The Medical Consumer's Advocate

Dizziness

Douglas Hoffman, M.D., Ph.D., February 1999

 

Synonyms: Vertigo, dizzy, lightheaded, unsteady, imbalance, vestibular dysfunction

More info on dizziness: the Q&A page.

 

Contents

Understanding the symptom of dizziness.

Do I need a doctor?

Conservative measures for new onset dizziness.

What your doctor needs to know.

What to expect from your doctor.

But what should your doctor do for you?

The differential diagnosis of dizziness.

Disclaimer: This information is meant to improve the interaction between you and your doctor. It is NOT meant to replace this interaction! There is no substitute for a history and physical examination administered by a competent physician. If you inappropriately use this information to treat yourself, you may be endangering your health.

 

Understanding the symptom.

The word "dizzy" means different things to different people. The sensation of spinning is referred to as "vertigo." This is primarily a visual symptom (the room actually appears to turn or jump repeatedly), but it is often accompanied by nausea and vomiting. It is a distressing symptom which often causes the person to lie down and close his eyes. When prolonged, it is an extremely disabling condition, since walking is difficult or impossible.

"Unsteadiness" and "imbalance" refer to a (usually) milder symptom in which the affected individual feels that he is about to fall. He can walk, but may feel the need to support himself in some way. He may also feel that he is veering in one particular direction when he walks.

"Lightheadedness" is an even less specific symptom. A lightheaded person simply feels that his head is "not right." Some people describe this as a drunken sensation. This symptom is usually not disabling, but it can still be very distressing.

In each case, what is disordered is the person's sense of how his head (and/or body) is positioned or moving. In order to understand dizziness, it is useful to first understand how we usually sense the position and motion of the head and body. One of my teachers, James Sheehy, M.D., told me that he usually explains this to his patients in the following way. Dr. Sheehy tells his patients that the brain is a computer which gathers information from a variety of sources. The brain uses this information to arrive at a sense of where the head and body are in space, and how the head and body are moving through space. The inner ear balance organs (the vestibular system), the eyes, and the muscles, joints and tendons of our neck, back and legs are the sources of this information. If for any reason one of these organs starts sending bad data to the brain, the brain may have difficulty reconciling the bad data with the good data. When this confusion is severe, the individual senses it as dizziness.

Continuing with this analogy, the treatment of dizziness can also be understood in very simple terms. If the disordered organ recovers from whatever is afflicting it, the brain will once again receive only good data, and the dizziness will soon resolve. If the disordered organ continues to send bad data, the brain must learn to ignore this data. The only way that the brain can accomplish this is to receive a great deal of "practice" distinguishing good data from bad. This explains why various forms of physical therapy (Cawthorne exercises and vestibular rehabilitation, both of which are discussed below) can be very effective in treating dizziness. If the disordered organ malfunctions intermittently, the brain may have a great deal of difficulty learning to ignore the bad data, and so physical therapy may be ineffective. (One example of this is Meniere's disease, in which the inner ear intermittently is afflicted.)

 

Do I need a doctor?

Dizziness which occurs often enough to cause you any degree of distress should be reported to your doctor.

You may be having repeated bouts of brief dizziness (lasting only for a few seconds) or sustained bouts of mild dizziness; in either case, this may be a sign of more severe illness. As such, even though the symptom is mild, consultation with your physician is advisable.

In some obvious cases, dizziness does not require a doctor's consultation. Dizziness following the use of a new medication is not uncommon. If you continue to experience dizziness every time you take the medication, you will need to report this to your doctor, but dizziness associated only with the first or second dose is almost always a benign problem. Certain antibiotics, tranquilizers, blood pressure medications, heart medications, and anti-seizure medications can often cause dizziness. Although herbal preparations may be "natural," some are very potent medications which can cause a variety of side effects, including dizziness.

Dizziness associated with recreational drug use (especially alcohol and barbiturates) also has an obvious explanation, and as such, does not require a doctor's opinion.

Dizziness that is clearly associated with a change in eyeglass prescription should only require a trip to the optometrist.

Dizziness following an accident (whiplash is a common example) may have an obvious origin, but will still benefit from a doctor's consultation, as physical therapy may help speed recovery.

Wondering how to use this information?

Refer to Symptom Guide Help for a bit of advice.

Danger Signs

In some cases, dizziness requires more urgent consultation with a physician. If any of the following symptoms are also present, you should see a doctor as soon as possible.

 

Conservative measures for new onset dizziness

First, read Do I need a doctor? to determine whether it is a good idea for you to attempt to treat yourself. Pay particular attention to the Danger Signs.

The only situation in which it is safe to self-treat dizziness is when the cause is obvious and avoidable. Motion sickness is an obvious example. People who suffer from motion sickness usually learn that they can avoid motion sickness by avoiding the precipitating cause (e.g., reading while in a car) or by premedicating (with drugs such as Antivert, Dramamine, or scopolamine patches).

New onset dizziness related to a new medication: in most cases, you should consult with your doctor before discontinuing the medication. If it is an over the counter medication (a cold remedy, for example) which you have taken without a doctor's recommendation, you can certainly stop the medication without speaking with your doctor.

 

What your doctor needs to know.

The questions below are specific to your dizziness. Your doctor will also need to know your general medical history. This includes: any problems for which you are under a doctor's care; problems for which you take medications; a list of all of your
medications, including over the counter drugs, vitamins and herbal remedies; a list of the operations you have had; whether you are allergic to any medications; whether you drink alcohol, smoke tobacco, or use other drugs; whether there are any illnesses that run in your family.

 

Dizziness is often episodic. In other words, the patient experiences bouts (or "spells") of dizziness and is relatively well between bouts. Often, the circumstances and symptoms of the very first bout can be revealing. These details can be very helpful in enabling your doctor to establish a diagnosis. You should try to describe this first bout to your physician in as much detail as possible. The following are particularly important details:

At present, what precipitates a bout of dizziness? Common precipitating factors are: certain head movements, rolling over in bed, getting up out of bed quickly, certain eye movements. Other possible factors are: medications, particular foods, particular activities, and recreational drug use.

If the dizziness is constant and not episodic, are there any things which make the sensation better or worse?

As discussed in the box above, it is essential that you provide your doctor with a list of the medications that you are currently taking. Be sure to include herbal remedies and over the counter medications. Pay particular attention to timing with respect to the onset of your symptoms: did you start a new medication, or change the dosage on a medication, before your symptoms started?

Be prepared to review with your doctor the current status of your other medical problems. Particularly relevant are disorders such as heart disease, migraine, hypothyroidism (low thyroid), diabetes, anemia, and emotional conditions such as anxiety or panic attacks. If you have a history of ear surgery, severe ear infections, or chronic ear infections, you should inform your doctor of this.

Think carefully whether any other odd symptoms accompany your dizziness. Although such symptoms may not seem related to your dizziness, they could provide important clues as to the nature of your problem.

 

What to expect from your doctor.

Although there are a number of sophisticated tests available for the diagnosis of dizziness, it is safe to say that a careful history (as described in the preceding section) will enable a doctor to diagnose most patients.

A careful physical examination may confirm the physician's suspicions based on the history. Your doctor should examine your ears and eyes with particular care. A neurological examination, as well as examination of other relevant body systems (such as the cardiovascular system), is often necessary.

Further testing may be necessary to establish particular diagnoses. Hearing tests, balance system tests (such as electronystagmography or posturography), special radiological tests (such as CT or MRI), and blood tests are all required on occasion.

It is very difficult to list all of the situations in which referral to a specialist (an ENT) is indicated. In general, patients with dizziness that is disabling or longstanding should be referred to an ENT (see comments in next section.)

 

But what should your doctor do for you?

If any danger signs are present, your doctor should refer you to an ear, nose, and throat specialist at once. Your doctor should also refer you to an ENT if he is uncertain as to your diagnosis or is uncomfortable treating your problem.

Your doctor should inform you of your diagnosis, or give you a list of likely diagnoses. He should clearly indicate how you will be treated, and what he will do if you do not respond to treatment or if your dizziness worsens.

In some cases, other studies may be necessary before your doctor can determine your diagnosis. These studies may include an MRI, CT ("CAT scan"), special tests of the balance system, or blood tests.

Your doctor should be persistent. He should investigate your problem until a diagnosis has been determined and treatment has proven effective.

Drug treatment for dizziness is appropriate for sudden, severe vertigo that is disabling. These drugs (such as Valium or meclizine) are balance system sedatives, and as such, they slow the recovery process (see comments above regarding the treatment of dizziness). They should be stopped as soon as the dizziness has become less disabling.

Patients with sudden, severe vertigo should be referred to an ENT as soon as possible, since certain diagnoses (such as vertigo caused by worsening of a chronic ear infection) require prompt surgical treatment. Longstanding dizziness (symptoms persist, without improvement, for more than one month) is often best treated with physical therapy (see Boxes, below). Once again, an ENT should be consulted in cases of chronic dizziness so that the correct diagnosis can be determined, and the most appropriate treatment initiated.

Cawthorne exercises

You suffer from dizziness, unsteadiness or vertigo. Physical therapy can greatly diminish these symptoms. Cawthorne exercises are a form of physical therapy that has been used successfully for many decades to help patients with your problem. These exercises may provoke an attack of dizziness; if this happens, try to continue the exercises despite the dizziness.

Do one set of exercises in the morning and one set in the evening. Begin at 5 minutes per set, and gradually (over several days) extend this time to 10 minutes. You can extend this time by increasing the number of repetitions.

The exercises are done as follows:

1. Sit in an arm chair. Hold your upper body and head still and move only your eyes. Look up, then down, and repeat this 10 times. Look left, then right, and repeat this 10 times.

2. Now you may move your head. Look up, then down, and repeat this 10 times. Rotate your head to the left, then right, and repeat this 10 times.

3. Remain seated, and bend forward from the waist and then back. Repeat this 10 times. Bend to the left from the waist and then to the right. Repeat this 10 times.

This completes one set.

Vestibular rehabilitation

Like Cawthorne exercises, vestibular rehabilitation programs help speed recovery by improving adaptation, the process whereby the brain learns to adapt to disordered sensory data. Vestibular rehabilitation employs specific exercises that are performed under the guidance of a trained therapist (usually a physical or occupational therapist.) For example, the therapist may ask the patient to walk across a foam pad, or walk while moving the head from side to side. A variety of exercises have been designed to improve both the static and dynamic aspects of balance. (Here, static refers to the ability to maintain appropriate posture at rest, while dynamic refers to the ability to maintain appropriate posture while in motion.)

Interestingly, training within a variety of Eastern disciplines (particularly T'ai Chi and Aikido) can also be a very effective form of vestibular rehabilitation. Some patients may prefer this to working with a rehabilitation therapist.

 

The differential diagnosis of dizziness.

The list which follows is intended to stimulate discussion between you and your physician, particularly if your dizziness has proven difficult to diagnose and treat. Hypochondriacs should skip this section.

On a more cynical note, readers whose health care is administered through a managed care program may have encountered difficulty obtaining referrals to specialists. Sometimes, an informed patient can obtain a referral by gently informing their physician that he is not really capable of determining the diagnosis. The differential diagnosis which follows may provide you with the necessary ammunition. (For example, "But doctor, how do you know that this isn't a brain tumor?" may be a very effective prod.)

While not complete, this list will serve to illustrate the great variety of illnesses that can cause dizziness.