Dizziness

A person may be suspected to have dizziness if they suffer from the following:

• Giddiness, lightheadedness, or feeling faint.
• A sensation of abnormal swaying, such as feeling of moving from side to side.
• A sensation where the person feels they are spinning or the world around them is spinning.
• A feeling of imbalance or loss of balance.
• A sensation of nausea, which may or may not be accompanied by vomiting.

Dizziness is a symptom that occurs in many diseases and may be caused by various underlying disorders. It is important to correctly differentiate and determine the cause of dizziness as treatment varies with each cause.

Problems with the ear and vestibular system

The ear is the organ responsible for maintaining normal balance and equilibrium of the body. Problems in the ear and vestibular system can lead to vertigo, a type of dizziness. Multiple conditions can be associated with vertigo, such as:

• Benign paroxysmal positional vertigo (BPPV)
  • Benign: not dangerous to health
  • Paroxysmal: presents as a sudden, brief episode
  • Positional: set off by particular head or bodily movements
  • Vertigo: an internal sense of irregular or spinning movement either of oneself or of the surroundings

  BPPV is the most common cause of vertigo. It is a harmless condition that presents as mild to intense dizziness lasting for a few seconds or minutes. It is often associated with a sudden change in the position of the head or body, like bending over, turning in bed, or sitting up. BPPV usually resolves on its own and is not serious. The inner ear is a system of canals filled with fluid that lets the brain know about movements of the head. In BPPV, small calcium crystals in the inner ear move out of place, preventing the system from sending the correct signals to the brain. BPPV can occur due to a head injury or aging as well. The natural breakdown of cells that happens with age or during injury is thought to be responsible for this.

• Meniere’s disease

  This rare condition causes severe vertigo, nausea, ringing in the ears, muffled or distorted hearing, hearing loss, and a feeling of a plugged ear. This condition is characterized by excess fluid buildup in the inner ear. Meniere’s attacks usually occur suddenly and can last from 20 minutes to 24 hours. Patients often feel worn out after the attack passes.

• Ear infections

  Viral and less commonly bacterial infections can cause inflammation of the nerves in the ears. The vestibulocochlear nerve, a nerve in the inner ear, has two branches:

  • The vestibular nerve sends signals to the brain about balance. Its inflammation leads to vestibular neuritis.
  • The cochlear nerve sends signals about hearing. Its inflammation causes labyrinthitis.

  This inflammation hinders the messages the nerves of the ear send to the brain, leading to symptoms of vertigo.

• Acoustic neuroma (vestibular schwannoma)

  This benign tumor develops on the vestibular or cochlear nerves leading from the inner ear to the brain. The pressure on the nerve from the tumor may cause vertigo.

• Vestibular migraine

  Migraines are often characterized by painful headaches; however, vestibular migraine may or may not involve headaches along with vestibular symptoms such as vertigo and imbalance. People with vestibular migraine report common migraine symptoms such as sensitivity to light and sound.

Problems with blood circulation

• Hypotension or low blood pressure

  Dizziness is commonly seen in people who have low blood pressure. Due to low blood pressure, enough oxygen-rich blood is not delivered to the brain, thereby affecting its function. This can lead to dizziness. Some common causes for low blood pressure include:

  • Dehydration or loss of water during extreme heat, heat cramps, heat exhaustion, or heat stroke. Dehydration often occurs along with vomiting and diarrhea. Fever can also cause a significant loss of water due to elevated metabolic rate and profuse sweating when the body tries to cool itself.
  • Anemia due to decreased production or increased destruction of red blood cells.
  • Bleeding may cause loss of red blood cells and lead to anemia.
  • Alcohol use.
  • Pregnancy.
• Postural hypotension (orthostatic hypotension)

  If someone is dehydrated or anemic, blood pressure readings may be normal when lying down. However, when they sit up or stand up too quickly, they may experience a brief feeling of lightheadedness. This feeling may go away in a few seconds as the body adapts. If dehydration or medications like beta blockers prevent the body from reacting, the dizziness may continue to the point at which the patient faints.

• Heart diseases

  Conditions such as cardiomyopathy, heart attack, heart arrhythmia, and transient ischemic attack could cause dizziness.

Endocrine diseases

• Diabetes

  Uncontrolled diabetes is one of the main diseases that may cause dizziness. Hypoglycemia or low blood sugar can occur due to reduced food intake or overmedicating with diabetes medication. In this situation, the person experiences dizziness because the brain doesn't get enough glucose to function properly. Hyperglycemia or high blood sugar levels may also cause dizziness due to dehydration, which happens due to a lack of sufficient insulin to allow cells to use glucose for energy metabolism.

• Thyroid diseases

  Abnormalities of the thyroid may also cause dizziness as a symptom. Hyperthyroidism or high levels of thyroid hormone may cause palpitations and lightheadedness. Hypothyroidism or low levels of thyroid hormone may lower blood pressure and heart rate, leading to dizziness and weakness.

• Addison's disease

  This condition occurs when the adrenal glands do not produce enough cortisol to meet the demands of the body. Low cortisol levels may result in weakness, low blood sugar, low blood pressure, and dizziness.

Other causes

• Neurological conditions

  Rarely, the cause of vertigo may arise from the brain. Stroke, tumors, seizures, peripheral neuropathy, Parkinson’s disease, and multiple sclerosis may be associated with vertigo.

• Trauma

  Concussions and minor head trauma can also cause vertigo.

• Certain medicines

  Dizziness can be a side effect of certain medications such as antibiotics like gentamicin and streptomycin, anti-seizure drugs, antidepressants, sedatives, tranquilizers, antihypertensive drugs like beta-blockers, diuretics, ACE inhibitors, and medications for erectile dysfunction.

• Psychological disorders

  Stress, anxiety, panic attacks, and depression can also cause dizziness when hyperventilating or breathing too quickly.

• Carbon monoxide poisoning

  Symptoms of carbon monoxide poisoning may include nausea, vomiting, shortness of breath, dizziness, weakness, and confusion.

Dizziness can happen to anyone at any point in their life. It may occur as a one-time, brief episode or may be long-lasting with intermittent periods of symptoms. It is estimated that most people over the age of 40 might have experienced dizziness at least once in their lifetime. Certain factors can increase the chance of dizziness, such as:

• Old age, especially in people over 65
• Being a woman
• A medical history of past episodes of dizziness
• Having a family member who has vertigo
• Hyperlipidemia
• Vitamin D deficiency

Anemia is one of the causes of dizziness. Here are a few simple tips to increase hemoglobin levels in the blood and prevent anemia.

If a patient presents with symptoms of dizziness, a thorough history and detailed physical examination are key to diagnosis. Aggravating and relieving factors of dizziness, along with other associated symptoms, are assessed. A review of the past medical history and current medications the patient is taking is also conducted.

I. Blood tests

The requirement for blood tests depends on the cause of the dizziness. Common tests that are done include:

• Complete blood count (CBC)
• Blood sugar tests
• Electrolyte levels
• Thyroid tests
• Kidney function tests

II. Cardiac tests

Sometimes cardiac health needs to be assessed using the following tests to rule out any heart diseases that can cause dizziness:

• Electrocardiography (ECG)
• Echocardiography (Echo)

III. Imaging studies

Radio imaging tests may be performed to determine the cause of dizziness. Possible causes include inner ear disturbances or other head and neck conditions, such as cervical spondylosis, brain tumor, or insufficient blood supply to the brain. Common tests that are recommended include:

• CT scan (head)
• CT neck plain
• MRI brain
• MRI brain with contrast
• MRI cervical spine

IV. Balance tests

These tests check for balance disorders by evaluating how the body responds to changes in posture. The vestibular system, located in the inner ear along with the central nervous system, is responsible for maintaining body balance. The following tests can be done to evaluate the functioning of these systems:

1. Rotary chair test: This test records eye movements while the patient is sitting on a rotational computerized chair, evaluating the vestibular system that regulates balance, posture, and the body's orientation in space.
2. Computerized dynamic posturography (CDP): Also known as the test of balance (TOB), it evaluates the ability to remain standing in either stationary or moving conditions.
3. Vestibular-evoked myogenic potentials (VEMP) test: This test assesses vestibular function by measuring the reaction of muscles to a repetitive sound stimulus.
4. Video head impulse test (vHIT): The doctor gently moves the patient’s head to each side while recording eye movements as the patient focuses on a stationary object, such as a spot on the wall.
5. Vestibular test battery: This includes several tests to assess if vertigo is due to problems in the inner ear or due to a neurological cause, aiding in the development of an appropriate treatment plan.
6. Electronystagmography (ENG) and videonystagmography (VNG) tests: These tests record and measure eye movements. In ENG, electrodes or small sensors are placed around the eyes, while in VNG, special goggles are used. The patient is asked to follow light patterns on a screen and move into different positions. Warm and cool water or air is then introduced into each ear, causing the eyes to move in specific ways. If the eyes do not respond, it indicates damage to the nerves of the inner ear.

Dizziness may be caused by a disturbance in the equilibrium mechanism regulated by the inner ear. It may also occur due to other head and neck conditions that affect balance or due to problems with nutrition and blood circulation. It is possible to prevent these spells of dizziness by avoiding certain activities such as:

• Avoid sudden movements of your head from one position to another, or standing up suddenly after lying down for a prolonged period.
• Do not insert sharp objects or foreign matter deep into your ears for cleaning purposes, as it may damage the inner ear.
• Always monitor your blood sugar levels closely if you are a diabetic on insulin therapy.
• Drink plenty of water to avoid dehydration, especially in the summer season.
• Closely monitor your blood pressure levels.
• Certain medications may trigger spells of dizziness. In such cases, consult your doctor to make the necessary adjustments.

Often, episodes of dizziness are mild and do not require any treatment as they resolve on their own. Treatment for dizziness is necessary when the episodes do not go away or are so severe that they interfere with a patient’s day-to-day activities. The treatment for dizziness depends on the cause and severity of symptoms. Here are some medicines that are generally suggested:

I. Dizziness due to vertigo

• Betahistine: Used to treat vertigo caused by Meniere’s disease (a disorder of the inner ear that can lead to dizzy spells and hearing loss). It works by improving blood flow in the inner ear and reducing the pressure of excess fluid that causes the symptoms of vertigo.
• Antiemetics: This class of medicine helps ease the symptoms of nausea and vomiting, frequently associated with vertigo. Effective medicines include:
  • Promethazine
  • Ondansetron
• Antibiotics: If the cause of vertigo is a middle or inner ear infection, it must be treated with antibiotics to resolve the infection. Oral antibiotics and ear drops help fight bacterial infections of the ear, reducing the inflammation that causes vertigo.
• Vestibular suppressants: Medications that reduce the intensity of vertigo due to vestibular imbalance. There are three main categories of drugs:
  • Antihistamines: The most commonly prescribed medicines that help relieve symptoms such as dizziness and prevent motion sickness.
  • Benzodiazepines: Medications like clonazepam and lorazepam can act as vestibular suppressants in low doses and help reduce symptoms of an acute vertigo episode. These medicines are not routinely prescribed and are reserved for acute severe episodes of vertigo or to manage anxiety associated with vertigo.
  • Anticholinergic drugs: Such as scopolamine, help with dizziness and motion sickness.

II. Dizziness due to problems with nutrition

• Electrolytes/glucose drinks: When a person starts feeling dizzy, along with symptoms of cold extremities and profuse sweating, it may be due to reduced blood glucose levels or dehydration. In such situations, it is important to immediately offer the patient a rapid source of glucose and electrolytes.
• Iron supplements: Correcting iron deficiency with iron supplements helps improve dizziness caused by anemia.
• Medications as per diseases: Dizziness due to various conditions can be corrected by obtaining appropriate treatment for them.

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A one-off episode of dizziness does not require any special care. However, if these episodes are severe and frequent, the patient needs to take utmost care. Some tips to circumvent dizziness are:

• Avoid sudden, jerky movements of the head and neck.
• When you feel dizzy, stop what you are doing immediately and sit down until it passes.
• Lie down flat immediately when symptoms occur. This will allow blood to reach your brain quickly.
• Rest as much as possible.
• Change positions slowly, especially when standing up after lying down. Try to sit for a couple of minutes before standing up.
• Drink plenty of water. Ensure you consume at least 8 glasses of water every day, unless advised otherwise by your doctor.
• Maintain a healthy balanced diet comprising all essential nutrients.
• Closely monitor blood sugar levels if you have diabetes and are on insulin therapy.
• Regularly monitor blood pressure levels.
• Avoid engaging in activities that involve rapid movements, such as driving or joy rides.
• Avoid standing at high places or climbing ladders. Refrain from wearing high-heeled shoes as well.
• Use walking aids such as a cane or walking stick in case of severe dizziness and increased risk of falling.
• Hold onto the railing when going up and down stairs.
• Avoid driving or operating equipment or machinery while feeling dizzy, as this could be dangerous to yourself and others.
• Install hand grips in bathrooms and showers.
• Remove clutter from the floor, such as rugs and loose electrical wires.

• Increased falls due to loss of balance.
• Accidents may occur if the patient feels dizzy while driving or operating heavy machinery.
• Loss of consciousness or fainting.
• Hypotensive shock if dizziness is due to extremely low blood pressure.
• Ischemic stroke if dizziness is due to poor blood supply to the brain.

Some forms of dizziness, such as vertigo, can benefit from alternative therapies such as:

• Physiotherapy: Vestibular rehabilitation and balance training exercises, such as standing on a bosu ball, a tilt board, walking in an S shape, and standing with eyes closed, are specific exercises that can help improve balance. These exercises can decrease the chances of falls and dizziness.
• Homeopathy: Homeopathic preparations, such as Bryonia and Cocculus Indicus, have shown effectiveness comparable to conventional medications in controlling the symptoms of vertigo.
• Canalith Repositioning Maneuver: The canalith repositioning procedure can help relieve benign paroxysmal positional vertigo (BPPV). A doctor may guide you to perform simple head exercises called the Epley maneuver or canalith repositioning procedure (CRP). These exercises help to reposition dislodged calcium crystals effectively, and most people feel better after one to three treatment sessions.

Dizziness can affect the quality of life as it often imposes certain restrictions on an individual's lifestyle. As dizziness may be aggravated by sudden rapid movements of the head, a person with dizziness may not be able to enjoy adventure activities like joyrides. One may also experience aggravated motion sickness that may hinder traveling.

Patients with underlying health conditions such as:

• Low blood sugar
• Low blood pressure
• Anemia
• Neurological disorders

often face a lack of productivity due to the symptoms of dizziness and fatigue. Severe forms of dizziness that impair balance may lead to increased chances of falls and the complications arising from falls. Patients with dizziness should not drive a car or operate heavy machinery to avoid any mishap.