Stop the Spinning
By Daniel DeNoon
Sept. 17, 2001 -- At first, Diane Tucker just felt a little dizzy once in a while. Then the spells got worse.
"It would come on out of the clear blue," Tucker tells WebMD. "I remember being at a movie when I just started feeling nauseous. My husband had to carry me home. There was no way I could walk. It was like having the spins from drinking too much, but it wouldn't stop. The spells went on for over a year -- it would last for a few hours and then it would be gone. "
During one of these spells, Tucker was sent to an emergency room where doctors -- fearing she had eaten contaminated oysters -- ordered her stomach pumped. After seeing four doctors, all she was told was that she probably had "some kind of allergic reaction."
Fortunately for Tucker, her job is managing records for a medical clinic. One record that crossed her desk described a young woman with symptoms exactly like hers. She called the doctor -- a neuro-otologist, a specialist in disorders of the brain and ear. Tests showed she had Meniere's disease.
"It was such a relief to get a diagnosis," Tucker says. "I was wondering if I had a brain tumor, or if I was just crazy. They put me on a diuretic and an antihistamine, and that controlled it for a year. Finally, my doctor talked me into surgery because I couldn't hear out of that ear anyway."
The recovery was difficult, says Tucker. "You come out of that surgery and you are spinning again just like you are having one of those reactions. You have to learn how to walk again, because your balance is totally off."
If You're Dizzy, See a Doctor
Relatively few dizzy people will have to go through an ordeal like Tucker's, but dizziness, a very common complaint, can be serious. If you're experiencing unexplained dizziness, a trip to the doctor is a good idea, says neurologist Martin Allen Samuels, MD, professor of neurology at Harvard Medical School and chairman of the neurology department at Boston's Brigham and Women's Hospital.
"Dizziness is a very rich problem because it contains pieces of internal medicine, a lot of neurology, a lot of otolaryngology [ear, nose, and throat medicine], and a lot of psychiatry," Samuels tells WebMD. You have to know a fair amount of medicine to be a 'dizzy' doctor, [so some] primary care doctors get anxious. They order too many tests ... and patients get frustrated."
"You should tell your primary care doctor what the sensation is like," says Samuels. "Dizziness means something different to every person -- it has no specific medical meaning, and different cultures have different words to refer to it."
Thoroughly describing your symptoms can really help your primary care doctor get to the root of the problem. "He or she should take a careful history, do a brief examination, and make the proper referral" to a specialist, if necessary.
If your primary care doctor thinks your dizziness is due to a heart problem, for example, you would be sent to a cardiologist. If your symptoms suggest a brain or nerve problem, you would be sent to a neurologist. And if the problem seems to be psychological in nature, your may be referred to a psychiatrist or psychologist.
But don't just get a bunch of tests without some idea of where the problem lies. Samuels and otolaryngologist Richard L. Prass, MD, PhD, both say that expensive tests can be a waste of money unless ordered by a specialist looking for something specific.
How can a doctor tell where to send you? Samuels says that the type of dizziness you describe can point a primary care provider in the right direction. He identifies four distinct types: vertigo, lightheadedness, disequilibrium, and anxiety.
Type 1 -- Vertigo
"Vertigo is the feeling of motion when there is no motion," Samuels says.
It's a feeling common to every child who's spun himself around and around. "But if it happens in the course of normal daily living, it is a symptom -- one that accounts for half of all dizzy complaints," he says.
Vertigo means there is a problem with the vestibular system of the inner ear -- the part of the nervous system that tells you which way is down (the sense of gravity), and also lets you sense the position of your head.
"When the vestibular system is malfunctioning, people have a sensation of motion either of their head or of their relation to the earth below them -- that is the symptom of vertigo," Samuels says.
There are two very common causes of vertigo:
- Infectious agents, such as the viruses that cause the common cold or diarrhea. "A week after infection some people get vertigo," Samuels says. This harmless condition usually goes away by itself within 6-8 weeks, although drugs are available if it is severe.
- Benign paroxysmal positional vertigo or BPPV. This is another harmless condition caused by movement of the otolith -- a tiny calcium particle the size of a grain of sand -- from the part of the ear that senses gravity to the part that senses head position. The person feels as if their head is turning when it isn't. A two-minute therapy done right in the doctor's office can move the otolith back where it belongs and fix the problem.
Another cause of vertigo is Meniere's disease, a disorder characterized by long-lasting episodes of severe vertigo.
"A person usually can't do anything but lie down or they get very nauseated," says Prass, president of Atlantic Coast Ear Specialists and assistant professor at Eastern Virginia Medical School, in Norfolk.
"Other typical symptoms of Meniere's disease are tinnitus -- a roaring and obnoxious buzzing [in the ear], hearing loss, and a feeling of pressure or fullness in the ear," he says. In fact, symptoms of Meniere's disease may be what led van Gogh to cut his ear off.
Another vestibular problem is Dandy's syndrome.
"Dandy's syndrome is when everything bounces up and down," Prass says. "It can happen [to people who have] had to have an antibiotic that is toxic for the ears. Such patients can lose all of their inner ear function for balance [and] have a real bad problem when they try to walk: The world bounces up and down and sometimes all they can do is put their head against a building and hold on. Even a heartbeat will make the world jump."
Dandy's syndrome usually improves over time. The bad news is that less common, deadly diseases also can cause vertigo.
"The most serious conditions are related to stroke," Samuels says. If a stroke damaged an artery that supplies blood to the brain, dizziness can result. "But generally," he says, "people with vertigo from a serious cause also have other symptoms, the most important of which are double vision and slurred speech. It would be very uncommon to have only vertigo and to have a very serious [central nervous system] disease."
Type 2 -- Lightheadedness
The technical term for type 2 dizziness is "near syncope" -- the feeling that one is about to faint.
"Like vertigo, everyone knows what this feels like because we all know what it is like to breathe deeply [enough times] to produce a sensation of lightheadedness," Samuels says. Usually, lightheadedness is caused by some surrounding circumstance impairing blood flow to the brain when a person is standing up, he says.
Blame this problem on our ancestors who learned to walk upright -- putting our brain above our heart. It's a challenge for the heart to keep the brain supplied with blood -- and it's easy for this system to break down.
When blood vessels in the brain become dilated, or expand, due to high temperature, excitement or hyperventilation, alcohol consumption, or prescription medications such as antidepressants, a person can become lightheaded. There can also be more serious causes, such as a stroke and heart disease.
Most of the time, lightheadedness is harmless, says Samuels. "We treat [patients] by getting rid of the cause, or warning them not to stand too rapidly, or to put their brain at the level of their heart if they feel lightheadedness coming on. We doctors worry if we hear of [lightheadedness] in an older person, in a person not on suspect drugs, or if it happens while exercising."
Type 3 -- Disequilibrium
"Type 3 dizziness is disequilibrium -- a problem with walking," says Samuels. "People feel unsteady on their feet, like they are going to fall."
Disorders that can disequilibrium include:
- A kind of arthritis in the neck called cervical spondylosis, which puts pressure on the spinal cord.
- Parkinson's disease, or related disorders that cause a person to stoop forward.
- Disorders involving a part of the brain called the cerebellum.
- Diseases such as diabetes that can lead to loss of sensation in the legs.
Doctors diagnose disequilibrium by conducting a simple neurological exam and watching the patient walk, says Samuels. Treatment involves determining and then treating the underlying cause which could be alcohol, or a drug such as Dilantin that affects the cerebellum, or a disease such as cancer, he says.
Type 4 -- Anxiety
Dizziness type 4 is anxiety.
According to Samuels, people who are scared, worried, depressed, or agoraphobic [afraid of open spaces] use the word dizzy to mean frightened, depressed, or anxious.
"You can recognize this type of dizziness because if you take the word 'dizzy' out of all their sentences and replace it with the word 'anxious,' their sentences make more sense," he says.
Type 4 dizziness is often, but not always, caused by depression, says Samuels.
"It could also be [due to] an anxiety disorder, or the patient may have phobias in the family, in which case a psychiatrist could [prescribe] appropriate medications or psychotherapy or behavior-modification therapy," he says.
Samuels says that on average, every 1,000 dizzy patients will have 1,500 dizzy complaints. This means that many people will have more than one type of dizziness.
"It is common to see a person with vertigo from post-viral infection [and also from] anxiety -- because vertigo makes them anxious -- so they have a combination of type 1 and type 4 dizziness," he says. "Or, they are dizzy because of near-fainting episodes because one doctor has put them on medications that cause dizziness, and this has made them anxious. A patient could have all four types of dizziness, but that would be quite rare indeed."
In these mixed-type dizziness cases, Samuels would try to identify the main cause and treat it first in the hope that secondary causes would be related to the first.
Long-Lasting, Chronic Dizziness
Nearly everybody who is dizzy will get better. This is because a person's sense of balance is a complex interaction between the brain, each ear's separate vestibular system, and the sense of vision. When one component breaks down, the others usually learn to compensate.
"There is not a major chance of permanent dizziness," Samuels says. "I don't think there is any reason why the nervous system can't compensate for a broken vestibular system. People with vestibular problems due to physical injury nearly always compensate. So if you can't [compensate] when there is no physical injury, it means [a problem of mental or emotional origin]. This doesn't mean a person is not suffering -- if they say it, it is so. The question is how can I help them. The answer is by not messing with the vestibular system, but by dealing with the psychogenic issue."
This may be trickier than it seems.
"Patients want us to fix their problem either by giving medicine or by cutting something out," says otolaryngologist Prass.
"Chronic imbalance can be fixed with balance therapy, but if a person is uptight it is not going to work," he says. "For example, if you always associate symptoms with going to the grocery store, we can treat the person's disease, but if you still tighten up when you approach the store, it can be a real roadblock to recovery."
In such cases, says Prass, stress management and relaxation therapy may help.
Balance therapy uses sophisticated devices to make a person relearn their sense of balance. Samuels notes that there is no evidence that the difficult-to-tolerate treatment has any long-lasting benefit. But Prass says that it can help some patients who tend to get dizzy on specific, predictable occasions.
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