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What is dizziness and how can we manage it?

By Marios Panagi – Specialist Musculoskeletal and Sports Physiotherapist, Vestibular Physiotherapist – BSc (Hons), MSc (Merit), HCPC, MCSP, MACPSEM

The word dizziness is used to describe a variety of sensations, such as light-headedness, imbalance, vertigo, etc. Specifically, it is the sensation of instability as if the ground is moving. In true vertigo, the sensation the person experiences are the illusion of movement of the self around the environment, or vice versa the self around the environment.

The sensation of dizziness can cause significant limitation and restriction from daily activities and therefore, we will take some time to explain this here and how this can be managed.

The age factor

– In the age group of 50-65 years old, 20-30% of the individuals suffer from dizziness
– At 70 years old or older, more than 40% of them report dizziness
– The most common visit to the GP is dizziness in those over the age of 75 years old

What are the reasons we have dizziness?

The feeling of dizziness, instability or vertigo are sensations that can be quite disabling and limit the individual from participating in normal daily activities, joining crowded events, avoiding busy environments (i.e., supermarkets, shops) and even walking down a busy high street.

Even though the symptoms cause a great amount of worry, the chances of suffering from a serious pathology are small. For this reason, I will try to briefly summarize the possible causes of dizziness below, categorizing them according to their onset and severity.

Acute Onset

The most common reasons for the new onset of dizziness are commonly due to:

– Vestibular Neuritis: Present in approximately 30% of the cases and refers to the inflammation of the 8th cranial nerve. It usually has a viral cause, and it is managed by medication and vestibular rehabilitation.

The majority of individuals recover fully within 3 months, although about one-third of cases, unfortunately, develop a more chronic presentation

– In some cases of acute onset of dizziness, there will be associated hearing loss on one side. Those cases show that the cochlear nerve or end organ is affected, and it is probably due to Labyrinthitis or Acoustic Neuroma. These will be managed by an Ear Nose and Throat Consultant (ENT) for medical management and with vestibular therapy.

-SERIOUS CAUSE: The main differential in the acute presentation, is to exclude the presence of a stroke (Very uncommon ≈ <5%) which has characteristic signs and symptoms. I will briefly summarize a mnemonic of 5Ds and 3Ns that should be alarming to those with a new onset of dizziness. In the presence of those symptoms, then the individual should seek immediate medical attention in the A&E to rule out the possibility of stroke.

5Ds: Diplopia (double vision), dizziness, drop attacks (sudden falls with or without loss of consciousness), dysarthria (difficulty pronouncing words), dysphagia (difficulty swallowing)
3Ns: Nausea, numbness, and nystagmus (repetitive and uncontrolled eye movements)

Intermittent Onset

Intermittent onset refers to spells of dizziness that come and go at different intervals. The most common pathologies that have an intermittent nature are:

-BPPV (Benign Paroxysmal Positional Vertigo): It is the most common (≈50%) cause of the intermittent onset of dizziness. The symptoms are a result of a displaced fragment of “crystals” (otoconia) within the semi-circular canals of the inner ear. Most commonly the cause of BPPV is idiopathic (unknown) but can also be secondary to head injury, neuronitis, migraines or medical causes.

The symptoms of BPPV are severe spinning of yourself or the environment around you. It is positioning dependent, which means that it gets aggravated by movement of the head or body, such as lying down, rolling in bed, looking upwards, etc. The symptoms can last anywhere between 1-60 seconds.

The management of BPPV is with particle repositioning manoeuvres that are performed by a trained medical or healthcare practitioner, that usually have a miraculous quick resolution of symptoms. It can also be managed with home exercises and vestibular therapy.

-Meniere’s Disease: It is a long-term, degenerative disease affecting the balance organs and inner ears. The attacks, unlike BPPV, last for hours and present with hearing loss. Symptoms tend to get aggravated by salty diets. The management is multifaceted, and it includes a combination of medications, dietary changes and vestibular therapy during periods of relapse.

-Migraine-Associated Vertigo: Very similar presentation of long-lasting symptoms (hours) but without hearing loss. The triggers tend to be stress and anxiety in those with a history of migraines. This is managed with stress and anxiety relaxation techniques, dietary changes, vestibular rehabilitation and anti-migraine medications.

Chronic presentation

Chronic presentation refers to the symptoms of dizziness that are constant and daily and can be mainly divided into two groups:

– Cerebellar Ataxia: It is a central problem in the brain that has a gradual onset with age. Commonly this is associated with a history of alcohol abuse and presents with poor muscle control that causes clumsy voluntary movements. This is managed by a multi-disciplinary team and should be guided by a neurologist.

– Non-compensated Peripheral Vestibular Dysfunction: This category includes a large number of patients who have had a previous peripheral pathology, such as vestibular neuritis, Meniere’s disease, etc., who have never fully recovered. In this category, there is no visible pathology, and it is most commonly mislabeled as psychological. This causes an unnecessary, lengthy and very demoralizing journey since these patients are not seen soon enough by trained vestibular therapists and feel alone and unsupported.

For these individuals, vestibular rehabilitation is effective and causes compensations centrally from the brain that restores the normal equilibrium between vestibular stimuli and therefore decreases the symptoms.

Take home message

A. Dizziness is well understood and there are very efficient ways to manage your symptoms
B. Discuss your symptoms with your doctor. Get referred to see a specialist (ENT, neurologist, Vestibular therapist etc)
C. Don’t wait and get help to manage your symptoms!

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