation syndrome
• Panic attacks

These conditions can cause a range of physical symptoms, including dizziness. It’s important for healthcare providers to consider mental health factors when evaluating patients with persistent lightheadedness, especially when other causes have been ruled out.

How can hyperventilation syndrome be distinguished from other causes of lightheadedness?

Hyperventilation syndrome can often be identified by associated symptoms such as numbness or tingling in the extremities, chest tightness, and a feeling of air hunger. A simple breathing exercise, where the patient is asked to breathe slowly and deeply, may temporarily alleviate symptoms, helping to confirm the diagnosis.

Diagnostic Approach to Dizziness in Primary Care

Diagnosing the cause of dizziness can be challenging, but a systematic approach can help narrow down the possibilities. Key components of the diagnostic process include:

1. Detailed patient history, focusing on the nature and timing of symptoms
2. Physical examination, including neurological and vestibular tests
3. Targeted diagnostic maneuvers, such as the Dix-Hallpike test for BPPV
4. Orthostatic blood pressure measurements
5. Evaluation for nystagmus

It’s important to note that laboratory testing and radiography generally play a limited role in the initial diagnosis of dizziness, unless specific neurological abnormalities are present.

When should advanced imaging be considered in the evaluation of dizziness?

Advanced imaging, such as MRI or CT scans, should be considered when there are signs of a central nervous system disorder, such as persistent unilateral symptoms, new-onset headaches, or focal neurological deficits. These tests can help rule out serious conditions like strokes or tumors affecting the brainstem or cerebellum.

Evidence-Based Treatments for Different Types of Dizziness

Treatment approaches for dizziness vary depending on the underlying cause. Some effective interventions include:

• For BPPV: The Epley maneuver (canalith repositioning) and vestibular rehabilitation
• For Meniere’s Disease: Intratympanic dexamethasone or gentamicin injections
• For Vestibular Neuritis: Short-term corticosteroid treatment
• For Orthostatic Hypotension: Alpha agonists, mineralocorticoids, or lifestyle modifications

For cases of disequilibrium and lightheadedness, treatment typically focuses on addressing the underlying cause, whether it’s a neurological condition, medication side effect, or psychiatric disorder.

What is the success rate of the Epley maneuver in treating BPPV?

The Epley maneuver has shown high success rates in treating BPPV, with studies reporting symptom resolution in 70-80% of patients after a single treatment. Multiple treatments may be necessary for some patients, and combining the Epley maneuver with vestibular rehabilitation exercises can further improve outcomes.

Challenges in Diagnosing and Managing Chronic Dizziness

While many cases of dizziness can be effectively diagnosed and treated, some patients experience persistent or recurrent symptoms that prove challenging to manage. Factors contributing to chronic dizziness include:

• Multifactorial causes
• Overlapping symptoms from different conditions
• Psychological factors, such as anxiety about dizziness
• Age-related changes in balance and sensory systems

In cases of chronic dizziness, a multidisciplinary approach involving primary care physicians, neurologists, otolaryngologists, and physical therapists may be necessary to achieve optimal outcomes.

How can vestibular rehabilitation therapy help patients with chronic dizziness?

Vestibular rehabilitation therapy can be highly beneficial for patients with chronic dizziness. This specialized form of physical therapy focuses on exercises that help the brain compensate for inner ear deficits and improve balance. Exercises may include gaze stabilization, balance training, and habituation techniques. Studies have shown that vestibular rehabilitation can significantly reduce symptoms and improve quality of life in patients with various causes of chronic dizziness.

In conclusion, dizziness is a common and often complex symptom that requires a thoughtful and systematic approach to diagnosis and treatment. By understanding the different types of dizziness, their potential causes, and evidence-based treatment options, healthcare providers can effectively manage most cases of dizziness in the primary care setting. When faced with challenging or persistent cases, referral to specialists and consideration of multidisciplinary care may be necessary to achieve the best possible outcomes for patients.

Dizziness: A Diagnostic Approach | AAFP

ROBERT E. POST, MD, AND LORI M. DICKERSON, PharmD

A more recent article on evaluation and management of dizziness is available.

Am Fam Physician. 2010;82(4):361-368

Patient information: See related handout on dizziness, written by the authors of this article.

Author disclosure: Nothing to disclose.

Dizziness accounts for an estimated 5 percent of primary care clinic visits. The patient history can generally classify dizziness into one of four categories: vertigo, disequilibrium, presyncope, or lightheadedness. The main causes of vertigo are benign paroxysmal positional vertigo, Meniere disease, vestibular neuritis, and labyrinthitis. Many medications can cause presyncope, and regimens should be assessed in patients with this type of dizziness. Parkinson disease and diabetic neuropathy should be considered with the diagnosis of disequilibrium. Psychiatric disorders, such as depression, anxiety, and hyperventilation syndrome, can cause vague lightheadedness. The differential diagnosis of dizziness can be narrowed with easy-to-perform physical examination tests, including evaluation for nystagmus, the Dix-Hallpike maneuver, and orthostatic blood pressure testing. Laboratory testing and radiography play little role in diagnosis. A final diagnosis is not obtained in about 20 percent of cases. Treatment of vertigo includes the Epley maneuver (canalith repositioning) and vestibular rehabilitation for benign paroxysmal positional vertigo, intratympanic dexamethasone or gentamicin for Meniere disease, and steroids for vestibular neuritis. Orthostatic hypotension that causes presyncope can be treated with alpha agonists, mineralocorticoids, or lifestyle changes. Disequilibrium and lightheadedness can be alleviated by treating the underlying cause.

Diagnosing the cause of dizziness can be difficult because symptoms are often nonspecific and the differential diagnosis is broad. However, a few simple questions and physical examination tests can help narrow the possible diagnoses. It is estimated that primary care physicians care for more than one half of all patients who present with dizziness. ¹ Dizziness is the chief presenting symptom in about 3 percent of primary care visits for patients 25 years and older, and in nearly 3 percent of all emergency department visits.^2,3

Dizziness can be classified into four main types: vertigo, disequilibrium, presyncope, or lightheadedness. Although appropriate history and physical examination usually leads to a diagnosis, the final cause of dizziness is not identified in up to one in five patients. ^4,5

Patient History

The initial description of dizziness can be difficult to obtain because patient responses are not always consistent. ⁶ Therefore, the history should first focus on what type of sensation the patient is feeling. Table 1 includes descriptors for the main categories of dizziness.^4,5,7,8 It is important to note that some causes of dizziness can be associated with more than one set of descriptors.

A medication history should be obtained because dizziness (especially from orthostatic hypotension) is a well-known adverse effect of many drugs⁹(Table 2^10,11). Patients should also be asked about caffeine, nicotine, and alcohol intake.⁹ Head trauma and whiplash injuries can cause a variety of dizziness symptoms, from vertigo to lightheadedness. The incidence of dizziness with a head injury or vertigo initially after whiplash have been reported as high as 78 to 80 percent.¹² Selected causes of dizziness are summarized in Table 3.^{4,7,8,13–20}

Cardiac medications

Alpha blockers (e.g., doxazosin [Cardura], terazosin)

Alpha/beta blockers (e.g., carvedilol [Coreg], labetalol)

Angiotensin-converting enzyme inhibitors

Beta blockers

Clonidine (Catapres)

Dipyridamole (Persantine)

Diuretics (e.g., furosemide [Lasix])

Hydralazine

Methyldopa

Nitrates (e. g., nitroglycerin paste, sublingual nitroglycerin)

Reserpine

Central nervous system medications

Antipsychotics (e.g., chlorpromazine, clozapine [Clozaril], thioridazine)

Opioids

Parkinsonian drugs (e.g., bromocriptine [Parlodel], levodopa/carbidopa [Sinemet])

Skeletal muscle relaxants (e.g., baclofen [Lioresal], cyclobenzaprine [Flexeril], methocarbamol [Robaxin], tizanidine [Zanaflex])

Tricyclic antidepressants (e.g., amitriptyline, doxepin, trazodone)

Urologic medications

Phosphodiesterase type 5 inhibitors (e.g., sildenafil [Viagra])

Urinary anticholinergics (e.g., oxybutynin [Ditropan])

VERTIGO

Otologic or vestibular causes of vertigo are the most common causes of dizziness,^21,22 and include benign paroxysmal positional vertigo (BPPV), vestibular neuritis (viral infection of the vestibular nerve), labyrinthitis (infection of the labyrinthine organs), and Meniere disease (increased endolymphatic fluid in the inner ear). ^7,13 An estimated 35 percent of adults 40 years and older have vestibular dysfunction.¹⁴

Hearing loss and duration of symptoms help narrow the differential diagnosis further in patients with vertigo. Vertigo with hearing loss is usually caused by Meniere disease or labyrinthitis, whereas vertigo without hearing loss is more likely caused by BPPV or vestibular neuritis.⁸ Unilateral auditory symptoms help localize the cause to an anatomic abnormality, particularly in patients with peripheral disease.⁹ Episodic vertigo tends to be caused by BPPV or Meniere disease, whereas persistent vertigo can be caused by vestibular neuritis or labyrinthitis.⁸

Migrainous vertigo, or vestibular migraine, is another underlying cause of vertigo that affects about 3 percent of the general population and about 10 percent of persons with migraine.¹⁵ This diagnosis should be considered after other causes of vertigo have been ruled out. Diagnosis of migrainous vertigo is established in patients with a history of episodic vertigo with a current migraine or history of migraine and one of the following symptoms during at least two episodes of vertigo: migraine headache, photophobia, phonophobia, or aura.¹⁵

PRESYNCOPE

Cardiovascular causes of dizziness include arrhythmias, myocardial infarction, carotid artery stenosis, and ortho-static hypotension.²¹ Of patients with supraventricular tachycardia, 75 percent experience dizziness and about 30 percent experience syncope.²³ Symptoms brought on by postural changes suggest a diagnosis of orthostatic hypotension.⁹ A variety of cardiovascular medications increase the risk of orthostatic hypotension in older persons, including reserpine (at doses greater than 0.25 mg), doxazosin (Cardura), and clonidine (Catapres).²⁴

DISEQUILIBRIUM

There are many underlying conditions that may cause a sense of imbalance. Stroke is an important and life-threatening cause of dizziness that needs to be ruled out when the dizziness is associated with other symptoms of stroke. However, other neurologic findings are generally present. In a population-based study of more than 1,600 patients, 3.2 percent of those presenting to an emergency department with dizziness were diagnosed with a stroke or transient ischemic attack (TIA), but only 0.7 percent presenting with isolated dizziness were diagnosed with stroke or TIA.²⁵

Poor vision commonly accompanies a feeling of imbalance,¹⁶ leading to falls. The physician should inquire about a history of other problems that may cause imbalance, such as Parkinson disease, peripheral neuropathy, and any musculoskeletal disorders that may affect gait.¹⁷ Use of benzodiazepines and tricyclic antidepressants increase the risk of ataxia and falls in older persons.²⁴

LIGHTHEADEDNESS

Psychiatric causes of lightheadedness are common, particularly anxiety; therefore, questions about anxiety and depression should be included in the patient history. In one study, about 28 percent of patients with dizziness reported symptoms of at least one anxiety disorder.²⁶ In another study, one in four patients with dizziness met criteria for panic disorder.²⁷ A study of patients with chronic dizziness showed that those with panic disorder were more likely to have neurotologic findings than those without panic disorder.²⁸ Up to 60 percent of patients with chronic subjective dizziness have been reported to have an anxiety disorder.²⁹ Depression and alcohol intoxication have also been found to overlap with dizziness.^21,30

Hyperventilation syndrome is an important cause of lightheadedness. Although the condition can be associated with anxiety disorders, many patients without anxiety experience hyperventilation. Hyperventilation is defined as breathing in excess of metabolic requirements, causing a respiratory alkalosis and lightheadedness. Patients may sigh repeatedly and may have associated symptoms, such as chest pain, paraesthesias, bloating, and epigastric pain. ¹⁸

Physical Examination

The main goal of the physical examination is to reproduce the patient’s dizziness in the office. There are a few simple physical examination tests that can be performed to aid in this goal.

First, blood pressure should be measured while the patient is in a supine position and again at least one minute after the patient stands. A systolic blood pressure decrease of 20 mm Hg, diastolic blood pressure decrease of 10 mm Hg, or pulse increase of 30 beats per minute is indicative of orthostatic hypotension.^16,19

The Dix-Hallpike maneuver (Figure 1^9,16) is diagnostic for BPPV if positive, but does not rule it out if negative. The maneuver is performed on a flat examination table. While the patient is in a seated position, the physician turns the patient’s head 45 degrees to one side, then rapidly lays the patient into a supine position with the head hanging about 20 degrees over the end of the table and observes the patient’s eyes for approximately 30 seconds. The maneuver is repeated with the head turned to the opposite side. Nystagmus is diagnostic of vestibular debris in the ear that is facing down, closest to the examination table. There is usually a latent period of a few seconds before the patient develops nystagmus, and a sensation of vertigo for up to one minute.^9,16 The sensitivity of the Dix-Hallpike maneuver is 50 to 88 percent for BPPV.⁷

Lesions of the labyrinth and cranial nerve VIII (vestibulocochlear) commonly produce spontaneous nystagmus. Saccadic eye movements associated with a patient’s smooth ocular pursuit of the physician’s finger as it moves slowly left, right, up, and down may be associated with a central cause, such as brainstem or cerebellar disease. The head impulse test involves asking the patient to remain focused on a target while the physician moves the patient’s head back and forth rapidly. Eye movement to one side with a refixation saccade (rapid oscillatory eye movement that occurs as the eye fixes on an object) is indicative of a lesion on the side to which the eyes move. Bilateral refixation movements commonly occur with ototoxicity. Another test that can elicit nystagmus involves the patient leaning forward 30 degrees while the physician shakes the patient’s head back and forth vigorously for 20 seconds. The presence of nystagmus indicates a peripheral cause in the ipsilateral direction of the nystagmus.⁹

Other physical examination tests include the Romberg test and observation of gait. Swaying toward one side with the Romberg test is indicative of vestibular dysfunction in the ipsilateral side. Also, a patient’s gait will lean toward the side of a vestibular lesion. Ataxia is indicative of cerebellar dysfunction, and the patient’s gait is usually slow, wide-based, and irregular.^9,20 Observation of gait is also important to detect symptoms suggestive of parkinsonism in patients presenting with disequilibrium.⁴ In early Parkinson disease, gait is usually slower with smaller steps and reduced arm swing, and progresses to freezing and hesitation in later stages of the disease. ²⁰ Screening for peripheral neuropathy is also important in patients presenting with disequilibrium.⁴

If hyperventilation syndrome is suspected, the diagnosis can be confirmed by having the patient rapidly take 20 deep inhalations and exhalations, in an attempt to reproduce symptoms.^9,18

A thorough cardiovascular examination should be performed in all patients with dizziness. However, tests such as electrocardiography, Holter monitor testing, and carotid Doppler testing should be performed only if an underlying cardiac cause is suspected based on other findings or known cardiac disease.⁷

Additional Testing

In general, laboratory testing and radiography are not beneficial in the work-up of patients with dizziness when no other neurologic abnormalities are present.^31,32 Laboratory studies, including complete blood count, metabolic panels, and thyroid function tests, have very low yield in diagnosing a cause of dizziness. In one meta-analysis, only 26 of 4,538 patients (0.6 percent) had laboratory abnormalities that explained their dizziness.⁷

Electronystagmography tests vestibular function by using electrodes to detect nystagmus. The test has a reported sensitivity of 69 to 74 percent and specificity of 81 to 83 percent for peripheral vestibular disorders. For central vestibular disorders, sensitivity has been reported as high as 81 percent and specificity as high as 93 percent.⁷

Approach to the Patient

After obtaining the patient history, the physician can tailor the physical examination to best fit the differential diagnosis. One approach to the initial evaluation of patients with dizziness is presented in Figure 2.

The initial history can help place the diagnosis into one of the four major categories of dizziness. Then, questions specific to that category can further narrow the possible diagnoses. A thorough neurologic and cardiovascular examination should be performed in all patients, as well as targeted components of the physical examination based on suspicion of the underlying diagnosis. Further testing, such as cardiac and radiologic testing, is only needed when specific causes are suspected.

Treatment of vertigo has been addressed.³³Table 4 summarizes the treatment of selected causes of dizziness,^{10,18,34–49} and Figure 3 illustrates the Epley maneuver, an effective treatment for BPPV.⁴¹

Cause	Treatment	Comments
Vertigo
Benign paroxysmal positional vertigo	Meclizine (Antivert), 25 to 50 mg orally every four to six hours	Commonly used to reduce symptoms of acute episodes of vertigo, although there are no RCTs to support its use; use of vestibular suppressants can lead to brainstem compensation and prolong vertiginous symptoms
	Epley maneuver (canalith repositioning; see Figure 3)	Main benign paroxysmal positional vertigo treatment; safe and effective compared with placebo; video demonstration is available at http://www. youtube.com/watch?v=ZqokxZRbJfw&NR=1
	Vestibular rehabilitation	Series of head and neck exercises that can be performed daily at home; video demonstration available at http://www.youtube.com/watch?v=hhinu_oU_hM
		Evidence for balance therapy (e.g., tai chi, Wii Fit) is accumulating
Meniere disease	Salt restriction (less than 1 to 2 g of sodium per day) and/or diuretics (most commonly, hydrochlorothiazide/triamterene [Dyazide])	No large-scale RCTs to support these therapies
	Intratympanic dexamethasone or gentamicin	Referral to an otolaryngologist required; in one small study, dexamethasone resolved symptoms in 82 percent of patients; in a larger study, gentamicin resolved symptoms in 80.7 percent of patients46,47
	Endolymphatic sac surgery	Referral to an otolaryngologist required
Vestibular neuritis	Methylprednisolone (Depo-Medrol), initially 100 mg orally daily then tapered to 10 mg orally daily over three weeks	In an RCT, methylprednisolone was more effective in improving peripheral vestibular function than valacyclovir (Valtrex) in patients with vestibular neuritis49
Migrainous vertigo	Migraine prophylaxis with serotonin 5-HT1 receptor agonists (triptans)	Treatment based on expert opinion, not RCTs
Presyncope
Orthostatic hypotension	Review medication regimen	This is the first step, especially in older patients; rehydration (even increased water intake) can improve symptoms, especially in those with autonomic failure
	Midodrine (Proamatine) titrated up to 10 mg orally three times daily	Alpha-1 agonist metabolite; to avoid supine hypertension, the third dose should be given by 6 p. m.; should be used only in severely impaired patients; in placebo-controlled trials, midodrine was associated with increased standing blood pressures and fewer orthostatic symptoms compared with placebo36
	Fludrocortisone, initially 0.1 mg orally daily, titrated up weekly until peripheral edema develops or to a maximal dosage	Mineralocorticoids, such as fludrocortisone, are used to increase sodium and water retention; monitor blood pressure, potassium level, and for symptoms of heart failure
		Fludrocortisone and midodrine can be used in combination if either agent alone fails to control symptoms
	Pseudoephedrine, 30 to 60 mg orally daily Paroxetine (Paxil), 20 mg orally daily	These drugs are options when midodrine and fludrocortisone are ineffective
	Desmopressin (DDAVP), 5 to 40 mcg intranasally daily	Nondrug therapy includes replacement of fluids, rising slowly from lying or sitting positions, sleeping with the head of the bed elevated, increasing salt intake, and regular exercise
Disequilibrium	Treatment of underlying cause (e. g., peripheral neuropathy, Parkinson disease)	Because disequilibrium is generally a symptom of an underlying condition, treatment of the condition improves symptoms of disequilibrium
Lightheadedness
Hyperventilation syndrome	Breathing control exercises, rebreathing into a small paper bag	Reverses hypocapnia-related symptoms
	Beta blockers	Treats associated symptoms, such as palpitations and sweating; not for use in patients with asthma
	Antianxiety agents (e.g., selective serotonin reuptake inhibitors) or short-term use of benzodiazepines	For use in patients with underlying anxiety

The Difference between Giddiness and Vertigo: NY Neurology Associates: Neurologists

The Difference between Giddiness and Vertigo: NY Neurology Associates: Neurologists

Giddiness and dizziness describe feeling  imbalanced, lightheaded, unsteady, as if you are about to faint. It is important to distinguish between feeling dizzy from experiencing vertigo. There are different causes for these types of sensations. Dizziness can be a symptom of vertigo. Vertigo is the sensation of your surrounding spinning. Both giddiness and vertigo are often accompanied by nausea or vomiting.

While giddiness can have a severe impact on the persons well-being and ability to go on about their daily lives, it is not a diagnosis, but a symptom of some other underlying condition.

The underlying condition could be just an overexertion or something serious such as stroke. Most often giddiness is caused by either neurological or innerear issues.

Symptoms

Some symptoms of giddiness may include:

• Feeling faint or lightheaded
• Feeling unsteady and imbalanced
• Feeling like the surrounding is moving or spinning
• Feeling woozy or heavy-headed

In addition to balance issues, some symptoms of vertigo may include :

• Motion sickness
• Tinnitus, or ringing in the ear
• Headaches
• Nystagmus, or an uncontrollable eye movement

It is important to note that there are two types of vertigo that can occur : peripheral and central vertigo. Peripheral vertigo is caused by an issue in the inner ear, while central vertigo is caused by a brain damage, including brain injury, stroke, tumors, or infection.

What are the causes ?

Some of the major causes of vertigo include :

• Benign Paroxysmal Positional Vertigo – one of the most frequent condition seen causes for the feeling of giddiness. The patient experiences a spinning sensation with mild to severe giddiness, It is caused by problems with the inner ear.
• Hypotension – or a low blood pressure (lower than 90 mmHg/ 60mmHg).
• Hypoglycemia – or low blood sugar (less than 70 mg/dL).
• Inner ear problems due to irritation or inflammation of the inner ear can cause balance problems and giddiness.
• Circulatory problems leading to a reduction in blood supply and, therefore, oxygen supply to all parts of the body.
• Motion sickness
• Dehydration .
• Overexertion or excessive exercise
• Migraines
• Head Injury – can be very serious, if the person is experiencing dizziness after a head injury they should go to the emergency room as soon as possible.
• Stroke is caused when the blood supply to the brain is disrupted.
• Neurological Problems, such as  Multiple Sclerosis or Parkinson’s can manifest as giddiness
• Vestibular Neuritis and Labyrinthitis are the conditions of inflammation of nerves. Vestibular neuritis involves the vestibular nerve, while labyrinthitisis involves the inflammation of both the vestibular nerve and the cochlear nerve.
• Anxiety Disorders can elevate stress hormone called cortisol, and can impact the vestibular system function that controls imbalance
• Heatstroke
• Side Effect of Certain Medications a lot of allergy and pain medications can cause dizziness

When you should consult a doctor ?

Dizziness is not a problem in itself, but can be a symptom of an underlying health problem. When it occurs  frequently or for prolonged periods of time, it is important to consult a neurologist.

Vertigo accompanied by the following symptoms prompts an appointment with a medical professional

• ChestPain
• Drooping of the Eyes or a Mouth
• Headache
• Head Injury
• Hearing Loss
• Blurred Vision
• High Fever
• Loss of Consciousness
• Numbness or Tingling
• Ongoing Vomiting
• Speech Difficulties

Treatment Options

Usually a  physical exam is first performed to determine the cause of the giddiness or dizziness.

Dizziness can often resolve on its own within a couple weeks, however, if it does not our neurologists can help find the root cause and develop a custom treatment plan that would address  the symptoms as well as the underlying issue. Treatment can include medication or medical techniques.

Epley maneuver can be used for Benign Paroxysmal Positional Vertigo (BPPV). As BPPV is caused by the inner ear issue, this technique involves canaliths repositioning.  Canaliths are calcium crystals that help detect motion, when the crystals detach in the semicircular canals, they may send incorrect signals to the brain causing vertigo. This technique is a series of movements that cause the crystals in the ear to be dislodged from the ear canals thus resolving vertigo. It can be done by a neurologist, an audiologist or a physical therapist.

Sometimes BPPV requires medication to be resolved. This would include anticholinergics, antihistamines or sleep aids.

Balance therapy. You may learn specific exercises to help make your balance system less sensitive to motion.  This physical therapy technique called vestibular rehabilitation. It is used for people with dizziness from inner ear conditions such as vestibularneuritis.

When dizziness is caused by circulatory issues, the treatment can involve medications or procedures that help regulate heart rate. In case of tachycardia-bradycardia syndrome, when the heart rate vacillates between beating too quickly or too slowly, ablation or pacemaker implantation can resolve the giddiness.

Dizziness caused by medication requires an adjustment in the dosage or in severe cases, a change of medication altogether. This would have to be done in consultation with the treating doctor.

Simple measures such as healthyt diet and hydration are a good start for addressing giddiness.

Psychiatric and neurological conditions, such as anxiety or migraines can be addressed with medication and lifestyle changes. Stress relief and balance improvement practices such as yoga and meditation, as well as Tai Chi can also help.  It is advised to avoid salt, caffeine, tobacco and alcohol as these may exacerbate dizziness symptoms.  

Michael Gudleski,PA was interviewed for this article.

More posts on this and other related topics can be found below :

• Dizziness
• Causes Of Fainting 

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Contents

IMPORTANT!

The information in this section should not be used for self-diagnosis or self-treatment. In case of pain or other exacerbation of the disease, only the attending physician should prescribe diagnostic tests. For diagnosis and proper treatment, you should contact your doctor.

Dizziness is a symptom that can accompany a variety of neurological diseases. The patient complains of an imaginary sensation of rotation, translational movements of his own body or surrounding objects. At the same time, the gait becomes uncertain, the balance is disturbed, the person feels as if he “fails”. Dizziness can also be accompanied by vegetative reactions (sweating, blanching or redness of the face), nausea, vomiting, discomfort in the heart area.

Doctors of the Department of Neurology of the Clinical Hospital on Yauza conduct comprehensive diagnostics to identify the causes of dizziness and identify the diseases with which it may be associated.

Our doctors specialize in the diagnosis and treatment of a wide range of diseases, including cerebrovascular pathology, dizziness and stability disorders, sleep disorders, memory and attention impairment, pain syndromes of various origins, spinal diseases, mobility disorders, muscular dystonia, etc. For treatment for a number of diseases, specialists successfully use botulinum toxin type A preparations.

When a patient complains of dizziness, the doctors of the Yauza Clinical Hospital conduct the most thorough diagnostics.

Causes of dizziness

True dizziness is the result of disturbances in the functioning of the vestibular apparatus, as well as visual and kinesthetic analyzers involved in the regulation of human balance.

True vertigo can be both permanent and episodic (paroxysmal). There are conditions that patients describe as dizziness, but they are associated with other causes. For example, dizziness is often called an attack of lightheadedness, a fainting state, when a person may experience severe weakness, sweating, suddenly turns pale. This condition is typical for cardiovascular pathologies, a sharp decrease in pressure and is not related to the vestibular apparatus. Another set of sensations that patients may mistake for dizziness is associated with neurological pathologies leading to unsteady gait and disorientation in space (cerebellar disorders, parkinsonism). Also, dizziness can be called a feeling of heaviness in the head, similar to intoxication, characteristic of people with neuroses.

Diseases accompanied by dizziness

Dizziness is a symptom of many diseases, including severe ones, including:

• osteochondrosis of the cervical spine
• vegetovascular dystonia
• vestibular neuritis (inflammation of the vestibular nerve)
• diseases of the inner ear
• neck and head injuries
• brain tumors
• migraine
• epilepsy
• diabetes mellitus (dizziness is a sign of dangerously low blood glucose levels)
• stroke
• Meniere’s disease (dizziness accompanied by tinnitus, hearing loss, nausea, vomiting) and others

Diagnosis of dizziness at the Yauza Clinical Hospital

Diagnosis of the causes of dizziness at the Yauza Clinical Hospital begins with a detailed conversation between the doctor and the patient. The true cause of the disease is often allowed to establish the symptoms associated with dizziness, the duration, frequency and nature of the attacks.

Specialists of the Department of Neurology of our clinic perform the following examinations, which help to establish an accurate diagnosis:

• clinical blood test
• MRI of the brain (including with intravenous contrast)
• MR angiography of intracranial arteries and vessels of the neck
• MSCT of neck vessels with contrast
• X-ray of the cervical spine
• extracranial (neck) and intracranial (head) triplex scanning
• consultations of an endocrinologist, otolaryngologist, ophthalmologist

Treatment of vertigo at the Yauza Clinical Hospital

Based on the diagnosis, the neurologist at the Yauza Clinical Hospital prescribes treatment.

Dizziness can be alleviated by the appointment of vasodilators, drugs that improve the microcirculation of the brain, and tranquilizers.

In addition to prescribing medications, our neurologist develops a diet for patients (restriction in the consumption of salty foods, liquids, tea, coffee, chocolate, exclusion of tobacco and alcohol) and advises special exercises designed to train the vestibular apparatus.

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Algorithms for the diagnosis and treatment of dizziness | Veselago O.

V.

Dizziness is a subjective symptom that accompanies the course of a number of diseases of various organs and systems of the body. Patients’ complaints of dizziness occur in approximately 12% of the total number of cases in neurological practice.

The first step in the algorithm for diagnosing vestibular disorders is to determine the nature of dizziness, i.e. whether it is vestibular or non-vestibular. Under vestibular (systemic, true) dizziness is understood the illusion of movement of the person himself or objects of the environment. Vestibular dizziness always indicates a pathology of the vestibular analyzer.
The following types of vestibular vertigo are distinguished:
• proprioceptive – the illusion of movement of one’s own body in space;
• tactile or tactile – illusions of movement, unsteadiness, uneven support under the feet or hands, swinging on the waves, falling through space;
• visual – the illusion of movement of motionless objects.
All other sensations and conditions that differ from systemic dizziness (cerebellar and frontal ataxias, feelings of intoxication and lightheadedness, syncopal and pre-syncope states, a veil before the eyes, emptiness and lightness in the head, discomfort in the head) are not associated with the pathology of the vestibular analyzer and are the name of non-vestibular (non-systemic) dizziness (Fig. 1).
The next stage of diagnosis is to determine the level of damage to the vestibular analyzer, depending on which peripheral (PVS) and central (CVS) vestibular syndromes are distinguished.
According to the topical classification of vestibular syndromes N.S. Blagoveshchenskaya, PVS is associated with damage to the vestibular formations of the inner ear, the vestibular ganglion and the root of the VIII pair of cranial nerves. PCV is caused by pathology of the vestibular nuclei and pathways in the posterior cranial fossa, as well as vestibular formations in the cortical-subcortical regions of the brain. CVD is subdivided into subtentorial stem lesion (nuclear, subnuclear, supranuclear in the pons and supranuclear in the midbrain) and supratentorial lesion (diencephalic-hypothalamic, subcortical, cortical).
Dizziness caused by the pathology of the peripheral part of the vestibular analyzer, as a rule, develops suddenly, has a pronounced rotational character, and is often accompanied by nausea, vomiting and other autonomic disorders. Peripheral dizziness is limited in time – the duration of the attack usually does not exceed 24 hours. After an acute attack of dizziness, residual vestibular dysfunction persists, but due to the inclusion of central compensatory mechanisms, its duration is short – several hours, maximum – several weeks. In the interictal period, vestibular disorders are not observed.
With damage to the central part of the vestibular analyzer, dizziness is not so pronounced, but longer in time (several days, weeks). However, if the process in the central nervous system acutely affects the vestibular formations, then dizziness is in many ways similar to that observed in the pathology of the peripheral section. Compensatory capabilities in CVD are less pronounced, so residual vestibular dysfunction may be present for a sufficiently long time (months and years).
With PVS, dizziness is usually accompanied by auditory disorders (hearing loss, tinnitus). Auditory disorders are not characteristic of CVD, with the exception of nuclear damage (lateral sections of the bridge) and disorders in the midbrain. The defeat of the latter is accompanied by bilateral hearing loss.
With PVS, spontaneous nystagmus in direction can only be horizontal or horizontal-rotary. The characteristic features of peripheral spontaneous nystagmus are its isolated character (presence in only one direction of gaze), binocularity (equal participation in nystagmus of both eyes), uniformity in amplitude and rhythm, combination with a harmonious (to the side opposite to nystagmus) deviation of the arms and torso.
Unlike peripheral, with a central lesion of the vestibular analyzer, both horizontal or horizontal-rotary, and vertical, diagonal, convergent spontaneous nystagmus can be observed. The last three types of spontaneous nystagmus (vertical, diagonal, convergent) never occur in PVS. In addition, central nystagmus, as a rule, is multiple (observed in several directions), monoocular (one eye nystagmus more) – uneven in amplitude and rhythm, accompanied by disharmonious (toward nystagmus or remain in place) deviation of the arms and torso.
After determining the level of damage to the vestibular analyzer, all identified symptoms are compared with individual nosological units of vestibular disorders. If the symptoms fit into the framework of a specific nosological form, then this is reflected in the diagnosis. If it does not fit, then they are limited to indicating the level of damage to the vestibular analyzer.
The most common nosological forms caused by damage to the peripheral part of the vestibular analyzer are Meniere’s disease, benign paroxysmal positional vertigo (BPPV), acute labyrinthitis, acute circulatory disorders in the internal auditory artery, neurinoma VIII of the cranial nerve, and some others (Table 1).
A special place among the disorders of the peripheral part of the vestibular analyzer is BPPV – a pathology that occurs as a result of the movement of otolith fragments into the semicircular canals of the inner ear (canal- or cupulolithiasis). Otoliths (ear stones, or otoconia) basically contain calcium carbonate crystals and make up the otolithic membrane, which serves as a kind of cargo for receptors located in the spherical and elliptical sacs of the vestibule, which perceive rectilinear acceleration and gravity. Probably, for some reason (viral infection, trauma, vascular and degenerative changes in the inner ear), otolith particles can be isolated from the otolith membrane and, with some movements of the patient, move into the semicircular canals. Thus, under the influence of the weight of the otolith fragment, the ampullary receptor, which normally perceives angular acceleration, enters a state of irritation. As a rule, the ampullar receptors of the external (horizontal) or posterior (vertical) semicircular canals are affected.
Despite the fact that BPPV as a separate nosological entity was described by Dix and Hallpike back in 1952 and, according to foreign literature, it accounts for 17–35% of cases of damage to the peripheral part of the vestibular analyzer, nevertheless, due to poor illumination in domestic literature This disease causes the greatest diagnostic and therapeutic difficulties. Our own observations show that at the onset, BPPV is often mistaken for an acute cerebrovascular accident, which forces one to resort to massive vascular therapy, which does not lead to the desired effect.
DPPG has a pronounced and specific clinical picture – the occurrence of attacks of systemic dizziness, accompanied by nystagmus and violent vegetative manifestations with strictly defined movements of the body or head. Trigger movements are – taking a horizontal position on the back, turning in bed on its side, verticalization, tilting the head back, tilting the head or torso down. Seizures can occur with all of the above provocative movements or only with some. The side of the lesion is considered to be the one that, when turned, develops dizziness. Sometimes dizziness is present when turning both on one side and on the other side, but on the side of the lesion, the intensity of dizziness is always more pronounced. Hearing is not affected by BPPV.
Attacks of BPPV disturb patients with a regular frequency – daily, with almost every provocative movement. The duration of the attack is no more than 60 seconds. Sometimes patients cannot accurately indicate the duration of the attack, because, without waiting for the spontaneous end of the attack, they get out of a critical situation.
BPPV is usually accompanied by positional nystagmus. In the vast majority of cases, nystagmus is geotropic, i.e. directed towards the underlying ear, “towards the ground.” It is rare to observe ageotropic nystagmus – directed towards the overlying ear. The ageotropic form of BPPV occurs with horizontal cupulolithiasis.
Diagnosis of BPPV is carried out by performing a Dix-Hallpike test (Fig. 2).
• The examined person sits on the couch, his gaze is fixed on the doctor’s forehead.
• The doctor turns the patient’s head 45o to the side, and then, holding the head with his hands, quickly lays the patient on his back, so that the head hangs back by 20–30o. This movement should not take more than 3 s.
• Observe eye movement for at least 20 seconds if nystagmus is absent and longer if it occurs.
• The procedure is repeated with the head turned in the opposite direction.
The diagnostic test is considered positive if positional vertigo and nystagmus occur. When the posterior semicircular canal is affected, rotatory nystagmus is observed, directed towards the underlying ear. With the defeat of the horizontal – horizontal nystagmus also towards the underlying ear. Characteristic features of dizziness and nystagmus in BPPV are the phenomena of exhaustion (decrease in intensity with repeated trigger movements) and adaptation (spontaneous disappearance after a while – no more than 60 s).
CVD, as a rule, is observed in the pathology of the central nervous system of various origins. Diagnosis of the underlying disease in central vestibular syndrome is performed by a neurologist.
Thus, the main diagnostic search for patients complaining of dizziness comes down to three main stages:
I. Determination of the nature of dizziness.
II. Determination of the level of damage to the vestibular analyzer.
III. Definition of nosological form.
Treatment of dizziness
BPPV occupies a special place in terms of treatment tactics. Based on the pathogenetic mechanism of the occurrence of BPPV, rehabilitation vestibular maneuvers are used as therapeutic measures – turns of the head and torso in a certain sequence, leading to the return of otoliths from the canal to the sac. Complete cure after a single maneuver, according to our data, is observed in approximately 83% of patients.
Therapeutic measures for vestibular disorders should first of all be aimed at eliminating the causes of such disorders. This may be a specific treatment of diseases of the middle and inner ear, peripheral and central nervous system.
Symptomatic pharmacological treatment of vestibular disorders is carried out with drugs that have a sedative effect on vestibular activity (vestibulolytic agents), among which the main ones are listed below.
histamine analogues. Betahistine dihydrochloride (Tagista®). Betahistine is considered to be one of the leading vestibulolytic agents. Its main advantage over other drugs is not only its pronounced vestibulolytic activity, but also the ability to have a pathogenetic effect in vestibular disorders of vascular origin. Betahistine is effective against both peripheral and central vestibular disorders.
An important role in the functioning of the vestibular structures is played by the histaminergic system. Thus, the transmission of impulses from vestibular receptors and vestibular nuclei is provided mainly by histaminergic neurons. A number of studies have shown that the effectiveness of betahistine is associated with a decrease in both spontaneous and evoked impulses from vestibular receptors and vestibular nuclei. So, in the experiment it was found that betahistine reduces the intensity and amplitude of neuronal impulses of the lateral vestibular nucleus both at rest and during stimulation.
Along with the effect on histamine receptors in peripheral and central vestibular formations, betahistine also has a vasoactive effect. It causes dilation of the arterioles and capillaries of the inner ear, which leads to a selective increase in blood flow. In addition, against the background of taking betahistine, there is some increase in cerebral blood flow both in the vertebrobasilar and carotid systems. The vasoactive effect of betahistine is presumably due to the blocking of histamine H3 receptors and, possibly, the effect on presynaptic adrenoreceptors.
An analysis of the action of betahistine indicates its versatile effect on various pathogenetic mechanisms of dizziness and, therefore, the pathogenetic validity of the use of the drug.
Betahistine does not cause significant side effects. In rare cases, there are mild dyspepsia, allergic skin reactions and headache.
Currently, there are a number of generic betahistine preparations, one of which is Tagista®, which has proven itself in the treatment of patients with various types of systemic vertigo.
H1 blockers (antihistamines): promethazine, dimenhydrinate, meclozine, diphenhydramine. Dizziness is reduced only by those H1-blockers that have a central anticholinergic effect. Perhaps this action explains the vestibulolytic effect of these drugs, since the suppression of dizziness is not associated with either blockade of H1 receptors or inhibition of the vomiting center of the brainstem (many antiemetics do not affect dizziness).
The main side effect of H1 blockers is sedative and hypnotic. It is more pronounced in dimenhydrinate and diphenhydramine. In an acute attack of dizziness, this action is desirable, otherwise meclozine is preferable. H1 blockers can cause anticholinergic effects such as dry mouth or accommodation disturbance.
Promethazine (an aliphatic derivative of phenothiazine) is usually classified as an antihistamine, although it also has mild antipsychotic, sedative, adreno- and anticholinergic effects. Good for motion sickness and acute vestibular disorders. It is also possible course use for chronic vestibular dysfunction, accompanied by neurosis and neurosis-like conditions, anxiety, sleep disturbances. The drug should not be prescribed to patients suffering from diseases in which anticholinergics are contraindicated (glaucoma, peptic ulcer, prostatic hypertrophy, epilepsy, etc.).
Anticholinergic drugs: scopolamine, atropine. Anticholinergics inhibit the activity of the central vestibular structures. Side effects of anticholinergic drugs are mainly due to the blocking of M-cholinergic receptors, so their use is limited to the relief of acute attacks of dizziness or the prevention of motion sickness. Contraindications to the use of drugs in this group are the same as those of other M-anticholinergics. Sometimes, together with atropine or scopolamine, promethazine is used, which has a synergistic effect.
Phenothiazine derivatives: thiethylperazine, promethazine. Thiethylpyrazine (piperazine derivative of phenothiazine), along with a pronounced antiemetic effect, also has vestibulolytic and neuroleptic activity. It is used both for the relief of acute attacks of dizziness, and for the treatment of chronic vestibular disorders, mainly of central origin. The use of thiethylpyrazine is somewhat limited by its possible side effects: dry mouth, drowsiness, extrapyramidal disorders.
Tranquilizers: hydroxyzine, diazepam. Tranquilizers are used to reduce the anxiety that often accompanies chronic vestibular disorders. In hydroxyzine, the anti-anxiety effect is combined with anti-neurotic, vegetostabilizing, sedative and antihistamine activity, which makes it especially effective in the treatment of chronic dizziness.
Phenibut is a derivative of GABA and phenylethylamine. It has a vestibulolytic, nootropic and tranquilizing effect. It is used in the treatment of acute and chronic vestibular disorders.
Barbiturates. The pronounced side effects of barbiturates in the form of the development of addiction and dependence preclude the use of these drugs for the treatment of vestibular pathology. Belladonna alkaloids in combination with ergotamine and barbiturates can be prescribed for the treatment of vertigo in migraine patients.
Vasoactive drugs. Cinnarizine effectively reduces vestibular activity, and also has a vasodilating effect, mainly on the vessels of the brain, and moderate antihistamine activity. In cases where dizziness is accompanied by anxiety and stress, it is recommended to combine cinnarizine with diazepam. It is prescribed in courses of 1-2 months. with chronic dizziness.
The above review of vestibulolytic agents clearly indicates that the use of the vast majority of drugs is limited by their side effects. Therefore, their use is only possible to relieve an attack of acute vestibular dysfunction or situationally, for example, with motion sickness.