Dizziness is a term used to describe sensations of lightheadedness or imbalance. The term is non-specific and can mean different things to different people. Some people may use the term to describe a spinning sensation, known as vertigo. Others may feel dizziness before a temporary, full, or partial loss of consciousness, known as syncope. Balance problems due to inner ear disturbances are responsible for many cases of dizziness.
The general population experiences some form of dizziness from time to time, or about 20-30% of the time. Dizziness accounts for many visits to physicians and emergency services. In most cases, the cause is benign. The condition limits itself and an individual suffers no consequences. Some causes of dizziness are common while other causes are rare. Some causes are minor, other causes are serious and even life threatening. Vestibular systems, neurological and cardiovascular conditions can produce dizziness. Migraine headaches, benign positional paroxysmal vertigo (BPPV), and Meniere’s disease are the most commons causes of dizziness.
Dizziness usually passes on its own; however, it may be a sign of more serious problems like an underlying cardiac or neurological problem. A physician should be consulted for severe or repeated bouts of dizziness. Identifying the cause can be problematic and treatment may not be satisfactory to the patient. Describing and defining the sensations accurately may be very helpful in helping the physician identify the cause.
Dizziness of a vertigo type is characterized by a spinning or moving sensation. The identifiable feature is movement related. The person may feel like they are moving or the world is moving around them. The other type of dizziness is a fainting sensation where the central nervous or proper sense of the body is lost. Vertigo type dizziness is usually vestibular system related. Faintness is related to the cardiovascular system, infection or metabolism. Some of the ways that people describe dizziness:
- Faintness – lightheadness before fainting or nearly fainting. Low blood pressure and not eating can cause a feeling of faintness. A drop attack or syncope may occur after feeling faint.
- Spinning – a rotary, tilting, or floating sensation in the patient or surroundings. Vertigo is a spinning sensation.
- Imbalance – an unsteady feeling with trouble maintaining an erect posture. Inner ear disturbances and imbalance may lead to an increase in falls. Lack of coordination may feel like dizziness but without the spinning from vertigo. The sensations, which orient the person in space, may be misinterpreted by the brain.
Other descriptions used to describe dizziness:
- Swimming sensations
- Light and free
- Seeing stars
- Double vision
Balance and Orientation
The normal system for keeping a person oriented in space is the brain, eyes, and ears. The muscles, nerves, and skin of the movement systems also feed information to the brain. The brain is constantly interpreting the body’s position in space with these data-gathering organs and systems. When the head moves, the labyrinth fluid in the ear helps to control balance and sense of consciousness. The labyrinth sends messages to the brain through the vestibular nerve. Even if the eyes are closed, the brain knows what position the head occupies. When the labyrinth or vestibular nerve malfunctions, the signals cause conflicts in the brain, causing the movement or disorientation called dizziness.
The peripheral or central vestibular system is responsible for most cases of dizziness. These sensorineural disturbances are common. Peripheral vertigo is when the inner ear, the vestibular labyrinth, semicircular canals or the vestibular nerve malfunction and incorrect signals are sent to the brain. Central vertigo occurs in the brain stem or the cerebellum. The vestibular system is also responsible for hearing loss. Hearing loss can be due to old age, noise exposure, and infection. Other cases of dizziness are cardiovascular or neurological in nature.
Types of Dizziness
The mechanical, physical and biochemical functions of the human body are categorized into systems which describe their function. Systems are further defined by anatomy, including the organs, and the cells and tissue of which they are composed. Many systems overlap and share biological pathways and function. For instance, labyrinthitis is a common cause of dizziness and is part of the vestibular system. However, communication with the neurological system is achieved through electrical and chemical means. Reception and transmission of signals that integrate the systems and functions, depend on interactions with the whole organism. The main biological systems and their medical conditions known to cause dizziness include:
- BPPV (benign paroxysmal positional vertigo)
- Menieres disease
- Vestibular neuritis (neuronitis)
- Perilymph Fistula
- Bilateral vestibular loss
- Superior semi-circular canal dehiscence
- Middle-ear disease
- Acoustic neuroma
- Bone fracture
- Cogan’s syndrome
- Mondini’s dysplasia
- Multiple sclerosis (MS)
- Cerebellar degeneration
- Chiari malformation
- Cerebellar stroke
- Vertebrobasilar ischemia
- Wallenberg’s syndrome
- Normal pressure hydrocephalus
- Paraneoplastic cerebellar degeneration
- Hereditary ataxias
- Benign intracranial hypertension
- Posterior fossa tumors
- Mal de Debarquement syndrome
- Orthostatic (or postural) hypotension
- Autonomic dysregulation
- Psychogenic dizziness
- Low blood pressure including syncope, orthostatic hypotension, cardiac arrhythmia
- Medication side effect
- Psychophysiological dizziness
- Anxiety and panic disorder
- Somatization syndrome post-traumatic dizziness
- Psychogenic dizziness
- Diabetes mellitus
- Systemic lupus erythematosus
- Rheumatoid arthritis
- Cogan’s syndrome
- Wegener’s granulomatosis
- Behcet’s disease
Medications or Substances
- Ototoxic drugs
- Chemotherapeutic drugs
- Other drugs
- Second-generation antiepileptic drugs
Traumatic or surgical
- Post-traumatic vertigo
- Post-surgery dizziness
- Lyme disease
- Cytomegalovirus (CMV)
- Herpes simplex virus 1 (HSV-1)
- Unknown causes or multi-faceted causes
Different Health Conditions Causing Dizziness
Dizziness can be caused by a number of different health conditions. In some cases, the condition will overlap and be a part of one or more biological systems. For instance, aging is associated with dizziness. Aging is a complex process which affects almost all systems including the neurological, cardiovascular and metabolic systems. Conditions which are associated with dizziness include:
- Acoustic neuroma – this rare condition is caused by a benign or non-cancerous tumor growing on the acoustic nerve, which joins the ear and the brain. Tinnitus, dizziness and hearing loss are the usual symptoms. The pressure on the nerve is ongoing and may get worse. Surgery is successful for a majority of cases. Surgeons are able to remove the tumor in 95% of cases. Slow growing tumors behind the ear can also cause facial paralysis and even be fatal. Microsurgery and radiation therapy are other alternatives.
- Aging – the normal process of aging may produce vestibular problems, hearing loss (Presybyacusis), frailty, weakness, lack of coordination and a combination of factors that cause dizziness.
- Alcohol – indulging in alcoholic beverages may induce dizziness depending on the volume, sensitivity, or the ability to metabolize alcohol. Morning after symptoms may include headache and dizziness.
- Anemia – oxygen poor blood in the brain can cause lightheadness. Increasing dietary iron, zinc, vitamin A, and vitamin D may be helpful.
- Anxiety – general anxiety, and anxiety with panic attacks, may trigger dizziness, either real or imagined. Heart rate and ventilation may increase rapidly and cause lightheaded sensations.
- Auditory cortex – abnormal neural networks between the vestibular cortical area and the auditory cortex can cause dizziness. Normal auditory cortex response declines with advanced age. However, musicians seem to be protected from these age related diminishments. Musical training may have a positive effect in maintaining the auditory cortex.
- Autonomic dysregulation – when doing physical activities or exerting oneself, a person may get dizzy. Swimming, running, and sexual activities can lead to a feeling of disconnection from the body or a feeling of spaciness.
- Bacterial otitis media – acute onset of dizziness with fever, irritability and B12 deficiency. When this condition becomes chronic, hearing can become impaired which may limit acquiring verbal interactions and education especially in children.
- B12 deficiency – a common cause of dizziness may be due to genetic factors or a problem absorbing B12.
- Behcet’s disease – a systemic disease affecting the vascular and neurological pathways. Symptoms include ulcers on the mouth and genital, hearing impairment, tinnitus, and dizziness.
- Benign intracranial hypertension – pseudotumor cerebri causes an increase in cranial pressure. A mass lesion is not present. Dizziness, headache, poor vision, imbalance, nerve palsy and tinnitus may be the common symptoms.
- Benign positional paroxysmal vertigo – the most common cause of vertigo, caused by loose particles in the ear canals. The posterior and the lateral canal is the most common site for otoconia particles. The Dix-Hallpike test is performed first. A negative test should be followed by a supine roll test for horixonatal canal BPPV. About 20% of all cases of dizziness are due to this condition. Older people with dizziness due to BPPV, account for 50% of all dizziness cases. Episodes can last for seconds or minutes.
- Cardiovascular – dizziness with fainting is indicative of cardiopulmonary disease. Myocardial ischemia, obstructive hypertrophic cardiomyopathy, pulmonary embolism, or hypertension merits urgent physician care.
- Cogan’s syndrome – inner ear inflammation with plasma cell and lymphocyte infiltration. Demyelization of the cranial nerves also occurs. Patients often have photophobia, ocular discomfort, ocular redness, fluctuating sensorineural hearing loss, and imbalance or vertigo.
- Cytomegalovirus (CMV) – both the mother and child may experience dizziness when the mother is exposed to this virus while pregnant. Some children may have indicators of the disease, others may have severe hearing loss, and other children may experience hearing loss and dizziness later. CMV virus is one of the leading causes of hearing loss in children. A new method to take a sample of an infant’s saliva correctly found CMV 97 percent of the time.
- Diabetes mellitus – hypoglycemia may provoke dizziness. Those patients with peripheral neuropathies may have increased rates of dizziness.
- Heart conditions – abnormal heart rhythms where the heart beats too fast or too slowly are caused by various factors. An arrhythmia may cause fainting or lightheadness. The blood supply to the brain is hampered and causes dizziness. Supraventricular tachycardia and bradycardia, and cardiomyopathy are other causes of dizziness.
- Hereditary ataxias – a genetic disorder that usually is found before a person is 20 years of age. The nervous system malfunctions and muscle movements may be uncoordinated.
- Herpes simplex virus 1 (HSV-1) – this virus inhabits nerve cells and ganglia in an active or dormant stage. The infection may cause audiovestibular symptoms including dizziness. HSV is also known for causing eye problems. The systemic infection invades all the sensory nerve structures. Anti viral medications may reduce nerve damage.
- High blood pressure – hypertension is often found when an individual complains of headache, nausea, or dizziness.
- HIV – central nervous system changes can cause dizziness and lack of coordination. Positional vertigo, labyrinthitis and Meniere’s disease are the most common culprits for HIV patients. Cardiovascular disease, stroke and brain tumors are sometimes the cause.
- Hypothyroidism – inner ear disturbances and Meniere’s disease is more likely for those with this condition.
- Labyrinthitis – viral or bacterial infection in the vestibular system. Trauma can also lead to labyrinthitis. An ear infection or upper respiratory infection may lead the patient to seek help. Mild hearing loss may accompany this condition. Viral labyrinthitis may be accompanied by flu like symptoms like a sore throat or cold symptoms. This condition can last for days or weeks. Vision problems or unnatural eye movements or nystagmus may accompany traumatic labyrinthitis.
- Lyme disease – caused by tick-borne spirochete Borrelia burgdorferi, and other Borrelia species.
- Mal de Debarquement syndrome – sensory inputs from the vestibular system and the visual systems may conflict. The parietal cortex and the cerebellum are involved and lead to a feeling of unnatural movement sensations. Travelers with a history of sea, air, or train travel, or who have traveled in space may have this condition. The symptoms are unlike motion sickness with no nausea or vomiting and can last for years.
- anesthetic medication
- anti-arrhythmic medication
- high blood pressure medications
- sedatives and tranquilizers
- pain relievers
- antiepileptic drugs
- ototoxic drugs
- antibiotics such as gentamicin and neomycin
- chemotherapeutic drugs such as cisplatin
- Meniere’s disease – episodes of vertigo, tinnitus, hearing loss and a full ear canal feeling. The cause is not known, but is associated with endolymphatic hydrops. One percent of the population, of all ages, has this condition. Episodes last from minutes to hours. Permanent hearing loss and the ringing or buzzing from tinnitus may occur.
- Middle-ear disease – labyrinthitis and otitis media, infection or fluid in the middle ear. Those who have had mastoid surgery can have dizziness with an ear infection. Cholesteatomas usually have a malodorous ear discharge, hearing loss and/or tinnitus.
- Migraine-related vestibulopathy – migraine headache are often accompanied by vertigo and dizziness. Migraine sufferers have over activated neuronal systems and vascular dilation. Central nervous system and vasospasm can affect auditory artery and neuropeptide release during a migraine. Patients often have migraine aura, visual disturbance, photophobia, or phonophobia.
- Multiple sclerosis – about 50 percent of MS patients will experience vertigo at some point. Dizziness is a common first symptom for MS cases. Dizziness may be prolonged as demylinating plaque can occur at the entry to the vestibular nerve. There may be an associated hearing loss.
- Normal pressure hydrocephalus – lack of coordination, urinary incontinence and cognitive difficulties are the symptoms. Intracranial pressure is normal but the ventricles may be enlarged.
- Orthostatic hypotension – systolic and diastolic blood pressure decreases. Vasoconstriction occurs or intravascular volume is impaired. People often feel dizzy when standing or sitting up. Blood pressure falls and the person may feel dizzy. This condition may get worse as the person gets older.
- Paraneoplastic cerebellar degeneration – cancer of the ovaries breast or lung increase and antibodies attack neurons in the brain.
- Perilymph Fistula – vertigo, imbalance, hearing loss, and/or tinnitus are seen in people with head trauma, undersea divers, or surgery patients. Exploratory surgery is the method to find this condition.
- Post-traumatic vertigo – accidents, sports injuries, falls and violence induce traumatic injury. Blunt head trauma patients have vertigo, tinnitus, headache and imbalance.
- Pregnancy – first trimester dizziness during pregnancy is common and may occur at any time during pregnancy. Hormones and blood pressure are usually the causes.
- Presyncope – experienced as lightheadedness immediately preceding a loss of consciousness. The patient can also feel this sensation with a near fainting episode. Blurred vision, nausea, vomiting, weakness, giddiness, and paralysis may also precede fainting. Problems with blood supply to the brain are nearly always the cause. Physical positions, conditions or circumstances may cause fainting.
- Psychogenic dizziness – certain situations may provoke those with personality disorders, panic, anxiety, agoraphobia, and depression to experience dizziness.
- Psychophysiological dizziness – dizziness may persist after a real injury. The patient may continue to experience dizziness even when the medical condition is no longer there. Stress, fatigue, and life changes may make complaints worse. Dementia, malingering, depression, phobia and panic disorders are common causes for dizziness.
- Rheumatoid arthritis – patients with this condition may have normal hearing but they may have perceptions of hearing loss and dizziness.
- Spinning around – amusement rides, spinning around in a chair, recreational games and similar activities produce a temporary spinning sensation.
- Superior semi-circular canal dehiscence – loud sounds, ear pressure and vertigo is usually caused by trauma or concussion. Diagnosis is made with a CT scan.
- Surgery – middle ear surgery, cochlear implants and related vestibular surgeries can be followed by dizziness and balance disturbances immediately after surgery or some time later.
- Syncope – a drop attack, or sudden loss of consciousness followed by a spontaneous recovery. Hypotension, medications, stroke, and cardiac events lead to syncope. Fear of needles, blood or other triggers may initiate a fainting episode. Researchers say that 50 percent of the population will faint in their lifetime.
- Syphilis – congenital or secondary syphilis is known to cause inner ear problems with vertigo and hearing loss or fluctuating hearing loss.
- Systemic lupus erythematosus – an autoimmune disorder with symptoms of vertigo and vision abnormalities. There may be an associated hearing loss.
- Trauma – inner ear dysfunction may arise from a fall, an accident, a violent incident or sports injury. A skull fracture or concussion may induce vertigo, headaches and dizziness.
- Vertebrobasilar ischemia – clumsiness and a drop attack with vertigo lasting one to fifteen minutes is characteristic of a stroke in the cerebellar artery.
- Vertigo – central vertigo in inner ear dysfunction happens when the labyrinth or vestibular nerve is inflamed or damaged. Patients have the sensation that they are spinning around, or the world is spinning around them. Nausea and vomiting often accompany vertigo. Lying down often helps vertigo symptoms. Blood vessels dilation and inflammation in the brain and nerves can cause vertigo.
- Vestibular neuritis (neuronitis) – a viral infection, usually herpes, inflames the vestibular ganglion, vestibular nerve, and labyrinth. The vestibular nerve coming from the inner ear becomes inflamed, but usually clears when the infection is treated. An early diagnosis and treatment is important for long-term functioning.
- Wallenberg’s syndrome – vertigo that can last for several days due to a lateral medullary infarction, a sudden blockage or clot in a vertebral artery that supplies a cerebral artery.
- Wegener’s granulomatosis – symptoms of vertigo, hearing loss and facial palsy.
Dizziness is diagnosed with a patient history and physical evaluation. Diagnostic and laboratory tests are often unnecessary except for serious symptoms of cardiovascular or neurological origin. A detailed history and a catalogue of the patient’s symptoms can provide important information. Describing the attacks according to their nature, duration and concurring symptoms, especially auditory symptoms can help the physician to make a diagnosis. Examination of the ear, eyes and throat is an important step. Serious cases of dizziness are uncommon and most likely a diagnosis will be made according to vestibular causes.
Physicians will take a medical history and ask questions such as:
- What happens when you feel dizzy? What are the signs of the episode?
- What does it feel like? Is it spinning or do you feel lightheaded?
- How long does the episode last?
- What position are you in when you feel dizzy? Standing? Sitting?
- Do you hear a buzzing noise? Is your hearing worse?
- Do you feel weak or have problems walking?
- Do you have panic or anxiety?
- Have you had recent surgery or a head trauma?
- Do you have any other illnesses?
- Does your family have a history of illnesses?
- What medications do you take?
- Are you using drugs or alcohol?
- Acoustic reflex assessment – a loud noise test for the muscle that protects the ear.
- Audiometric confirmation – tests for sensorineural hearing loss, tinnitus, and aural fullness.
- Blood glucose monitoring – for possible diabetes.
- BP – lying down and standing up BP check.
- Computerized dynamic post-urography testing – assesses balance with a computerized platform.
- Dix-Hallpike test – if BPPV is suspected. The patient sits on a bed and the physician moves the head and the body in an attempt to replicate the patient’s symptoms. The procedure may be surprising or painful to the patient.
- Electrocochleography – useful in the diagnosis of Meniere’s disease.
- Computed tomography (CT) – useful in identifying bone fractures.
- MRI scans -can find fluid in the middle ear. Patients with acute vertigo and cardiovascular symptoms often require urgent MRI.
- Observation of eye movements – nystagmus and visual acuity can give clues to the diagnosis.
- Pure-tone audiogram – for the discovery of hearing loss.
- Romberg and Unterberger (Fukuda) tests – balance and coordination tests with eyes closed.
- Screening for depression and anxiety disorders.
- Supine roll test – the patient lies on his back while the physician examines the eyes as the head is rolled from side to side.
- The head impulse test – the patient is asked to keep their eyes on a target in the distance while the physician turns the head from side to side.
Treatment for dizziness will vary as widely as the causes and conditions which cause the dizziness. Urgent treatment may be necessary for cardiovascular conditions including surgery for pulmonary embolisms, anticoagulation medications to prevent stroke and emergency revascularization procedures. Observation of neurological symptoms may be necessary on an emergency basis. The goals of increasing vestibular function include decreasing dizziness, increasing balance and increasing activity levels. Medication commonly prescribed:
- Motion sickness pills
An implanted device could improve the quality of life for vestibularly damaged patients. An implantable prosthesis is being investigated that would restore proper sensation in the vestibular system. The device is designed to interpret all three dimensions of head rotation. The neuroelectronic prosthesis would interpret head rotation and encode the branches of the vestibular nerve
Vestibular function loss is often related to vestibular hair cell loss for diseases processes such as vestibular neuronitis, aminoglycoside ototoxicity, and aging. Recovery of inner ear hair may improve balance. Regeneration of hair provides a way to stimulate local tissue healing. One study demonstrated that mice treated with Admath 1.11D recovered their vestibular neuroepithelium within 8 weeks. Genetic testing is also underway to find a way to grow new hair using DNA.
Modified Cochlear Implant
The Nucleus® cochlear implant has been changed to adapt it for vestibular therapy. Three leads are implanted in three sites in the semicircular canals of the inner ear. This device helps the brain to decode 3D rotational information.
Patients can use specialized exercises that seek to restore function by improving balance, inner ear function and eye reflexes. Exercises can be performed with a therapist or at home. Multisensory integration and integration of the central nervous system is critical to restore a whole and functional vestibular system.