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Saturday, August 23, 2025

Dizziness


Introduction

Dizziness is a broad term used by patients to describe abnormal sensations of balance and spatial orientation. It is not a disease itself, but a symptom of diverse conditions ranging from benign to life-threatening.

The main categories of dizziness are:

  1. Vertigo: Illusion of movement or spinning, usually inner ear or vestibular nerve.

  2. Presyncope: Feeling of near-fainting, often cardiovascular.

  3. Disequilibrium: Sense of imbalance, often neurological or musculoskeletal.

  4. Non-specific lightheadedness: Often due to anxiety, medications, or metabolic disorders.

Physiology of Balance

Balance depends on integrated input from:

  • Vestibular system (inner ear): Detects head motion and position.

  • Vision.

  • Proprioception: Sensory input from muscles and joints.

  • CNS integration (brainstem, cerebellum, cortex).

Disruption in any system may lead to dizziness.

Causes of Dizziness

1. Vestibular (Peripheral) Causes

  • Benign paroxysmal positional vertigo (BPPV): Otolith crystals in semicircular canals, brief vertigo with head movement.

  • Ménière’s disease: Triad of vertigo, hearing loss, tinnitus.

  • Vestibular neuritis/labyrinthitis: Acute, prolonged vertigo ± hearing loss (labyrinthitis).

  • Acoustic neuroma (vestibular schwannoma).

  • Ototoxic drugs: Aminoglycosides (gentamicin), loop diuretics.

2. Neurological (Central) Causes

  • Stroke/TIA (especially posterior circulation).

  • Multiple sclerosis.

  • Cerebellar tumors.

  • Migrainous vertigo (vestibular migraine).

3. Cardiovascular Causes

  • Arrhythmias (atrial fibrillation, bradycardia, ventricular tachycardia).

  • Postural (orthostatic) hypotension.

  • Heart failure, valvular disease.

  • Carotid sinus hypersensitivity.

4. Systemic and Metabolic Causes

  • Hypoglycemia.

  • Anemia.

  • Dehydration.

  • Thyroid disease.

  • Electrolyte imbalance.

5. Psychiatric Causes

  • Anxiety disorders, panic attacks.

  • Hyperventilation syndrome.

6. Medication-Induced

  • Antihypertensives, diuretics.

  • Sedatives (benzodiazepines).

  • Antidepressants.

  • Antiepileptics.

Clinical Presentation

  • Vertigo: Spinning, nausea, vomiting, worsened by movement.

  • Presyncope: Lightheadedness, dimming of vision, weakness.

  • Disequilibrium: Difficulty walking, leaning to one side.

  • Nonspecific: Floating, detachment, anxiety.

Associated features:

  • Hearing loss, tinnitus (inner ear).

  • Diplopia, dysarthria, weakness (central neurological).

  • Palpitations, chest pain (cardiac).

  • Tremor, fatigue, endocrine features (systemic).

Diagnostic Approach

1. History

  • Clarify type of dizziness (spinning, fainting, imbalance).

  • Onset (sudden vs gradual), duration (seconds, minutes, hours, days).

  • Triggers: positional changes, exertion, stress.

  • Associated symptoms: hearing loss, headache, visual changes, neurological deficits.

  • Medications and comorbidities.

2. Examination

  • Vital signs (orthostatic BP, pulse).

  • Neurological exam: cranial nerves, coordination, gait.

  • ENT exam: nystagmus, hearing tests.

  • Cardiovascular exam: murmurs, arrhythmias, carotid sinus sensitivity.

3. Investigations

  • Bedside tests: Dix–Hallpike maneuver for BPPV; head impulse test for vestibular neuritis.

  • Audiometry: For Ménière’s, acoustic neuroma.

  • ECG/Holter monitor: For arrhythmias.

  • Blood tests: CBC, glucose, electrolytes, thyroid function.

  • Imaging: MRI brain for central causes; CT/MRI internal auditory canal for acoustic neuroma.

Management and Treatment

Treatment depends on cause.

A. Vestibular Disorders

1. Benign Paroxysmal Positional Vertigo (BPPV)

  • Epley maneuver (canalith repositioning).

  • Medications (short-term if severe nausea):

    • Betahistine: 16 mg orally three times daily.

    • Dimenhydrinate: 50 mg orally every 6–8 hours as needed.

    • Meclizine: 25–50 mg orally every 6 hours as needed.

2. Ménière’s Disease

  • Low-salt diet, avoid caffeine and alcohol.

  • Betahistine 16 mg orally three times daily.

  • Diuretics (hydrochlorothiazide 25 mg orally daily).

  • Corticosteroids (intratympanic dexamethasone injection in resistant cases).

3. Vestibular Neuritis/Labyrinthitis

  • Symptomatic treatment:

    • Prednisone: 60 mg orally daily for 5–7 days, taper.

    • Meclizine 25–50 mg orally every 6 hours (short-term only, avoid long-term suppression).

    • Vestibular rehabilitation exercises.

  • If bacterial infection suspected: antibiotics (e.g., Amoxicillin–clavulanate 875/125 mg orally twice daily for 10 days).

B. Central Neurological Causes

  • Stroke/TIA: Urgent evaluation and treatment.

    • Aspirin 160–325 mg orally daily.

    • Statins (e.g., Atorvastatin 40–80 mg orally daily).

    • Blood pressure and diabetes control.

  • Multiple sclerosis: High-dose corticosteroids (Methylprednisolone 1 g IV daily × 3–5 days).

  • Vestibular migraine:

    • Acute: NSAIDs (ibuprofen 400–600 mg orally as needed), triptans (sumatriptan 50–100 mg orally as needed).

    • Preventive: Propranolol 40 mg orally twice daily, Amitriptyline 10–25 mg nightly.

C. Cardiovascular Causes

  • Arrhythmias: Antiarrhythmic therapy depending on type (e.g., Amiodarone 200 mg orally daily for recurrent atrial fibrillation under specialist care).

  • Orthostatic hypotension:

    • Increase fluids and salt intake.

    • Midodrine: 5–10 mg orally three times daily.

    • Fludrocortisone: 0.1 mg orally daily.

D. Systemic/Metabolic Causes

  • Hypoglycemia: Oral glucose or IV dextrose.

  • Anemia: Iron supplementation (ferrous sulfate 325 mg orally daily).

  • Electrolyte imbalance: IV replacement as appropriate.

  • Thyroid disease: Levothyroxine (25–100 mcg orally daily, titrated).

E. Psychiatric Causes

  • Anxiety-related dizziness:

    • SSRIs (Sertraline 50–100 mg orally daily).

    • CBT (cognitive-behavioral therapy).

  • Hyperventilation syndrome: breathing retraining.

Complications

  • Falls, injury from vertigo or imbalance.

  • Dehydration, malnutrition in severe Ménière’s disease.

  • Stroke-related morbidity.

  • Social withdrawal, anxiety, reduced quality of life.

Prognosis

  • BPPV: Excellent, responds to repositioning maneuvers.

  • Ménière’s disease: Chronic, but controlled with diet and medication.

  • Vestibular neuritis: Gradual recovery with rehabilitation.

  • Central causes (stroke, tumor): Prognosis depends on rapid diagnosis and treatment.

  • Cardiac causes: May be life-threatening if untreated.

Patient Education

  • Identify and avoid dizziness triggers (sudden movements, dehydration, stress).

  • Stand up slowly, especially in orthostatic hypotension.

  • Maintain hydration and balanced diet.

  • Avoid driving until cause is clarified.

  • Seek urgent medical care if dizziness is sudden and accompanied by weakness, speech difficulty, vision loss, or chest pain.




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