Dizziness – Diagnosis and treatment

Diagnosis

If your doctor suspects you are having or may have had a stroke, are older or suffered a blow to the head, he or she may immediately order an MRI or CT scan.

Most people visiting their doctor because of dizziness will first be asked about their symptoms and medications and then be given a physical examination. During this exam, your doctor will check how you walk and maintain your balance and how the major nerves of your central nervous system are working.

You may also need a hearing test and balance tests, including:

• Eye movement testing. Your doctor may watch the path of your eyes when you track a moving object. And you may be given an eye motion test in which water or air is placed in your ear canal.
• Head movement testing. If your doctor suspects your vertigo is caused by benign paroxysmal positional vertigo, he or she may do a simple head movement test called the Dix-Hallpike maneuver to verify the diagnosis.
• Posturography. This test tells your doctor which parts of the balance system you rely on the most and which parts may be giving you problems. You stand in your bare feet on a platform and try to keep your balance under various conditions.
• Rotary chair testing. During this test you sit in a computer-controlled chair that moves very slowly in a full circle. At faster speeds, it moves back and forth in a very small arc.

In addition, you may be given blood tests to check for infection and other tests to check heart and blood vessel health.

Treatment

Dizziness often gets better without treatment. Within a couple of weeks, the body usually adapts to whatever is causing it.

If you seek treatment, your doctor will base it on the cause of your condition and your symptoms. It may include medications and balance exercises. Even if no cause is found or if your dizziness persists, prescription drugs and other treatments may make your symptoms more manageable.

Medications

• Water pills. If you have Meniere’s disease, your doctor may prescribe a water pill (diuretic). This along with a low-salt diet may help reduce how often you have dizziness episodes.
• Medications that relieve dizziness and nausea. Your doctor may prescribe drugs to provide immediate relief from vertigo, dizziness and nausea, including prescription antihistamines and anticholinergics. Many of these drugs cause drowsiness.
• Anti-anxiety medications. Diazepam (Valium) and alprazolam (Xanax) are in a class of drugs called benzodiazepines, which may cause addiction. They may also cause drowsiness.
• Preventive medicine for migraine. Certain medicines may help prevent migraine attacks.

Therapy

• Head position maneuvers. A technique called canalith repositioning (or Epley maneuver) usually helps resolve benign paroxysmal positional vertigo more quickly than simply waiting for your dizziness to go away. It can be done by your doctor, an audiologist or a physical therapist and involves maneuvering the position of your head. It’s usually effective after one or two treatments. Before undergoing this procedure, tell your care provider if you have a neck or back condition, a detached retina, or blood vessel problems.
• Balance therapy. You may learn specific exercises to help make your balance system less sensitive to motion. This physical therapy technique is called vestibular rehabilitation. It is used for people with dizziness from inner ear conditions such as vestibular neuritis.
• Psychotherapy. This type of therapy may help people whose dizziness is caused by anxiety disorders.

Surgical or other procedures

• Injections. Your doctor may inject your inner ear with the antibiotic gentamicin to disable the balance function. The unaffected ear takes over that function.
• Removal of the inner ear sense organ. A procedure that’s rarely used is called labyrinthectomy. It disables the vestibular labyrinth in the affected ear. The other ear takes over the balance function. This technique may be used if you have serious hearing loss and your dizziness hasn’t responded to other treatments.

Clinical trials

Explore Mayo Clinic studies testing new treatments, interventions and tests as a means to prevent, detect, treat or manage this condition.

Lifestyle and home remedies

If you tend to experience repeated episodes of dizziness, consider these tips:

• Be aware of the possibility of losing your balance, which can lead to falling and serious injury.
• Avoid moving suddenly and walk with a cane for stability, if needed.
• Fall-proof your home by removing tripping hazards such as area rugs and exposed electrical cords. Use nonslip mats on your bath and shower floors. Use good lighting.
• Sit or lie down immediately when you feel dizzy. Lie still with your eyes closed in a darkened room if you’re experiencing a severe episode of vertigo.
• Avoid driving a car or operating heavy machinery if you experience frequent dizziness without warning.
• Avoid using caffeine, alcohol, salt and tobacco. Excessive use of these substances can worsen your signs and symptoms.
• Drink enough fluids, eat a healthy diet, get enough sleep and avoid stress.
• If your dizziness is caused by a medication, talk with your doctor about discontinuing it or lowering the dose.
• If your dizziness comes with nausea, try an over-the-counter (nonprescription) antihistamine, such as meclizine or dimenhydrinate (Dramamine). These may cause drowsiness. Nondrowsy antihistamines aren’t as effective.
• If your dizziness is caused by overheating or dehydration, rest in a cool place and drink water or a sports drink (Gatorade, Powerade, others).

Preparing for your appointment

Your family doctor or primary care provider will probably be able to diagnose and treat the cause of your dizziness. He or she you may refer you to an ear, nose and throat (ENT) specialist or a doctor who specializes in the brain and nervous system (neurologist).

Here’s some information to help you get ready for your appointment.

What you can do

• Be aware of any pre-appointment restrictions. At the time you make the appointment, be sure to ask if there’s anything you need to do in advance, such as restrict your diet. If you’re scheduled for vestibular testing, your doctor will provide instructions regarding any medications to withhold the night before and what to eat on the day of testing.
• Be prepared to describe your dizziness in specific terms. When you have an episode of dizziness, do you feel like the room is spinning, or like you are spinning in the room? Do you feel like you might pass out? Your description of these symptoms is crucial to helping your doctor make a diagnosis.
• List any other health conditions or symptoms you have, including any that may seem unrelated to your dizziness. For example, if you have felt depressed or anxious recently, this is important information for your doctor.
• List key personal information, including any major stresses or recent life changes.
• Make a list of all prescription and over-the-counter medications, vitamins or supplements that you’re taking.
• List questions to ask your doctor.

Your time with your doctor is limited, so preparing a list of questions ahead of time will help you make the most of your time together. For dizziness, some basic questions to ask your doctor include:

• What’s the most likely cause of my symptoms?
• Are there any other possible causes for my symptoms?
• What tests do you recommend?
• Is this problem likely temporary or long lasting?
• Is it possible my symptoms will go away without treatment?
• What treatment options might help?
• Do I need to follow any restrictions? For example, is it safe for me to drive?
• Should I see a specialist?
• Is there a generic alternative to the medicine you’re prescribing?
• Do you have any brochures or other printed material that I can take home with me? What websites do you recommend?

What to expect from your doctor

Your doctor will likely ask you a number of questions about your dizziness, such as:

• Can you describe what you felt the first time you had an episode of dizziness?
• Is your dizziness continuous, or does it occur in spells or episodes?
• If your dizziness occurs in episodes, how long do these episodes last?
• How often do your dizziness episodes occur?
• When do your dizzy spells seem to happen, and what triggers them?
• Does your dizziness cause the room to spin or produce a sensation of motion?
• When you feel dizzy, do you also feel faint or lightheaded?
• Does your dizziness cause you to lose your balance?
• Are your symptoms accompanied by a ringing or fullness in your ears (tinnitus) or trouble hearing?
• Does your vision blur?
• Is your dizziness made worse by moving your head?
• What medications, vitamins or supplements are you taking?

What you can do in the meantime

If you tend to feel lightheaded when you stand up, take your time making changes in posture. If you have had episodes of dizziness while driving, arrange for alternate transportation while you’re waiting to see your doctor.

If your dizziness causes you to feel like you might fall, take steps to reduce your risk. Keep your home well lighted and free of hazards that might cause you to trip. Avoid area rugs and exposed electrical cords. Place furniture where you’re unlikely to bump into it, and use nonslip mats in the bathtub and on shower floors.

Oct. 15, 2020

How to Get Rid of Vertigo Once and For All

Physical therapy to improve balance and inner ear issues

Vestibular rehabilitation is a type of physical therapy that can benefit people with inner ear or balance problems. It helps your brain learn ways to use other senses (such as vision) to compensate for vertigo.

The exercises are typically customized to meet a person’s individual needs. They may include eye and head movements, balance training, or other maneuvers, depending on what’s causing your symptoms.

Vestibular rehabilitation is usually performed on an outpatient basis, but it can also be done in a hospital or home setting. (1)

Canalith Repositioning

—also known as the Epley Maneuver

Canalith repositioning, also known as the “Epley maneuver,” is a technique that involves a series of special head and body movements.

The purpose is to move crystals from the fluid-filled semicircular canals of your inner ear to a different area, so they can be absorbed by the body.

Canalith repositioning involves the following steps:

1. You sit on an exam table with your eyes open and your head turned 45 degrees to the right.
2. You lie on your back quickly with your head hanging off the end of the table.
3. Your doctor turns your head 90 degree to the left, and you hold this position for about 30 seconds.
4. Your physician turns your head another 90 degrees to the left while you rotate your body in the same direction. This position is held for another 30 seconds.
5. You sit up on the left side of the exam table.
6. The procedure can be repeated on both sides until you feel relief.

You’ll probably have symptoms of vertigo during your treatment. You might need to remain upright for 24 hours following your procedure to prevent crystals from returning to the semicircular canals.

A doctor or physical therapist typically performs canalith repositioning, but you may be shown how to do modified exercises at home.

Canalith repositioning is very effective for people with benign paroxysmal positional vertigo (BPPV) — the most common cause of vertigo. Results vary, but some studies have shown between a 50 and 90 percent success rate. (2)

If the crystals move back into your semicircular canals, your doctor can repeat the treatment.

You should tell your healthcare provider if you have any of the following before having this therapy:

• A neck problem
• A back condition
• Rheumatoid arthritis
• A detached retina in your eye
• Blood vessel or heart problems (3,4)

Related: YouTube Videos May Help Some Vertigo Patients

Medication that targets the cause of our symptoms

Various medicines are used to help improve symptoms of vertigo. Drugs are typically more effective at treating vertigo that lasts a few hours to several days.

People with Ménière’s disease may benefit from taking diuretics, medicines that help your body get rid of salt and water.

If your vertigo is caused by an infection, antibiotics or steroids may be given.

Sometimes doctors recommend antihistamines, such as Antivert (meclizine), Benadryl (diphenhydramine), or Dramamine (dimenhydrinate) to help vertigo episodes. Anticholinergics, such as the Transderm Scop patch, may also help with dizziness.

Anti-anxiety meds, like Valium (diazepam) and Xanax (alprazolam) may help relief vertigo in some people, especially if symptoms are triggered by an anxiety disorder.

If your vertigo is caused by a stroke, you may need drugs, such as aspirin, Plavix (clopidogrel), Aggrenox (aspirin-dipyridamole), or Coumadin (warfarin) to prevent a future event.

Certain medication to treat migraines may also help vertigo symptoms in some people. These might include various medicines from different drug classes, such as antidepressants, beta-blockers, selective serotonin reuptake inhibitors (SSRIs), benzodiazepines, anti-emetics, or calcium channel blockers.

Several other medicines are used to help symptoms of vertigo. Check with your doctor to see which drugs might be appropriate for your particular condition. (2)

Surgery

—an uncommon treatment for special cases

Surgery isn’t a common treatment for vertigo, but it’s sometimes needed.

You might require a surgical procedure if your symptoms are caused by an underlying condition, such as a tumor or an injury to your brain or neck.

In rare circumstances, doctors may suggest canal plugging surgery for people with BPPV when other treatments fail. With this procedure, a bone plug is used to block an area of your inner ear and prevent the semicircular canals from responding to particle movements. The success rate is around 90 percent. (3)

Another surgery, called labyrinthectomy, disables the vestibular labyrinth in your bad ear and allows the other ear to control balance. This procedure is rarely done but may be recommended if you have significant hearing loss or vertigo that hasn’t responded to other therapies.

Rarely, people with Meniere’s disease may also require surgery, such as a shunt surgery, to help symptoms.

A procedure to plug a leak in the inner ear is sometimes used for individuals with perilymph fistula.

Other surgical procedures may be necessary, depending on what’s causing your vertigo episodes.

Injections

—when other treatments haven’t worked

In cases in which patients have not responded to other treatments, injections are sometimes used to help people with vertigo symptoms. The antibiotic Gentamicin (garamycin) can be injected into your inner ear to disable balance. This allows the unaffected ear to perform the balance functions.

Psychotherapy can help alleviate the stress of symptoms

Some people with vertigo may benefit from psychotherapy, even if their symptoms aren’t caused by a psychiatric disorder. (4)

Psychotherapy, also known as “talk therapy,” helps you identify negative behaviors and replace them with positive solutions. There are several different types of psychotherapy.

You may need to be treated for an underlying problem

Your doctor might recommend other treatments for your vertigo, depending on the underlying problem that’s causing your symptoms.

For instance, people with conditions such as heart disease, diabetes, multiple sclerosis (MS), Parkinson’s disease, and anemia may develop vertigo. You might need specific treatments to target these diseases.

Related: The Most Surprising Symptoms of Multiple Sclerosis

Sometimes vertigo goes away all on its own

Your vertigo may go away on its own, with no specific treatment. For instance, people with BPPV often notice that their symptoms disappear within a few weeks or months. (3)

Your doctor can help you figure out if treatment is necessary for your condition.

Vertigo | Causes, and Medicines

What is vertigo?

Vertigo is a type of dizziness that can last just for a short period of time (minutes) or that can last for hours or even days. People who have vertigo have a false feeling of their surroundings moving or spinning. This is usually accompanied by a feeling of sickness (nausea) and a loss of balance. The condition can also cause someone with the condition to be sick (vomit). Vertigo is a symptom and not a condition in itself. In most cases there is a medical condition that causes vertigo. However, sometimes the cause is unknown.

Vertigo causes

The most common cause of vertigo is a problem with the inner part of the ear – for example, an infection or inflammation. When we move our head, the inner part of the ear tells us where our head is. It does this by sending signals to the brain and this helps us to keep our balance. If there are problems with the inner part of the ear then this causes us to feel sick (nausea) and dizzy.

Other conditions that can affect the inner ear and cause vertigo include Ménière’s disease, motion sickness and toxicity of the ear caused by medicines. A common cause of vertigo in older people is benign paroxysmal positional vertigo. This causes intense dizziness (short episodes of vertigo) when you move your head in certain directions. It it thought to be caused by tiny fragments of debris in the inner ear.

Less commonly, vertigo may be caused by conditions that make changes to certain parts of the brain – for example:

The treatment of vertigo depends on what has caused it. For example, if you have an ear infection your doctor may prescribe an antibiotic. For other causes of vertigo your doctor may give you special exercises to do. The rest of this leaflet only discusses medicines that help to ease the symptoms of dizziness and nausea caused by vertigo. There are separate leaflets called Benign Paroxysmal Positional Vertigo, Ménière’s Disease, Vestibular Neuritis and Labyrinthitis, Dizziness and Migraine.

Note: vertigo is sometimes referred to as a ‘fear of heights’ – this is not correct. The right term for the fear of heights is acrophobia.

What are medicines for vertigo and how do they work?

A number of medicines can be prescribed to help with the symptoms of vertigo. They include prochlorperazine or antihistamines such as cinnarizine, cyclizine or promethazine. These medicines are the same ones that are used to help treat any feeling of sickness (nausea) and motion sickness. They work by blocking certain chemicals in the brain. Prochlorperazine blocks a chemical called dopamine; this helps with severe sickness. Antihistamines block histamine, which helps with mild sickness and being sick (vomiting) as well as vertigo. Betahistine is an antihistamine that may be prescribed for patients with Ménière’s disease, to prevent attacks from occurring. It is thought that this medicine improves the blood flow around the ear.

These medicines come in various brand names and are available as tablets, capsules, liquids and injections. Some are available as tablets that dissolve between the upper gum and lip (sublingual tablets).

How well do these medicines work?

There are no good studies that tell us how well these medicines work. However, they have been prescribed to treat vertigo for many years.

Which medicine is usually prescribed?

The choice of medicine depends on what is causing your vertigo and how severe your symptoms are. If you have a severe feeling of sickness (nausea), your doctor may prescribe prochlorperazine. The advantage of this medicine is that it is available as an injection or as a tablet to dissolve between the upper gum and lip (a sublingual tablet). It may be more suitable for people who are very sick and being sick (vomiting).

If you have mild nausea, your doctor may prescribe an antihistamine such as cinnarizine, cyclizine or promethazine. These will also help to treat dizziness.

What is the usual length of treatment?

Medicines to treat vertigo and sickness are usually only taken for a short time – normally from 3 to 14 days. If you have vertigo frequently, your doctor may prescribe a short supply of these medicines to keep at home, to use when you have another attack.

What about side-effects?

It is not possible to list all the possible side-effects of each of these medicines in this leaflet. However, as with all medicines, there are a number of side-effects that have been reported. If you want more information specific to your medicine, see the information leaflet that came with your medicine.

Most side-effects are not serious and each person may react differently to these medicines. Common side-effects include drowsiness, constipation, headaches, tiredness, trouble with sleeping (insomnia) and indigestion. Prochlorperazine can cause muscle twitching of the shoulders, face and neck. This usually goes away once this medicine is stopped.

Who cannot take medicines for vertigo?

There are very few people who cannot take a medicine for vertigo. If for some reason one medicine has caused a side-effect or there is a reason you cannot take one, your doctor can choose a different type of medicine that will suit you.

Can I buy medicines for vertigo?

You can buy cinnarizine from your pharmacy but the pharmacist can only sell it to people who have motion sickness.

How to use the Yellow Card Scheme

If you think you have had a side-effect to one of your medicines you can report this on the Yellow Card Scheme. You can do this online at www.mhra.gov.uk/yellowcard.

The Yellow Card Scheme is used to make pharmacists, doctors and nurses aware of any new side-effects that medicines or any other healthcare products may have caused. If you wish to report a side-effect, you will need to provide basic information about:

• The side-effect.
• The name of the medicine which you think caused it.
• The person who had the side-effect.
• Your contact details as the reporter of the side-effect.

It is helpful if you have your medication – and/or the leaflet that came with it – with you while you fill out the report.

Dizziness/Vertigo Medications | Common Vertigo Medicine & Tablet

Drugs Used in Treatment of Vertigo

Vertigo is a distressing condition in which the patient feels unsteady or a spinning sensation. This feeling is often accompanied by nausea or vomiting. Many diseases can give rise to vertigo or imbalance and it is important to find out the correct cause to be able to manage the condition properly.

The ear is responsible for hearing as well maintenance of balance of the body. The most common causes of vertigo or imbalance are due to disorders related to the ear, brain and central nervous system, systemic illnesses, nutritional deficiencies, injuries or infections and certain psychiatric causes. Proper treatment of these patients is possible by identifying the underlying cause.

As the person with vertigo feels unsteady and may be scared of losing balance and falling, they often have a high level of anxiety. It is important to explain the condition along with underlying cause to allay the anxiety of the patient. This may be combined with certain medicines to control the vertigo.

Several drugs have been used to decrease the spinning sensation, control nausea and vomiting and allay the anxiety caused by vertigo.

A list of some of the commonly used drugs is given below. However, it is again emphasised that treating the underlying cause of genesis of vertigo will be more beneficial to the overall recovery of the patient than suppressing the symptoms.

Most vertigo suppressing medicines are advised to be taken for short durations only during the acute attack. These medicines should be stopped after the acute episode as when they are given for prolonged spells, they interfere with recovery initiated by the central nervous system called central compensation.

Commonly Used Drugs

Some of the commonly used drugs in treatment of vertigo include (listed alphabetically):

• Benzodiazepines – like clonazepam, diazepam, lorazepam
• Betahistine
• Cinnarizine
• Dimenhydrinate
• Meclizine
• Metaclopromide
• Procloperazine
• Promethazine
• Ondansteron
• Piracetam
• Scopalamine – may be used as a skin patch SSRI – like amitryptaline

Medicines used to suppress vertigo or dizziness should be given for short duration of 3-5 days. Giving vestibular suppressants for longer duration can be detrimental to the initial recovery of the patients. A brief description of the commonly used drugs is given below.

Benzodiazepines

Benzodiazepines commonly used medicines in this group include clonazepam, diazepam and lorazepam. They act through the central nervous system by suppressing the vestibular responses. A sensory mismatch of the vestibular responses leads to the feeling of dizziness. These medicines are useful to allay the anxiety of the patient in the short term but should be stopped as soon as possible due to the risk of addiction, impaired memory and chance of jeopardizing central compensation.

Benzodiazepines should be avoided in patients with myasthenia gravis, bronchitis, chronic obstructive pulmonary disease (COPD) and sleep-apnea as they can cause depression of respiration.

Betahistine

Betahistine is a histamine analogue which acts as a weak h2 agonist and strong h4 receptor antagonist. It is available in 2 forms – betahistine hydrochloride and betahistine mesilate. It is used in treatment of Meniere’s disease. It is said to be useful in increasing the blood supply to the inner ear and improve compensatory process. Literature quotes betahistine to be effective in high doses.

This salt should be avoided in patients with bronchial asthma and gastric ulcer in which higher concentration of histamine can aggravate the condition.

Cinnarizine

Cinnarizine is an antihistamine and calcium channel blocker which acts by reducing the irritability of the inner ear receptors helping to reduce the sensory mismatch, prevents constriction of blood vessels and improves lexibility of red blood cells to improve blood supply to end organs. It is effective in acute episodes of vertigo. It also suppresses the vomiting centre in the central nervous system. However, it should not be prescribed for long durations as it may lead to drug – induced Parkinsonism. Cinnarizine is also useful in prevention of motion sickness.

Dimenhydrinate

Dimenhydrinate is an antihistamine which is available over the counter. It is an effective medicine to control nausea and vomiting which may be associated along with vertigo. It is used only during acute symptoms. Drug combinations having cinnarizine with dimenhydrinate are now available to control the dizziness along with the vomiting. Dimenhydrinate may cause dryness of mouth and drowsiness.

Hence patients on this medication should avoid driving. It should not be given to patients suffering from glaucoma or urinary problems.

Meclizine

Meclizine is a medicine belonging to the anti-histaminic group. It is effective in reducing vertigo during acute phase. It is the only anti-vertigo medicine which is safe during pregnancy and lactation. It is also useful to treat motion sickness and sea sickness.

Similar to other antihistamine drugs, meclizine also can cause drowsiness and dryness of mouth.

Metaclopromide, Promethazine and Ondansterone

Metaclopromide, promethazine and ondansterone are medicines given to control nausea and vomiting. Patients should avoid taking anything by mouth for at least 30 minutes after taking these medicines to be more effective.

Piracetam

Piracetam is a nootropic agent which is a derivative of the neurotransmitter gamma-amino butyric acid (GABA). It is said to improve the neuroplasticity and provide neuroprotective effects. It reduces the adhesion of red blood cells, prevents spasm of smaller blood vessels and improves microcirculation. It is also said to improve cognition.

The drugs described above are the more commonly used medicines in vertigo treatment. Many other drugs are also used to treat specific conditions which can be started after thorough evaluation. Steroids may be given in patients of Vestibular neuritis, labyrinthitis and auto-immune inner ear disease.

Anti-migraine prophylaxis with medicines like lunerizine, propranolol, amitryptaline , divalproex sodium or topiramate may be required. This prophylaxis has to be tailored to age, BMI, severity of symptoms, any associated disorders like hypertension, prostrate enlargement, glaucoma etc. Vestibular paroxysmia which presents with multiple short lasting episodes of spinning caused by neurovascular compression of the balance nerve is treated by carbamezepine.

Vestibular rehabilitation may be required as a co-treatment with the medicines. This rehab needs to be targeted and evolving according to the area of dysfunction within the balance system.

BPPV which is one of the commonest causes of vertigo across all age groups requires no medicinal treatment. It is caused by otoliths consisting of calcium carbonate entering the inner ear and disturbing function of the balance nerve. This is treated with liberatory procedures like Epley’s, Semont’s and Barbeque maneuvres.

Management of Dizziness and Vertigo

US Pharm. 2012;37(1):30-33. 

Dizziness is a nonspecific term used by patients to describe a sensation of altered spatial orientation. It encompasses a wide range of symptoms that vary from violent, spinning vertigo to vague symptoms of unsteadiness, lightheadedness, imbalance, disorientation, incoordination, and clumsiness. Vertigo is medically defined as an illusion of movement, or any abnormal sensation of motion between a patient and his or her surroundings.^1-3 Dizziness is a common complaint among patients, particularly in the elderly, and is often difficult to describe. Thus, it is important to understand the etiology of dizziness and vertigo in order to properly evaluate and manage patients. 

Prevalence

Dizziness is the third most common complaint among outpatients.⁴ An estimated 5 out of 1,000 people consult their primary care physician annually for vertigo, and 10 out of 1,000 for dizziness.² In 80% of these cases, the effects of dizziness are severe enough to necessitate medical intervention,⁵ though causes remain unexplained 40% to 80% of the time.⁶ Dizziness affects >50% of the elderly population and is the most common reason for physician visits among patients >75 years of age.⁵ Less than half of patients who experience dizziness have true vertigo.¹ Chronic dizziness and vertigo can result in loss of function, falls, and injuries that can lead to nursing home placement, stroke, and death.^7,8 

Diagnosis

Assessment of a patient with complaints of dizziness requires a thorough history and physical examination in order to determine the actual issue. It is also important to note the onset, duration, number of episodes, triggers, and any associated auditory and neurologic signs.^1,3,7,9 Common causes of dizziness include benign paroxysmal positional vertigo (BPPV), fear of falling, migraines, sensitivity to motion, and vestibular loss.⁵ 

Due to the generality of the term dizziness, the classification of this condition has been proposed. The first type involves an illusion of movement, also described as a spinning sensation and termed vertigo. The second type is a presyncopal episode, or the feeling of imminent fainting or loss of consciousness. The third type is disequilibrium, or impaired balance and gait. The fourth type is lightheadedness, which is an indistinct term used to describe symptoms that do not fit the other categories. It may be described as feeling disconnected from the environment. If dizziness is not due to vertigo, other medical conditions (e.g., cardiac arrhythmia, diabetes, thyroid disorder) should be investigated.^9-11 

Patient History: A common feature of true vertigo is a spinning sensation that may present as objective (patients complain of objects moving around them) or subjective vertigo (patients feel they are spinning). If vertigo is suspected, it is important to determine whether the cause is central or peripheral (TABLE 1). Central vertigo is commonly due to migraines, cerebrovascular disease, or cerebellopontine angle tumors. Peripheral vertigo occurs more frequently and is primarily due to infection, inflammation, and/or stimulation of various auditory nerves and organs. Typical features of peripheral vertigo include a short or episodic time course, a precipitating factor, and the presence of autonomic symptoms (e.g., sweating, pallor, nausea, or vomiting). It may also be associated with tinnitus, hearing loss, auditory fullness, or facial nerve weakness. In central vertigo, autonomic symptoms are less severe and hearing loss is uncommon. It has a gradual onset and is associated with neurologic symptoms such as visual changes (e.g., diplopia, hemianopsia), weakness, numbness, dysarthria, ataxia, and loss of consciousness.^3,7,12

A comprehensive review of a patient’s medication history should be performed to determine whether therapy must be altered. The administration of certain drugs (e.g., acetyl-salicylic acid, amiodarone, cisplatin, ethacrynic acid, furosemide, gentamicin, quinine, streptomycin, tobramycin) may result in direct ototoxicity and should be discontinued in patients experiencing vertigo. Psychotropic agents, antihypertensives, anti-inflammatory agents, and muscle relaxants are also reported to cause lightheadedness and disequilibrium in patients (TABLE 2).^5,7 A number of these drugs can cause orthostatic hypotension, which may manifest as dizziness.¹¹ Symptoms of dizziness usually resolve after cessation of the offending agent. However, consequences such as vestibular and cochlear damage may result in permanent ataxia or hearing loss. Patients who chronically use vestibular suppressants (e.g., meclizine, scopolamine) may become sensitized to these drugs and experience withdrawal symptoms when they are discontinued.^3,5,7 

Social history should be evaluated, as many factors can precipitate or worsen dizziness and vertigo (e.g., alcohol, nicotine, caffeine). Current or prior history of illicit drug use, sexual history (e.g., syphilis, herpes), traumatic head injury, cervical trauma, depression, anxiety, and other conditions (e.g., blood pressure alterations, arrhythmias, hypoglycemia, dehydration) should be noted since all can manifest dizziness.^3,7,11

Physical Examination: A complete physical examination includes ocular, otologic, cardiac, and neurologic components. In the ocular examination, papillary reactivity and extraocular movements are tested because abnormalities can suggest cerebellar disease. Patients with nystagmus should be assessed and family members asked if any unusual eye movements have been noted during a vertiginous event. Patients with peripheral vestibular disease could suppress the nystagmus by focusing on a stationary target. The inability to do so suggests a central problem. Head thrusts and positional testing may also be performed to check for the vestibulo-ocular reflex in which eye movements are observed to determine whether nystagmus is present and vestibulo-ocular reflexes are intact.^1,3,5,7,11 

Otologic examinations evaluate for the presence of impacted cerumen or other foreign objects in the ear canal, which may require removal for relief of vertiginous symptoms. Signs of middle ear disease (e.g., fluid behind the eardrum, perforation, extensive scarring, hearing loss) should be further evaluated.⁷ 

The patient’s blood pressure should also be taken—once in a supine position and then a minute later upon standing. If the systolic blood pressure decreases by 20 mm Hg, diastolic blood pressure decreases by 10 mm Hg, or pulse increases by 30 beats per minute (bpm), the patient may have orthostatic hypotension.¹¹ Auscultation of heart and carotid arteries could reveal other vascular causes of dizziness. Findings of a carotid bruit, heart murmur, or irregular rhythm should be followed by a thorough cardiovascular workup, particularly in elderly patients.⁷ 

A neurologic examination is vital and should include a complete cranial nerve evaluation to help identify localized lesions in the brain. Finger-to-nose pointing and rapidly alternating movements are used to assess cerebellar function. The Romberg’s test involves balance and requires the patient to stand with feet together and arms folded (with a practitioner standing behind the patient). The inability to maintain this position by swaying or falling suggests vestibular dysfunction. Gait abnormality is usually indicative of a central lesion. Ataxic gait associated with cerebellar disease is characterized by slowness, wide base, unsteadiness, step irregularity, tremor of the trunk, and side-to-side lurching.^7,11 

Lightheadedness may be caused by a hyperventilation syndrome where a patient inhales and exhales faster than the body can accommodate, resulting in respiratory alkalosis. Diagnosis can be attested by having the patient rapidly inhale and exhale deeply 20 times, which simulates the symptoms.¹¹ 

Other Tests: Most routine laboratory tests are not helpful in assessing vertiginous symptoms. However, a complete blood and chemistry panel can be useful in patients without clinical findings or with near syncope. An electrocardiogram (ECG) should be obtained in older adults and those with significant or troubling cardiac risk factors. If arrhythmia is suspected, a 24- to 48-hour continuous ECG could help determine whether the dizziness is due to an arrhythmia. Electronystagmography (ENG) is a diagnostic test that records eye movements in response to vestibular, visual, cervical, caloric, rotational, and positional stimulation and is helpful in detecting vestibular dysfunction and nystagmus. In this test, electrodes are placed at the outer and inner canthi of the eyes for horizontal readings, as well as above and below the eye for vertical readings.^3,7,11 

A CT or MRI of the brain is indicated in patients with suspected cerebellar hemorrhage, cerebellar infarction, or other central lesions. Radiologic imaging should be considered in patients with new-onset vertigo, findings of neurologic abnormalities, or symptoms lasting longer than 2 weeks. MRI, vascular imaging, and cardiac imaging should also be considered in people at risk for stroke. If a patient has an implanted metal device or if there is middle ear pathology, CT of the temporal bones is recommended.^3,7 

Pharmacologic Management

Dizziness: In patients without apparent vertiginous symptoms, the distinction of the dizziness complaint remains broad and unclear. Oftentimes, dizziness is a multisensory disorder, affected by peripheral neuropathy, visual impairment, and musculoskeletal disease. Treatment of the underlying cause would relieve the dizziness. Anemia, iron deficiency, malignancy, vitamin deficiency, and chronic blood loss may result in insufficient blood flow to the brain and manifest as lightheadedness. Patients with thyroid dysfunction or hypoglycemia may also present with dizziness. Pregnancy or menstruation may cause lightheadedness due to acute changes in hormone levels.⁷ 

Patients with orthostatic hypotension can be treated with midodrine and fludrocortisone to increase blood pressure; however, blood pressure monitoring is necessary to prevent any consequential complication. Midodrine should not be taken within 4 hours of bedtime or when lying down, as it could cause supine hypertension. Other common side effects include urinary frequency, urinary retention, and skin rash. Fludrocortisone is a mineralocorticoid that increases sodium and water retention. Thus, it is important to monitor potassium levels and for heart failure symptoms. Other common side effects include edema, hyperglycemia, increased risk of infection, and muscle weakness. Pseudoephedrine, paroxetine, and desmopressin are other options when midodrine and fludrocortisones are not effective.^5,11,13,14 

Dizziness and vertigo can also present in patients with migraines. Migraines are a vascular disorder that manifest as periodic, unilateral headaches that are often preceded by neurologic symptoms called the aura. Acute migraine attacks can be treated with nonopioid analgesics, antiemetics, nonsteroidal anti-inflammatory drugs, and 5-HT antagonists. Preventative medications for migraines include amitryptyline, beta-blockers, calcium channel blockers, and acetazolamide.^2,7 

Psychogenic dizziness can occur in patients with chronic anxiety. Panic attacks are described as sudden intense fear or discomfort and are often associated with dizziness, nausea, shortness of breath, chest tightness, paresthesias, and perspiration. Selective serotonin reuptake inhibitors are frequently used to treat chronic anxiety and panic disorders. Benzodiazepines can also be used for short-term treatment of anxiety.^7,11 

Vertigo: Pharmacologic treatment of vertigo depends on the etiology of the condition. However, vestibular suppressants can be used to alleviate vertiginous symptoms. These drugs should only be taken for a short period of time (~1 week) and then be titrated off because of their potential to delay compensation. There are three main categories of vestibular suppressants: anticholinergics, antihistamines, and benzodiazepines. Anticholinergics decrease the rate of firing in the vestibular nuclei. Although not indicated for vertigo, glycopyrrolate is less sedating than the other drugs used to treat vertigo.³ Antihistamines, such as meclizine, have anticholinergic effects and are much more sedating than true anticholinergics. Benzodiazepines are effective for vertigo, but they may be habit-forming. For acute cases of severe vertigo, IM promethazine or IV droperidol can be used.^{2,3,5,7,13,14} 

Antiemetics may also be used to help with nausea associated with vertigo. Metoclopramide is a dopamine antagonist that also enhances gastrointestinal (GI) tract motility and accelerates gastric emptying. It has been associated with lightheadedness, drowsiness, headache, GI upset, diarrhea, and muscle weakness. Ondansetron is a serotonin antagonist used to prevent chemotherapy-induced emesis, but it has been used for other types of nausea as well. Side effects include headache, fatigue, malaise, constipation, and dizziness. Prochlorperazine and promethazine are both phenothiazines that affect several neurotransmitters (e.g., histamine, dopamine, norepinephrine, acetylcholine) and produce an antiemetic response. Side effects include dizziness, blurred vision, constipation, dry mouth, and photosensitivity. Prochlorperazine can also cause changes in gait, muscular tremors, and weight gain. The severity of the patient’s nausea and the drug’s side-effect profile will help determine which drug is more appropriate for the patient.^{2,3,5,7,13,14} 

TABLE 3 summarizes drugs that can be used to treat symptoms of dizziness, vertigo, and associated nausea.^5,11,13-15

Nonpharmacologic Management

Physical Therapy: In certain cases of dizziness and vertigo, vestibular rehabilitation may be beneficial. These activities help the brain to use certain visual and proprioceptive cues to maintain balance and gait. The Cawthorne-Cooksey exercises involve head and body movements, as well as eye-head coordination and balance tasks. Other customized programs that may improve compliance and outcomes include habituation exercises, balance and gait exercises, and general conditioning. Visual motion desensitization with repeated optokinetic stimulation uses moving visual environments to improve vestibular-ocular response as the brain attempts to stabilize gaze. With visual vertigo, optokinetic stimulation with full-field stimuli uses visual environmental displays in a controlled setting to promote compensation.^2,10,15 

Role of the Pharmacist

Dizziness and vertigo may affect patients of all ages and are commonly associated with neurosensory, cardiovascular, and psychiatric conditions, as well as with the use of multiple drugs. These symptoms can be severe enough to affect patients’ daily activities. Pharmacists can contribute to the management of dizziness by reviewing patient medication history and profiles, as well as by inquiring about the patient’s symptoms (e.g., severity, onset, duration, and associated symptoms). Pharmacists can help patients recognize whether dizziness may be more serious than transient discomfort and require further medical attention. After the evaluation and diagnosis of dizziness or vertigo, appropriate treatment plans can be developed. Pharmacists should counsel patients to properly take their medication(s), caution them about potential drug-related adverse effects, and encourage vestibular exercises (when necessary) in order to aid in improving overall quality of life. 

REFERENCES

1. Traccis S, Zoroddu GF, Zecca MT, et al. Evaluating patients with vertigo: bedside examination. Neurol Sci. 2004;25(suppl 1):S16-S19.

2. Pagarkar W, Davies R. Dizziness. Medicine. 2004;32:18-23.

3. Storper IS, Roberts JK. Dizziness, vertigo, and hearing loss. In: Rowland LP, Pedley TA, eds.  

Merritt’s Neurology

. 12th ed. Philadelphia, PA: Lippinocott Williams & Wilkins; 2010:38-43.

4. Kroenke K, Mangelsdorff AD. Common symptoms in ambulatory care incidence: evaluation, therapy, and outcome. Am J Med. 1989;82:262-266.

5. Tusa RJ. Dizziness. Med Clin N Am. 2009;93:263-271.

6. Neuhauser HK, Radtke A, von Brevern M, et al. Burden of dizziness and vertigo in the community. Arch Intern Med. 2008;168:2118-2124.

7. Chawla N, Olshaker JS. Diagnosis and management of dizziness and vertigo. Med Clin North Am. 2006;90:291-304.

8. Tinetti ME, Williams CS, Gill TM. Dizziness among older adults: a possible geriatric syndrome. Ann Intern Med. 2000;132:337-344.

9. Drachman DA. A 69-year-old man with chronic dizziness. JAMA. 1998;280:2111-2118.

10. Broomfield SJ, Bruce IA, Malla JV, Kay NJ. The dizzy patient. Clin Otolaryngol. 2008;33:223-227.

11. Post RE, Dickerson LM. Dizzines: a diagnostic approach. Am Fam Physician. 2010;82:361-369.

12. Labuguen RH. Initial evaluation of vertigo. Am Fam Physician. 2006;73:244-251.

13. Lexi-Drugs. Hudson, OH: Lexi-Comp, Inc; 2011.

14. Micromedex Healthcare Series. Greenwood Village, CO: Thomson Reuters (Healthcare) Inc; 2011.

15. Swartz R, Longwell P. Treatment of vertigo. Am Fam Physician. 2005;71:1115-1122. 

To comment on this article, contact [email protected].

Pharmacological treatment of vertigo – PubMed

This review discusses the physiology and pharmacological treatment of vertigo and related disorders. Classes of medications useful in the treatment of vertigo include anticholinergics, antihistamines, benzodiazepines, calcium channel antagonists and dopamine receptor antagonists. These medications often have multiple actions. They may modify the intensity of symptoms (e.g. vestibular suppressants) or they may affect the underlying disease process (e.g. calcium channel antagonists in the case of vestibular migraine). Most of these agents, particularly those that are sedating, also have a potential to modulate the rate of compensation for vestibular damage. This consideration has become more relevant in recent years, as vestibular rehabilitation physical therapy is now often recommended in an attempt to promote compensation. Accordingly, therapy of vertigo is optimised when the prescriber has detailed knowledge of the pharmacology of medications being administered as well as the precise actions being sought. There are four broad causes of vertigo, for which specific regimens of drug therapy can be tailored. Otological vertigo includes disorders of the inner ear such as Ménière’s disease, vestibular neuritis, benign paroxysmal positional vertigo (BPPV) and bilateral vestibular paresis. In both Ménière’s disease and vestibular neuritis, vestibular suppressants such as anticholinergics and benzodiazepines are used. In Ménière’s disease, salt restriction and diuretics are used in an attempt to prevent flare-ups. In vestibular neuritis, only brief use of vestibular suppressants is now recommended. Drug treatments are not presently recommended for BPPV and bilateral vestibular paresis, but physical therapy treatment can be very useful in both. Central vertigo includes entities such as vertigo associated with migraine and certain strokes. Prophylactic agents (L-channel calcium channel antagonists, tricyclic antidepressants, beta-blockers) are the mainstay of treatment for migraine-associated vertigo. In individuals with stroke or other structural lesions of the brainstem or cerebellum, an eclectic approach incorporating trials of vestibular suppressants and physical therapy is recommended. Psychogenic vertigo occurs in association with disorders such as panic disorder, anxiety disorder and agoraphobia. Benzodiazepines are the most useful agents here. Undetermined and ill-defined causes of vertigo make up a large remainder of diagnoses. An empirical approach to these patients incorporating trials of medications of general utility, such as benzodiazepines, as well as trials of medication withdrawal when appropriate, physical therapy and psychiatric consultation is suggested.

A Pharmacist’s Guide to Meniere’s Disease

Vertigo can last hours at a time and poor balance may persist afterward. Hearing loss tends to be one-sided at first, may remit and recur, and some patients will develop progressive, severe, permanent hearing loss. Continuous low-pitched tinnitus often accompanies the hearing loss. A sensation of fullness in the ears develops shortly before, at the onset, or during episodes.²

At episode onset, patients may suffer from sudden “drop attacks,” which are periods of strong sensation of directional tilting causing patients to overcompensate and fall in the other direction.

Providers should counsel patients to avoid driving or pull over if an episode is impending.

Fluid build-up in the inner ear (endolymph) precipitates the disease episodes and contributes to progressive hearing loss. Increased semicircular canal pressure impacts balance and fluid build-up in the cochlea, causes hearing loss. Patients are often unaware of the initial cause of their disease. The most common causes include genetics, trauma, and viral illnesses (eg, common colds, measles, or mumps). Episodes may be clustered, predictable and periodic, or years apart.

Ménière ’s disease is likely related to migraines in many patients because both are often inherited and share triggers, and some Ménière ’s patients experience aura, photophobia, and headache during episodes.³ A sizable minority of providers call migraines with Ménière’s-like symptoms “migrainous vertigo.”

Episode Triggers and Prevention

Salty foods, caffeine, nicotine, and stress are the most common dietary and lifestyle triggers.⁴ Smoking cessation is particularly important in this population. Pharmacists should remind smokers with Ménière ’s disease that quitting will improve disease control. Low sodium hypertension-directed diets (eg, using DASH instead of salt) aid Ménière ’s disease control. Sodium consumption below 2000 mg per day will manage most patients’ symptoms, and a 1500 mg target is effective for almost everyone.² Alcohol, caffeine, and smoking reduction or cessation, as well as stress relief, are all healthful overall lifestyle interventions.

Oral Treatment

The most commonly used maintenance medications for Ménière’s disease are diuretics, such as Diamox Sequels (acetazolamide extended-release capsules) and Dyazide (triamterene/HCTZ).² These medications relieve the inner ear fluid build-up thereby reducing vertigo frequency and avoiding hearing loss progression. Acetazolamide (a carbonic anhydrase inhibitor) alkalinizes urine, encourages kidney stone formation, and increases ammonia reabsorption and hypokalemia risk.⁵ The usual counseling points of Dyazide for hypertension apply to its use in Ménière’s disease. Little evidence exists investigating similar regimens. The single double-blinded cross-over study supporting Dyazide found no impact on hearing loss, but patients expressed an unspecified preference over placebo.⁶ Loop diuretics are less favored because of their ototoxic effects.

Providers often recommend or prescribe meclizine (OTC Bonine and prescription Antivert) to control vertigo as needed. Dramamine is less effective, but patients may prefer it to Bonine. Bonine “motion sickness only” labeling and Antivert are FDA approved for vertigo. A patient may use 12.5 mg to 50 mg up to 3 times daily. The reasoning behind this labeling differences is from the possibility for serious causes of vertigo (eg, stroke or ototoxin consumption).⁷ Transient ischemic attacks can present as periodic dizziness and headache for months prior to a larger stroke. This presentation is difficult to differentiate from combined Ménière’s disease with migraine. Pharmacists should recommend provider consultation if a patient wants to use Bonine for vertigo without a prescriber’s approval.

Small doses of diazepam or lorazepam, promethazine (oral or rectal), and dexamethasone are used infrequently for treatment-resistant vertigo.^1,2 Benzodiazepines are most effective for patients triggered by stress. Promethazine treats vertigo-induced nausea. The rectal suppository formulation has lower bioavailability and slower absorption than the oral syrup, so prescribers should reserve it for patients unable to take medications orally.⁸ Oral dexamethasone can reduce inner ear swelling and provide symptomatic relief.

Injectable Treatment

Some patients without relief may elect for in-office injections of gentamicin or dexamethasone into the middle ear (then absorbed into the inner ear).⁹ Gentamicin, as an ototoxic aminoglycoside, deadens the vestibular system of the injected ear. Gentamicin eliminates vertigo in 70% of patients and causes permanent deafness in 30% of patients. Steroids, like dexamethasone, provide temporary relief via their anti-inflammatory effects without ototoxicity.²

Complementary and Alternative Medicines

Patients have tried tai chi, positive pressure, acupuncture, homeopathy, and herbals such as gingko biloba, niacin, or ginger root for symptom relief.¹⁰ Tai chi has promise for Ménière’s by reducing stress (a trigger shared with hypertension and migraines). A Cochrane Database systematic review of 5 randomized controlled trials found positive pressure devices (eg, the Meniett device) provide no vertigo relief and may worsen hearing loss.¹¹ English-language literature concerning acupuncture is scant, but one study of 34 patients found 1 to 3 sessions of acupuncture eliminated vertigo and arrested hearing loss.¹²

Homeopathic vertigoheel contains (gamma aminobutyric acid) GABAergic compounds and nicotine receptor inhibitors. Cocculus indicus and Conium maculatum, respectively, cause these effects. Salicylicum acidum, natrum salicylicum nux vomica, and chenopodium are 3 other studied homeopathic regimens with positive results. Commonly used herbal medicines used across the world include vinpocetine, valerian, ginger root, and Gingko biloba. Vinpocetine dilates cerebral blood vessels, valerian acts like a benzodiazepine, ginger reduces nausea, and Gingko biloba is anti-ischemic.¹² Gingko is the most studied of these herbals, but it increases bleeding risk, the optimal dose is uncertain, and efficacy is variable.

Conclusion

Most patients affected by Ménière’s disease are unaware that their vertigo, hearing loss, tinnitus, and sensation of ear fullness are a medical syndrome. Symptom control curbs disease-related disability development, and prompt control can delay or prevent hearing loss and physical falls. The goal of care is to reduce episode frequency and severity, hearing loss, and dizziness-related disability.

References

• Meniere’s disease. Medscape website. http://www.medscape.com/viewarticle/509085. Accessed November 20, 2016.

• Center for Hearing and Balance. Ménière’s disease. Mount Sinai Hospital. website. mountsinai.org/patient-care/service-areas/ent/areas-of-care/hearing-and-balance/vertigo-and-balance-disorders/menieres-disease. Accessed November 20, 2016.

• Ménière disease. MedlinePlus website. medlineplus.gov/ency/article/000702.htm. Updated August 13, 2015. Accessed November 20, 2016.

• Ménière’s diseases. Johns Hopkins Medicine website. hopkinsmedicine.org/neurology_neurosurgery/centers_clinics/vestibular/conditions/menieres_diseases.html. Accessed November 20, 2016.

• National Institutes of Health. Diamox Sequels- acetazolamide capsule, extended release. DailyMed website. dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=74e47451-2bc8-496e-88ad-c10002ee8e22 . Updated December 7, 2015. Accessed November 21, 2016.

• van Deelen GW, Huizing EH. Use of a diuretic (Dyazide) in the treatment of Ménière’s disease. A double-blind cross-over placebo-controlled study. ORL J Otorhinolaryngol Relat Spec. 1986;48(5):287-292.

• Mayo Clinic Staff. Ménière’s disease. Mayo Clinic website. mayoclinic.org/diseasesconditions/menieres-disease/basics/treatment/con-20028251. Updated November 26, 2016. Accessed November 20, 2016.

• Strenkoski-Nix LC, Ermer J, Decleene S, Cevallos W, Mayer PR. Pharmacokinetics of promethazine hydrochloride after administration of rectal suppositories and oral syrup to healthy subjects. Am J Health Syst Pharm. 2000;57(16):1499-1505.

• National Institutes of Health. Ménière’s Disease. National Institute of Deafness and Other Communication Disorders website. nidcd.nih.gov/health/menieres-disease. Published July 2010. Accessed November 20, 2016.

• van Sonsbeek S, Pullens B, van Benthem PP. Positive pressure therapy for Ménière’s disease or syndrome. Cochrane Database Syst Rev. 2015;10(3):CD008419. doi: 10.1002/14651858.CD008419.pub2.

• Steinberger A, Pansini M. The treatment of Meniere’s disease by acupuncture. Am J Chin Med. 1983;11(1-4):102-105.

• Papesch M. Complementary and alternative treatments for Ménière’s disease. ENT Care website. entcare.co.uk/treatments_in_menieres_disease.html. Published June 2005. Accessed November 20, 2016.

90,000 Discharge instructions after radiation therapy

Radiation therapy uses powerful X-rays to kill cancer cells so you can fight cancer. Radiation destroys cancer cells gradually over time. The goal of therapy is to target the maximum number of cancer cells and destroy them. Radiation can also damage or kill some normal cells close to the tumor. Damaged normal cells can heal on their own, usually within a few days.

Skin care

You can ask your doctor for advice on specific products for washing and bathing. In general, a mild, non-detergent soap and warm (not hot) water should be used when washing the exposed area of ​​the body. The area should be gently dried, not rubbed.

Your healthcare professional can suggest products to moisturize your skin and prevent infection. It is necessary to protect the skin, which may be sensitive due to treatment, from cracks and damage.

• Do not be surprised if over time the treatment causes skin reddening and sun-like burns. This can happen with some types of radiation therapy.

• Ask your healthcare professional for the best lotion to use. Also ask when and how to use them.

• Avoid prolonged or direct exposure to sunlight on the treated area. Check with your healthcare professional regarding the use of sunscreen.You shouldn’t completely avoid walking outside, but you need to take appropriate precautions.

• Do not remove ink marks until your doctor has instructed you to do so. Do not rub or apply soap to these marks while washing. Rinse these areas with water and pat dry.

• Protect skin from heat or cold. Do not take baths, do not go to the sauna, do not use heating pads or ice packs.

• Do not wear clothes that chafe the skin.

Fighting fatigue

Radiation therapy can make you feel tired. Your body is working hard to heal and recover. To improve your well-being, follow these guidelines:

• Do light exercise every day. Take short walks.

• Schedule activities when you usually feel most alert. Ask for help when needed.

• Relax before bed.This will improve your sleep. Try reading or listening to soothing music.

Overcoming problems with changes in appetite

To overcome such problems, do the following:

• Tell your healthcare provider that you have difficulty eating or that you have no appetite. You may be referred to a dietitian to help you plan your meals.

• Radiation to certain areas of the body may cause nausea.This can affect your appetite. Consider healthy eating as part of your treatment. Follow these guidelines:

  • Eat slowly.

  • Eat small meals several times a day.

  • Eat more food when you feel better.

  • Ask others to accompany you as you eat.

  • Stock up on foods that are easy to prepare.

  • Eat foods that are high in calories and high in protein.Your healthcare professional may recommend liquid nutritional supplements.

  • Drink plenty of water and other liquids.

  • Consult your healthcare professional before taking any vitamins or supplements without a prescription. These drugs are not regulated by the Food and Drug Administration (FDA) and can sometimes affect your treatment.

Overcoming other side effects

The following are ways to overcome other side effects:

• Be prepared for hair loss in the area being treated.Hair loss can be permanent. Be sure to discuss this with your healthcare professional.

• Sip cold water in small sips if you feel dry or painful in your mouth or throat. You can also dissolve ice chips.

• If you have diarrhea or constipation, tell your doctor. You may be prescribed a special diet.

• If you have difficulty swallowing liquids, tell your doctor.

Follow-up

Make an appointment as directed by your healthcare provider.

When to contact your healthcare professional

Call your healthcare professional immediately if you experience any of the following symptoms:

• Sudden headaches

• Problems with concentration

• Constant fatigue

Shortness of breath, wheezing or shortness of breath

• Persistent pain, especially if it is constantly felt in the same place

• New or unusual swelling and bumps or swelling

• Dizziness or lightheadedness

, bruising, or bleeding

• Temperature 38 ° C (100.4 ° F) or higher, or chills

• Nausea and vomiting

• Diarrhea that does not go away with time

• Skin destruction; severe pain due to skin irritation

LOSS OF CONSCIOUSNESS.REASONS AND HELP. |

Quite often, patients go to the doctor with complaints of transient loss of consciousness, and the definitions are very different: fainting, seizure, “blackout”, etc. These different definitions are due to the fact that sometimes this condition is difficult to describe, it is very often accompanied by fear and confusion. Fear can be caused by both loss of control over oneself and physical trauma, falling during an attack.

Transient loss of consciousness is a fairly diverse condition that includes fainting (syncope), epileptic seizures, a critical drop in blood glucose levels (hypoglycemia), and transient cerebrovascular accidents.Fainting is understood as a short-term loss of consciousness due to a global decrease in the blood supply to the brain, usually leading to a fall.

TYPES OF FALCES AND TREATMENT TACTICS

There are three groups of syncope depending on the mechanism of their development:

• neuro-reflex – in which loss of consciousness occurs in certain situations: with a prolonged stay in an upright position, with strong emotions (joy and fear), after urinating, after eating, after exertion, while shaving and others;
• cardiac – the cause of loss of consciousness is a pathology of the heart: arrhythmias, defects, ischemic disease, damage to the heart muscle;
• Orthostatic – in which the regulation of maintaining the tone of the arteries is impaired, which leads to a decrease in blood pressure in an upright position.

Depending on the type of fainting state, its effect on the quality and duration of life changes, treatment tactics:

• neuro-reflex syncope is not (as a rule) life-threatening, but can significantly reduce its quality and cause injuries due to a fall;
• cardiac (cardiac) can be harbingers of life-threatening conditions and sudden death from a heart attack;
• Orthostatic increase the risk of serious cardiovascular disease and significantly impair quality of life.

It is worth noting that it is the decrease in blood pressure in an upright position that often causes dizziness and a decrease in exercise tolerance.

EXAMINATION AND DIAGNOSTICS OF CONDITION

In order to help a patient with transient short-term loss of consciousness, it is necessary to find out whether it is fainting or another condition (epilepsy, transient cerebrovascular accident, or other reason), and then prescribe reasonable treatment.

Examination of the patient begins with a thorough questioning and clarification of the nature of the episode, the circumstances and time of its development, the harbingers of the attack and the state after it. The survey is followed by a medical examination, which necessarily includes the measurement of blood pressure and heart rate in a horizontal and vertical position. Follow-up examination is aimed at identifying or excluding heart disease as the cause of fainting. It is likely that after the first examination of the patient, the diagnosis will become clear, and other studies will confirm it. In young people, dysfunction of the autonomic nervous system is the dominant cause of syncope, which is not life threatening. In patients of older age groups, frequent causes are heart disease, these patients are at risk and require special attention. In the absence of heart disease, special tests can be carried out aimed at provoking fainting and elucidating the specific mechanism of their development, which makes it possible to develop tactics for further treatment.Unfortunately, patients suffering from fainting are often deprived of adequate medical attention. This is due to the low awareness of doctors about the required examination algorithm and a lack of understanding of the role of the general practitioner, therapist and cardiologist in the treatment of these patients.

Syncope specialists say that three conditions are necessary for successful treatment: the right doctor, the right place, and the right time.

FEATURES OF TREATMENT AND METHODS OF PREVENTION

Treatment begins with explaining to the patient the nature of his illness and teaching him how to prevent the development of fainting and prevent their development (if possible)

The most common variant of fainting is the so-called “simple” , which develops during prolonged stay in an upright position (standing), in stuffy and cramped rooms, or is provoked by emotional stress.Predisposing points to its development are hot weather, insufficient fluid intake, alcohol consumption, overwork, and taking medications that lower blood pressure. Most often, such fainting develops in the summer, the primary places of occurrence are the metro and other types of transport, or queues. Thus, the methods of their prevention are:

• sufficient water regime (plentiful drink)
• Refusal of alcohol during the hot season
• Correction of drug treatment of hypertension (this is the task of your attending physician)
• avoidance of long passive in an upright position – even if you need to wait for a long time in one place, movement is necessary – walking in place (shifting from foot to foot), alternating leg muscles tension

In the event of an approach of fainting (when its precursors appear – a feeling of heat or cold, dizziness, “shroud”, “fog”, “stars” before the eyes, etc.)it is necessary to lie down or sit down quickly, this can prevent the development of unconsciousness and reduce the likelihood of developing an injury associated with a fall.

If it is impossible to take a horizontal position, you can try to cross your arms and legs with simultaneous muscle tension.

In any case, you need to see a doctor who, during a personal conversation, will assess your condition, plan an examination and teach you how to prevent fainting.

90,000 Infectionist: reception, examination and consultation on viral infections with a leading doctor in Moscow

An infectious disease specialist treats specific infectious or parasitic diseases, as well as conditions that are prolonged with acute fever or do not respond to therapy.Leads patients with chronic viral diseases, various forms of immunodeficiency.

Reception of an infectious disease specialist

An infectious disease specialist advises doctors of other specialties (general practitioners and pediatricians) in cases where it is difficult to identify the cause of the infection. Participates in the development of vaccination and drug prevention schemes, if a person needs to travel to epidemiologically unfavorable countries, diagnoses and treats travelers’ infections.

Diseases

• ORVI
• sore throat
• influenza and parainfluenza
• pneumonia due to bacteria, viruses, fungi and other agents
• viral gastroenteritis
• shigellosis
• Yersiniosis
• viral and bacterial meningitis
• measles and rubella
• chickenpox (chickenpox)
• mumps (mumps)
• scarlet fever
• infectious mononucleosis
• diphtheria
• tuberculosis
• botulism
• tropical diseases (malaria, dengue, sleeping sickness, yellow fever)
• infections of bones, joints, soft tissues
• urinary tract infections
• Lyme disease and other tick bite infections
• leptospirosis
• giardiasis
• toxoplasmosis
• helminthiasis
• viral hepatitis
• sexually transmitted infections (STIs): urogenital chlamydia, syphilis, gonorrhea
• HIV / AIDS
• heart valve infection
• methicillin-resistant Staphylococcus aureus (MRSA infection)
• postoperative infections
• rheumatic fever
• Hemorrhagic fever with renal syndrome (HFRS)
• travelers’ diarrhea (and other infections associated with visiting other countries)
• rare infectious diseases

Symptoms

• unexplained prolonged acute fever
• Severe headache (accompanying fever)
• dizziness
• Stiffness (increased tone) of the occipital muscles
• shortness of breath
• disorders of brain activity (paresis, hallucinations)
• diarrhea
• nausea, vomiting
• skin rash
• joint swelling / edema
• muscle and joint pain
• cough and runny nose (longer than one week)
• tickling and sore throat
• increased fatigue, weakness, apathy
• sudden visual impairment
• cardiac dysfunction (arrhythmia, chest pain, edema, cyanosis of the face and limbs)
• decrease in blood pressure
• yellowness of the skin
• enlarged lymph nodes

It is worth contacting an infectious disease specialist if you are going to visit an epidemiologically unfavorable country and want to find out what specific vaccinations are needed and get them.If you return from a trip, you feel bad for a long time, and the “cold” or “poisoning” does not go away. If there is an unexplained prolonged fever, diarrhea, vomiting, and a rash have joined it. If you feel unwell and associate it with an insect bite (mosquito, tick) or animal. If you feel unwell and associate it with the use of contaminated water or poorly (improperly) processed foods. If the therapist suspects an infectious or parasitic disease and recommends the consultation of a narrow specialist for an accurate diagnosis and correct treatment.If you are taking steroids or other immunosuppressive drugs (due to a chronic illness or transplant). If you have HIV or AIDS. If you have cancer or other disorders that affect the functioning of the immune system. If there is a need for health control after treatment of the infection; prevention of cancer and other diseases. If there was unprotected sexual contact.

Reception of an infectious disease specialist at the Rassvet clinic consists of several stages:

Consultation with an infectious disease specialist

At the consultation, the doctor will ask you to tell about the general state of health, chronic diseases and the treatment that was prescribed, to list alarming symptoms.

It will be necessary to list the vaccinations that you have received, or better yet, prepare a list in advance or bring a medical record with you.

The infectious disease specialist will also ask you to remember which countries you have recently visited, in what circumstances you might have been infected.

If you came for a consultation before traveling to an epidemiologically unfavorable area or country, the doctor will suggest an individual vaccination schedule and, if necessary, prescribe additional examinations.

If consultation is needed due to a chronic viral disease, you will also receive help and a further route for diagnosis and treatment.

Diagnosis of infectious diseases

The main purpose of diagnostics in an infectious disease is to identify the causative agent of the infection.

Usually, an infectious disease specialist prescribes general blood tests (biochemical, serological) and urine tests; microbiological and microscopic analysis of smears, scrapings, sputum, vomit; coprogram; analysis of cerebrospinal fluid; tests for viral load, drug resistance and others.

To clarify the diagnosis, medical imaging may be required: ultrasound, X-ray examination, MRI, CT, scintigraphy, endoscopic examination, colposcopy.

Treatment by an infectious disease specialist

Treatment of infections involves the use of antimicrobial, antiviral, antifungal and antiparasitic drugs. The type of medication depends on the type of infection and the pathogen.

Important: Antibiotics are not used to treat viral infections.

Antiretroviral therapy (for HIV infection) may be prescribed.

What will you get from an infectious disease specialist at the Rassvet clinic?

The Infectionists of Dawn believe that it is better to prevent disease, not cure. Therefore, the clinic pays great attention to the prevention of infections based on timely vaccination.

Together with therapists and pediatricians, the infectious disease specialists of Rassvet will develop an individual vaccination plan for you, tell you in detail about all the necessary preventive vaccinations, as well as vaccinations that will protect you when traveling to other countries.

In Rassvet, they provide assistance both for infectious diseases common in our country and for rare, tropical diseases.

We do not prescribe immunostimulants and immunomodulators, as well as methods of alternative medicine, since their effectiveness has not been proven.

90,000 best PCs for VR gaming – processors, …

Larger games and more stringent hardware requirements

As hardware advances, VR games become more ambitious.

In general purpose helmets, the supported games are limited by the capabilities of the onboard hardware. Depending on the capabilities of the helmet, this can be casual games ( Angry Birds VR: Isle of Pigs ) or games that require certain skills ( Superhot VR, Beat Saber ).

Because built-in tracking helmets use PC hardware, they allow for more ambitious games. Games like Insomniac Games’ Stormland * and Lo-Fi * , the spiritual forerunner of the 2020 VR blockbuster Technolust * , have large open worlds, and games like Lone Echo 2 * from Ready at Dawn, also scheduled for release in 2020, features larger and more complex environments than the original.

With the increasing complexity of games, their system requirements also grow. Half-Life: Alyx * has higher minimum system requirements than previous VR games.

• Processor: 7th Generation Intel® Core ™ i5-7500 processor
• RAM: 12 GB
• GPU: GTX 1060 / RX 580

Let’s compare these numbers with the VR game The Lab * from Valve, released in 2016.

• Processor: 4th Generation Intel® Core ™ i5-4590 processor
• RAM: 4 GB
• GPU: GTX 970 / R9 290

Other VR games are not far behind these, and yet have higher storage, memory and processor requirements.The fantasy VR game Asgard’s Wrath * requires 121 GB of free disk space to install as the game uses detailed textures. Meanwhile, DiRT Rally 2.0 * game takes up 91.63 GB of free disk space. While 4-8GB of RAM and a mid-range processor may be sufficient for many games, games in development will require a lot more resources. For example, The Walking Dead: Saints & Sinners * requires 16GB of RAM and an Intel® Core ™ i7-8700K processor.

The reason for this growing demand is the dramatic improvement in graphics quality in the latest games. As new AAA developers enter the BP market, this trend will only continue. The demands of big budget games are always higher than those of small independent studios, which now account for the majority of VR games. Better graphics and stable frame rates often require more powerful hardware.

What’s more, playing the latest games with a premium headset requires an even more powerful PC.How do you know what to choose?

FORM OF ISSUE AND COMPOSITION: – Stamina-RX Maximum Sexual Stimulant, 30tabs Hexagonal tablets in a blue enamel dissolving shell with a noticeable Rx marking in

– Stamina-RX Maximum Sexual Stimulant, 30tabs
Hexagonal tablets in a blue enamel dissolving shell with a noticeable Rx marking in a transparent bottle, closed with a hermetic protector and a lid on top with an additional celluloid protection against opening, in a pack of 30 tablets, the label contains information about the date of end use, lot number, factory data, list and number of ingredients, dosage recommendations and warnings.

Epimedium Extract (Leaves), Xanthoparmelia Scabrosa, Cnidium Monnier, Yohimbe Extract (Bark) (8 mg Yohimbe Alkoloids), Cnidium Extract (Fruit), Xanthoparmelia Scarbosa Extract (Lichen), Gamma Amino Butyric Acid, L-Argin
Auxiliary Ingredients:
microcrystalline cellulose, dextrose, starch, stearic acid, hydroxy propyl methylcellulose, magnesium stearate, silica, titanium dioxide, triacetin, fdc blue # 1 aluminum lake;
Date of use before: 09/09

For best results, take 1 maximum of 2 tablets without chewing with a volume of liquid 1 hour before sex.The maximum dose is 2 capsules per day. The effect will last up to 12 hours, while you will experience incredible sensations. “Wow !!!!!!!” – you say. Many people celebrate the action the next day. It goes well with fizzy low-alcohol drinks. Use as needed. With regular use – once every three days, it increases potency, provides a quick erection, allows you to get rid of the feeling of possible failure, restores strength, makes sex of high quality, satisfying the most demanding partner.For women, the same general recommendations are not to exceed 1 capsule per day. It is not recommended to use this drug in a dose exceeding the indicated one, or for a long period of time – more than 3 months without an interruption of 6-8 weeks.

The drug should not be used for severe diseases of the liver, kidneys and thyroid gland, the presence of various ulcers of the gastrointestinal tract, gastritis, glaucoma, during treatment with adrenergic agonists, with arterial hypertension (high blood pressure), severe atherosclerosis, cardiac disorders, mental disorders , symptoms of anxiety, depression.You should not take this medicine if you are using antidepressants, tranquilizers, or medicines to lower high blood pressure.
You can not take the drug to persons who have previously suffered from attacks of psychosis.
If you have any cardiovascular disease, it is recommended that you consult your doctor before taking this drug.
This medicine is intended for use in adults only. The drug is not intended for the elderly and children. Keep it out of the reach of children.If dizziness, insomnia, headaches and heart palpitations appear, stop taking the drug. Overdose of the drug is not recommended.

Pregnancy and breastfeeding
Women who are pregnant or breastfeeding should not take a product containing Yohimbe, as the full effect of the drug in these cases has not been studied.

Overdose
In case of an overdose, nervousness, migraine, tachycardia, abdominal pain, diarrhea, vomiting, dizziness and orthostatic hypotension are possible.Storage conditions
Store in a cool, dark place, protected from moisture.
Keep out of the reach of children.

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Resume Medical representative, Kerch, by agreement

Daily visits to hospitals and pharmacies.
Target audience: therapists, gynecologists, dermatovenerologists, dentists,
traumatologists, urologists, surgeons, ENT doctors.
Direction: OTS and Rx.
Drugs with which she worked: antibiotics (levofloxacin, azithromycin, ofloxacin + ornidazole, gatifloxacin) antifungal (fluconazole, ketoconazole, itraconazole), antihistamines (levociterizin),
NSAIDs (diclofenac + paracetamol, aceclofenac, nimesulide, lornoxicam), antiepileptic drugs
(carbamazepine (regular and prolonged), oxcarbamazepine), drug for
systemic enzyme therapy (serratiopeptidase),
a drug for the treatment of osteoporosis (sodium alendronate),
PPI (pantoprazole), a drug used to treat vertigo
(prochlorperazine), drugs that lower the level
serum cholesterol and triglycerides
(atorvastatin)
During my work, Ziomycin (azithromycin) has become the third most prescribed drug in this line!
During my work, on my territory, the drug Tigeron (levofloxacin) has become the number 1 drug prescribed by doctors in its lineup !!!
From the very beginning of my work at Kusum, the fulfillment of the sales plan in the territory entrusted to me was – 105%!
Based on the results of the annual fulfillment of the plan, I received a bonus trip to Italy!
Based on the results of the annual fulfillment of the sales plan in my territory, I received a company car!
My job responsibilities:
Visits to doctors in order to promote the company’s drugs (demand generation), work with doctors’ objections, informing doctors about the availability of drugs in pharmacies, about affordable (in comparison with competitors) prices for our company’s drugs, about the quality of drugs produced by our company.I have established friendly, trusting relationships with almost every doctor from my client base (220 people). Starting to work in a new company, I do not have to spend time establishing contact with doctors. I have maintained a benevolent and supportive attitude of the doctors towards me until the end of my work at Kusum. From the very beginning of my new career in a new company, I can most effectively promote the company’s drugs using the established connections!
Pharmacy visits:
Work with the chiefs and the head.pharmacy (supply formation)
Established friendly and trusting relationships
with the chiefs and heads of pharmacies. (52 pharmacies) I am recognized in every pharmacy in the former territory of my account! And they don’t just recognize, they are glad to see me! They always find time for me! I can always agree to order what I need and how much I need!
Regular and unimpeded conducting of thematic conversations with the leaders on the drugs of our company
(to whom and when to recommend, the advantages of our products and the disadvantages of competitors)

.