Dizziness

What you feel during an episode

Patients use the word “dizziness” for very different sensations, and the difference between them points to the cause:

• Vertigo: the sensation that you or the surroundings are spinning, often with nausea. It almost always indicates a problem of the vestibular system, that is, the inner ear, the vestibular nerve or the brain structures that process balance.
• Faintness (presyncope): weakness, dimming of vision, ringing in the ears, often on standing up. It is related to a temporary fall in blood flow to the brain.
• Unsteadiness (disequilibrium): difficulty with balance or walking, without a spinning sensation, common in older people and in neuropathies.
• Non-specific dizziness: lightheadedness, a feeling of being “out of oneself”, often in anxiety or fatigue.

These sensations can overlap. Duration (seconds, minutes, hours, days) and the link with position, standing up, exertion or hearing are important for the diagnosis.

What the causes are

Vestibular causes (inner ear), the most common for vertigo:

• Benign paroxysmal positional vertigo (BPPV): the most common cause. Tiny calcium crystals (otoconia) move from their normal place into the semicircular canals and, when you turn or change the position of the head (turning in bed, getting up, looking up), send a false signal. Attacks last less than a minute, without hearing loss.
• Vestibular neuritis and labyrinthitis: inflammation of the vestibular nerve or of the labyrinth, often after a viral infection; it causes severe continuous vertigo for days; in labyrinthitis hearing loss is added.
• Ménière’s disease: episodes of vertigo lasting 20 minutes to 12 hours with tinnitus (ringing in the ear), a sense of fullness in the ear and fluctuating hearing loss.
• Vestibular migraine: recurrent vertigo linked to migraine, often without headache during the episode.

Other causes: a fall in blood pressure on standing (orthostatic hypotension: a fall in systolic pressure of 20 mmHg or more, or in diastolic pressure of 10 mmHg or more, within 3 minutes of standing); dehydration; anemia (see iron deficiency anemia); hypoglycemia; heart rhythm disturbances (arrhythmias) and severe valve stenosis; anxiety and hyperventilation; and medicines (antihypertensives, diuretics, sedatives, anticonvulsants, antidepressants).

More rarely, dizziness is due to a central cause, for example a stroke or hemorrhage in the back of the brain (vertebrobasilar circulation), a tumor or multiple sclerosis, which needs urgent treatment. This is why accompanying neurological signs (see the emergency box) should not be ignored.

When to be seen

Seek assessment if episodes persist, recur, cause falls, interfere with work or are accompanied by a change in hearing. Sudden hearing loss in one ear, with or without dizziness, needs assessment within days, because treatment is most effective when started early. Dizziness with chest pain, palpitations or fainting also calls for cardiology assessment.

How the assessment is done

The doctor reviews triggers, duration, accompanying symptoms and medicines. The neurological examination includes eye movements (nystagmus), balance and gait; when BPPV is suspected, a diagnostic maneuver (Dix-Hallpike) is performed. Blood pressure is measured lying and standing to catch orthostatic hypotension.

As needed, blood tests (blood count, glucose, electrolytes), an ECG or Holter ECG to look for arrhythmia are used, and when necessary a separate assessment of the vestibular system at another center is recommended. CT and MRI are not needed for every episode; they are done when there are central signs, when the examination is abnormal or when the diagnosis remains unclear.

How it is treated and how to protect yourself

Treatment is tailored to the cause. BPPV is treated with repositioning maneuvers (for example the Epley maneuver), which return the crystals to their place and resolve the vertigo in most cases; drugs do not resolve it. Vestibular neuritis needs brief suppression of symptoms and then vestibular rehabilitation (exercises that stimulate the brain to compensate). Vestibular migraine is treated like migraine. Orthostatic hypotension is corrected with hydration, a review of medicines and gradual standing. Arrhythmias, anemia or hypoglycemia are treated according to the cause.

Anti-vertigo sedatives (antihistamines, benzodiazepines) are used only for a few days in the acute phase; prolonged use delays the brain’s compensation and should not be continued without clarifying the cause.

Safety: sit down as soon as dizziness starts, stand up gradually, drink enough fluids, and avoid driving, high ladders and working at height during symptoms. Regular check-ups when episodes recur, every 6 months to a year or sooner when the doctor considers it reasonable, assess progress.

Care at Tirana Polyclinic: we offer neurology consultation and, as needed, cardiology assessment and interpretation of examinations performed at other clinics.