You awaken in the morning thinking of that ﬁrst cup of coffee, or maybe even contemplating following your doctor’s advice about getting up and exercising. You roll over in bed and suddenly the world begins to spin. You stand up to go to the bathroom and ﬁnd a drunken, unstable gait has replaced your usual, steady morning stroll to the bathroom. You are scared, return to bed feeling a bit nauseated, and decide the only exercise you are going to do is exercise your right to call your doctor’s office directly to ask, “Why am I dizzy?”
When we get these types of calls, we ask a number of questions to decide what course to take. “Dizziness” is one of the most common complaints in a primary care doctor’s ofﬁce. The word dizziness is very nonspeciﬁc and the ﬁrst task is to ﬁt your symptoms into a more speciﬁc category. The history of your symptoms can help us sort out whether you are having true vertigo, low blood pressure (presyncope), loss of balance (disequilibrium), or simply nonspeciﬁc dizziness. Approximately 50 percent of patients with a dizziness complaint will have vertigo, 25 percent disequilibrium or presyncope, and the rest will be the less clear “nonspeciﬁc.”
Vertigo is an illusion of motion — either you feel you are moving or the environment is moving. Many patients equate it to the feeling they have when on a rocking boat, and indeed vertigo often leads to the cold sweats and nausea of seasickness. The most common description is a spinning sensation. It can be quite mild, or so severe you cannot stand up. We will ask you more questions to help us further categorize your vertigo. Other neurological symptoms such as visual or speech loss, double vision, headache, one-sided weakness or numbness are important. Hearing loss associated with ringing in the ear and ear fullness, especially when recurrent, can lead to an uncommon diagnosis of Meniere’s disease. How quickly symptoms come and go is very important, as is what brings on your vertigo. All vertigo is worse with movement, but it is important for us to know if a quick turn of the head or change in position starts your sensation. Lastly, have someone look directly at your eyes while you are looking straight ahead during movement symptoms. Often we will see involuntary shaking in the eyes, most commonly horizontal but occasionally vertical. This is called “nystagmus” and is an important clinical ﬁnding as we try to sort out the cause of your symptoms.
Disequilibrium is often less clear cut. It is usually much more subtle than vertigo, less episodic and more chronic in its presentation. Patients will have a sense of imbalance when they move, which they may describe as dizziness. When sitting or lying there will be no symptoms whatsoever. This type of dizziness is more vague, but unfortunately as we “mature” it becomes part of all of our lives. Its cause is multifaceted and involves decreasing vision (including cataracts), less efﬁcient muscles and joints, peripheral nerve degeneration and degenerative arthritis. Certain disorders such as Parkinson’s disease or even medication side effects can also cause these symptoms and should be inquired about.
Presyncope is usually the forerunner of fainting. It is the sensation of “blacking out” or light-headedness that often occurs when going from a seated to standing position, and because of that is sometimes confused with vertigo. The cause of presyncope, however, is low blood pressure and it will not usually be described as spinning or motion. There are many possible causes, the most common probably being medication side effects. Medications that treat prostate disorders, high blood pressure and heart disease are the most common but not the only culprits. Heart rhythm abnormalities must be considered and most work-ups for this type of dizziness involve our cardiologists.
Nonspeciﬁc dizziness is just that — nonspeciﬁc. History is much more difﬁcult in these cases and difﬁcult to categorize. Sometimes there may be motion symptoms, and other times the patient will feel as if they are “blacking out.” Usually patients are younger, and healthy with no other detectable problems. Hyperventilation is a common cause of symptoms, but often we cannot deﬁne the cause. In studies, patients categorized with this type of dizziness had a higher incidence of panic disorder, depression, heavy alcohol use, and somatization disorder. As always, it is difﬁcult to sort out whether the chronic dizziness caused the psychological symptoms, or vice versa.
So, back to our patient who is lying in bed talking to his or her physician: Obviously, after reading the previous paragraphs, you can see there are many possibilities. In my practice the most common cause of dizziness is a condition called “benign vertigo.” This is true vertigo brought on by head movement or position changes. It can be when walking, or even when lying in bed. It is not unusual for it to occur ﬁrst thing in the morning when you roll over to get up. Symptoms are transient and usually resolve quite quickly as long as you hold your head still and look straight ahead. Severity can vary. It seems to be worse at the onset, and then improves over a few days. You can usually control the symptoms by not moving, but unfortunately life involves movement, so after your evaluation is done we can give medications that improve symptoms. A physical therapist can also put you through a series of maneuvers that may resolve your symptoms quite dramatically. Most often, the symptoms will recur sometime in your lifetime.
My best advice to you if you develop symptoms of dizziness is to contact your primary care team. Most often, history can lead to a suspected diagnosis without the need for expensive testing.
Bruce Nitsche, MD, is a physician with the Lewis and John Dare Center. A version of this article originally appeared in the Dare Center Newsletter. For more information about the Dare Center, please visit VirginiaMason.org/Dare or call (206) 341-1325.