What to Do If You’re Dizzy

Feeling dizzy?

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
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
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
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
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.

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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.

Love in the Time of Meniere’s Disease

For most people marriage is a balancing act, but that goes double for me. I’m married to a man with Meniere’s disease, a chronic condition believed to be caused by faulty fluid pressure in the inner ear, resulting in hearing and balance problems. By hearing problems, I mean profound hearing loss, accompanied by an incessant buzzing in the affected ear. And by balance problems, I mean severe attacks of vertigo that forced my husband to the ground, where he had to stay and not move, sometimes for hours.
Heart
Meniere’s disease is invisible to others, at least between attacks. Who would know fluid was swelling the soft membranes of your inner ear? The fluid, called endolymph, must be of a certain volume and pressure within the inner ear to enable normal balance and hearing function. It is thought that for people with Meniere’s, excess fluid produces sudden swelling in one or more compartments and causes severe, episodic symptoms. The disease can progress slowly, which is why my husband, and our family, suffered plenty before he received a medical diagnosis.

Tinnitus – The First Symptom
I remember my husband’s first symptom being tinnitus, or a loud buzzing in one of his ears (other people hear different sounds). He would frequently ask if I was hearing something in the house, but I couldn’t hear anything. What I didn’t realize then was how lucky I was, because the thing he was hearing would never go away. Sure it would get softer at times, and finally it even switched ears. A bad omen, as it turned out, since this indicated both of his ears were affected.

“While no one knows for sure whether excess fluid in the ear causes Meniere’s symptoms or is the aftermath of another problem, we know it’s a chronic disease,” says Seth Schwartz, MD, MPH, otolaryngologist and medical director of The Listen For Life Center at Virginia Mason. “Meniere’s symptoms vary dramatically among individuals and sometimes are progressive. There are treatments designed to manage the disease but for now there’s no cure.”

The Worst to Come — Vertigo
The truly disabling symptom of Meniere’s is severe vertigo: spells of sickening dizziness as sudden as a thunder clap. The first time it happened to my husband he was sitting in a chair in a break room at work – then realized he couldn’t stand. I know from a single episode of vertigo in my 20s what it’s like: for me, everything in my vision flipped perfectly upside-down. I thought, earthquake, but knew the next second that was impossible. Your stomach doesn’t know that, however, so what follows is horrific nausea. Watching my husband having an attack, I understood he was completely trapped by the messed-up signals from his inner ear. No choice but to lie down. Violent vomiting followed minutes later. I wondered how we’d manage our lives, never knowing when it would strike.

Living with Meniere’s
Physicians were consulted who prescribed diuretics (to reduce fluids in the body), steroids (to reduce inflammation) and a low-salt diet (which my husband half-heartedly followed, at first). I desperately combed medical websites to find help with the vertigo attacks, and one sentence on a doctor’s Meniere’s web page had the single best tip. If a small dose of sedative, like Valium, is taken at the first sign of an attack, the worst of it may be avoided. My husband’s doctor agreed to try it and prescribed medication that would dissolve under the tongue. He kept a supply in his wallet at all times. In subsequent attacks he has managed to stay upright, control his nausea and recover much faster using the medication. But like full-blown attacks, he still needed to sleep for hours afterward.

Eventually, he saw a specialist to ask about possible surgery (a last resort in the treatment of Meniere’s due to the risk of permanent damage to hearing and balance function) and learned he could do a lot more to change his lifestyle and feel better. He was temporarily excused from working the night shift, which can stress the vestibular system, and told to cut out salt. For a few weeks now we’ve been cooking at home, with very little salt, and he’s been vertigo-free. The buzzing in his ear actually got louder due to fluctuating fluid levels, but his ear should adjust in time. Plus, living with the condition has, by default, taught him to cope.

“Being very strict with a low-salt diet is key since sodium causes fluid retention and could increase pressure in the inner ear,” says Dr. Schwartz. “Treating symptoms helps many people live with their condition, but there are more aggressive options if needed. The good news is that some cases will go into remission, or what we call ‘burning out,’ though unfortunately people may suffer permanent damage to their hearing or balance.”

For too long I was resistant to the truth about my husband’s condition, that Meniere’s disease is a chronic – yes, that means lifelong – illness. But we are both on board now with making it a manageable part of our lives. Love can conquer many things, even troubled ears.