Dizziness is a common problem affecting the general population, and accounts for about 5% of primary care visits. The term dizziness is vague, so the first question that a doctor should ask their patient is "What do you mean by you feel dizzy?" Then, the doctor should ask the follow up question , "Do you feel a spinning sensation , or do you feel off balance, or do you feel like you are going to faint?"
If the patient feels off balance, then their dizziness can be categorized as disequilibrium. The first item to check in this condition is to look for medications that could cause this problem when taking a patient history - this includes cardiac medications such as alpha blockers, beta blockers, diuretics, nitrates, incontinence medications and medications for sexual dysfunction, such as Viagra. If a medication is the cause, the medication should be reduced in dose, and changed , if possible. However, if medication has been ruled out, then the "off-balance" patient should be evaluated for gait and subjected to the Romberg test. These tests help to identify, if a patient is suffering from a peripheral neuropathy or neurological disorder such as Parkinson's disease. A peripheral neuropathy sometimes is easy to treat - for example, a deficiency of Vitamin B12, is responsible for one of the peripheral neuropathies, and is easily treated with monthly Vitamin B12 shots. This may be an easy way to catch a diagnosis such as Parkinson's disease early on, thereby improving the quality of life that the patient will have.
A second way a patient may categorize dizziness is a feeling of faintness, that they feel as if they will "pass out." This form of dizziness is categorized as presyncope. The underlying cause of this is usually cardiac in nature. First, the doctor must check the patient's medication list, for cardiovascular medications that could cause this condition. Once the physician has identified potential medications that could be responsible, the physician should check the patient's blood pressure, first sitting and then standing. If the patient's systolic BP drops by 20, and their diastolic BP drops by 10, then the patient has orthostatic hypotension. Orthostatic hypotension can be treated by reducing the dose patient's Blood pressure medications, and encouraging the patient to increase their fluid intake. However, if the patient does not have medications that could cause this condition, and is not exhibiting orthostatic hypotension, the physician needs to ask about the patient's history of irregular heart rhythms and heart attacks, Any positive history for either arrthymias or heart attacks, should prompt the physician to refer the patient for further cardiac testing, such as wearing a holter monitor for 24 hours to check for irregular rhythms.
A third way that a patient may categorize dizziness is a sensation of spinning. First, the physician needs to ask the patient about a history of migraines. If the patient is experiencing the spinning sensation at the same time they are experiencing the symptoms of a migraine, (such as sensitivity to light or sound, nausea, vomiting), then the diagnosis is vestibular migraine, and the patient can be treated with the same medications they use to treat migraine headache, such as sumatriptan.
If however, the spinning sensation is not associated with a migraine headache, then the physician needs to ask the patient whether they experience hearing loss at the same time as the spinning sensation. If the answer is yes, and the episodes of spinning occur periodically , the diagnosis is Meniere's disease. , which is increased fluid in the inner ear. The treatment for Meniere's disease is dietary salt restriction to less than one gram of salt a day, and diuretics such as hydrochlorothiazide. If the spinning sensation occurs all the time and is associated with hearing loss and nausea, then the diagnosis is labyrinthitis , which is an inflammation of the balance organs in the inner ear. It is usually caused by a virus. The patient will usually report that when they wake up and the room is spinning, and they move their head, their dizziness gets worse, and does not go away for at least 2 hours. Labrinythitis is treated with a vestibular suppressant medication such as Meclizine, and an antinausea medication such as Zofran.
If there is no hearing loss, and the spinning sensation happens periodically, the likely diagnosis is BPPV, or benign paroxysmal positional vertigo. BPPV is a condition where the crystals in the semicircular canals of the inner ear shift, causing a feeling of imbalance or spinning. The treatment for BPPV is the Dix-Hallpike manuveur, which can be done by physical therapy where the therapist takes the patient through a specific manuveur designed to turn the head in such a manner as to realign the crystals in the inner ear. Lastly if the spinning sensation is continuous , and there is no hearing loss, and nausea is present, the cause is due to vestibular neuritis, which is inflammation of the vestibular nerve . Again, the patient will state that moving their head makes their dizziness worse. The treatment for vestibular neuritis is similar to that of labrinythitis, with Meclizine for the spinning sensation and an antinausea medication such as Zofran. The vestibular nerve and labrinyth are different parts of the same system, which explains the similarity in presentation.
If the patient describes a vague lightheaded sensation that is periodic, and all other causes have been ruled out, assess the for anxiety or depression. Also get them to hyperventilate in a controlled environment such as the office, and see if that reproduces the symptoms. Often an anxious, hyperventilating patient can feel lightheaded as if they will pass out. Often, training such a patient in breathing exercises or short term use of a benzodiazepine can help to treat this condition.
If the spinning sensation is continuous, and all other causes have been ruled out, a CT scan should be done to rule out a central cause such as a brain tumor, especially if the spinning sensation is associated with nausea. A CT scan can also identify a stroke, as sometimes a stroke may just present as dizziness without any focal symptoms such as weakness. The patient's history of risk factors for stroke such as HTN and diabetes, and high cholesterol may also be weighting factors in considering whether to order a CT.
Dizziness can occur due to a variety of conditions, some of which can be severely disabling or life threatening if they are not caught early. My advice as a family practitioner is, it's better to be safe than sorry, so the next time you feel dizzy , go to the doctor and get it checked out!
Eshani Karu, MD