Learning Center: DIZZINESS

non-ear causes of dizziness

As noted above, the somatosensory and visual systems provide information to our cerebellum, which acts as the balance computer. An impairment of one or more of these systems can lead to or worsen imbalance. Common non-ear contributors to imbalance include: peripheral neuropathy (e.g., from diabetes or chemotherapy), presence of an artificial hip or knee joint, drugs that affect brain function, transient low blood flow to the brain (such as in low blood pressure from standing up quickly, a condition known as orthostatic hypotension), and anything impairing vision.

Other common causes of dizziness that do not start in the ear include:

• Vestibular migraine. Migraine can cause attacks of vertigo lasting from 5 minutes to 72 hours, with or without headache. The diagnosis is based on the pattern of symptoms, using criteria from the Bárány Society and the International Headache Society, because there is no test that proves it [3]. About 1% of adults have vestibular migraine in a given year, and in one survey only 1 in 5 of those who saw a doctor received the diagnosis [4]. Treatment follows migraine treatment: identifying triggers, regular sleep and meals, and preventive medication when attacks are frequent.

• Persistent postural-perceptual dizziness (PPPD). PPPD is a chronic, non-spinning dizziness or unsteadiness present on most days for three months or more. It is worse with standing, walking, moving and busy visual surroundings such as stores and scrolling screens. It often begins after an episode of BPPV, vestibular neuritis, migraine or a period of anxiety, and the balance system remains on high alert after the original problem has healed [5]. It is a real, recognized condition, and it is treated with vestibular rehabilitation, certain medications and cognitive behavioral therapy.

• Heart and blood pressure problems. Lightheadedness, especially on standing or with exertion, can come from low blood pressure, irregular heart rhythms, dehydration or blood pressure medications.

• Medications. Sedatives, sleeping pills, some antidepressants, anti-seizure drugs and blood pressure medications commonly cause unsteadiness, especially when several are combined.

• Stroke. Uncommonly, a sudden, continuous vertigo is caused by a stroke in the back of the brain (the brainstem or cerebellum) rather than by the ear. Warning signs include new double vision, trouble speaking or swallowing, weakness or numbness, inability to walk, or a new severe headache. These require emergency evaluation by calling 911.

evaluation for dizziness

As noted above, there are many distinct causes for a sense of dizziness or imbalance, and evaluation starts with the presenting history. Based on this, ruling in or ruling out various causes of dizziness may require additional testing (e.g, audiogram, various balance tests, brain imaging, blood pressure or heart rate monitoring) and/or referral to a neurologist or cardiologist.

Current thinking emphasizes the timing and triggers of dizziness more than the exact word used to describe it [8]. Useful questions are whether the dizziness comes in episodes or is constant, how long each episode lasts, and what sets it off:

• Brief episodes triggered by head position (seconds): usually BPPV.

• Spontaneous episodes lasting minutes to hours: Meniere's disease (especially with hearing changes in one ear), vestibular migraine, or, less often, transient reduced blood flow to the brain.

• A single prolonged episode lasting a day or more (acute vestibular syndrome): usually vestibular neuritis or labyrinthitis, but sometimes a stroke.

• Chronic unsteadiness: loss of balance function in both ears, neuropathy, medication effects, PPPD, or a neurologic condition.

The examination includes looking for nystagmus (involuntary, rhythmic eye movements that reflect the vestibular system), the Dix-Hallpike test for BPPV, a check of walking and standing balance, and a neurologic examination. For a person with continuous vertigo, a three-part bedside eye examination called HINTS (head impulse test, nystagmus pattern, and test of skew) helps separate an inner ear cause from a stroke. In a study of 101 high-risk patients, HINTS was 100% sensitive and 96% specific for stroke, and was more sensitive than an MRI done in the first 48 hours, which missed 12% of strokes [9]. HINTS requires training and is most reliable in the hands of examiners experienced with it.

Tests that may be ordered include an audiogram (hearing test), videonystagmography (VNG) with caloric testing to compare the balance function of the two ears, video head impulse testing, rotary chair testing, and vestibular evoked myogenic potentials (VEMP). An MRI is used when hearing loss is worse in one ear, when the examination suggests a problem in the brain, or when symptoms do not fit an inner ear pattern. Routine imaging is not recommended for typical BPPV [10].

Here are some forms that you can fill out and bring with you to your doctor’s appointment to assist with diagnosis:

• How severe is the dizziness? (Dizziness Handicap Inventory)

• Make the most of your appointment for dizziness

What are the characteristics of the dizziness?

BENIGN PAROXYSMAL POSITIONAL VERTIGO

Benign Paroxysmal Positional Vertigo (BPPV) involves brief but intense periods of vertigo that are triggered by specific changes in head position. It occurs when tiny crystals in the otolith organs become dislodged and migrate to the semicircular canals.

Typical triggers are rolling over in bed, lying down or sitting up, looking up to a high shelf, or bending over. Each spell lasts less than a minute, though nausea and a sense of unsteadiness can linger between spells. In a German population study, the lifetime prevalence of BPPV was 2.4%, about 0.6% of adults developed it each year, and it became more common with age. The median episode lasted two weeks, and only 8% of affected people received effective treatment [11]. Most cases have no identifiable cause; head injury, prolonged bed rest and other inner ear disorders are known triggers.

The Dix-Hallpike test diagnoses BPPV of the posterior canal, the most common type. The patient is moved quickly from sitting to lying with the head turned to one side and tipped slightly back; a characteristic upbeating, twisting nystagmus confirms the diagnosis. A different test (the supine roll test) checks the horizontal canal [10].

BPPV is treated with a canalith repositioning procedure, a series of head positions that moves the crystals out of the canal and back into the utricle, where they no longer cause symptoms. The Epley maneuver is used for the posterior canal. In a Cochrane review of randomized trials, vertigo resolved completely in 56% of patients after the Epley maneuver compared with 21% after a sham maneuver or no treatment [12]. The maneuver can be repeated at the same visit or at follow-up, and some patients learn a version to do at home. The American Academy of Otolaryngology–Head and Neck Surgery guideline recommends canalith repositioning as the treatment, and recommends against routine anti-vertigo medications such as meclizine, routine imaging, and postural restrictions (such as sleeping upright) after the maneuver [10]. BPPV comes back in some patients, at a rate often quoted near 15% per year, and is treated the same way when it does [10].

• Link to frequently asked questions about benign paroxysmal positional vertigo (BPPV) on the ENTHealth website.

• Short YouTube video demonstrating the workings behind the Epley maneuver, which is done specifically for benign paroxysmal positional vertigo (BPPV).

Meniere’s disease

Meniere’s disease is a chronic condition that causes vertigo, tinnitus, fullness in the ear and fluctuating hearing loss that may eventually become permanent. Meniere’s is usually confined to one ear and though its cause is unknown it may be the result of abnormal fluid buildup in the inner ear.

Meniere’s disease is diagnosed by the presence of episodes of

1. tinnitus (noise or ringing perception in the ear),

2. vertigo (a spinning sensation), and

3. sensorineural hearing loss, which is shown on repeat hearing tests to improve.

The international criteria used today define "definite" Meniere's disease as two or more spontaneous attacks of vertigo, each lasting 20 minutes to 12 hours; low- to mid-frequency sensorineural hearing loss in the affected ear documented on a hearing test at least once; fluctuating hearing, tinnitus or fullness in that ear; and no other diagnosis that better explains the symptoms [13]. Meniere's disease is uncommon: in a large United States insurance database, about 190 per 100,000 people carried the diagnosis, women nearly twice as often as men, and it was more common with age [14].

The cause of Meniere’s disease remains uncertain. Treatment, while not curative, may lessen these attacks. Meniere’s disease usually affects only one ear and usually “burns out” over time, with permanent hearing loss as well as fewer episodes.

Treatment follows a stepwise approach in the American Academy of Otolaryngology–Head and Neck Surgery guideline, starting with the least invasive options [15]:

• Education, lifestyle and diet. Limiting salt, caffeine and alcohol and managing stress are commonly advised. The evidence for these measures is limited, but they are low risk [15].

• Medications for attacks. Short courses of anti-vertigo and anti-nausea medicines help during an attack but are not used daily.

• Maintenance medications. Diuretics ("water pills") are often used to reduce attacks, although high-quality trials are lacking. Betahistine is widely used in Europe but is not approved in the United States. In the largest placebo-controlled trial (BEMED, 221 patients), betahistine at low or high dose did not reduce attacks more than placebo; attacks fell by a similar amount in all groups, which shows how much Meniere's improves on its own or with placebo [16].

• Vestibular rehabilitation for unsteadiness between attacks [15, 7].

• Injections through the eardrum (intratympanic therapy) when attacks continue. In a randomized trial of 60 patients with hard-to-control Meniere's disease, two injections of the steroid methylprednisolone reduced vertigo attacks by 90%, compared with 87% for two injections of gentamicin, an antibiotic that works by partially destroying the balance function of the ear [17]. The benefit held up in long-term follow-up [18]. Steroid injections do not damage the ear, so they are often tried first; gentamicin remains an option when steroid injections fail.

• Surgery (endolymphatic sac surgery, vestibular nerve section or labyrinthectomy) is reserved for the small number of patients whose vertigo is not controlled with the above. Labyrinthectomy is used only when hearing in that ear is already poor [15].

Hearing aids help the hearing loss, and the hearing should be checked periodically. More information is on the Meniere's disease treatment page.

Additional resources I recommend:

• Frequently asked questions about Meniere’s disease, from ENTHealth.org.

• Plain language summary of Meniere’s disease from The Academy of Otolaryngology—Head and Neck Surgery. This is excellent.

• A more detailed description of Meniere’s disease by Vestibular Disorders Association.

• Ménière’s Resources Inc.: http://menieresresources.org

• Ménière’s Society: http://www.menieres.org.uk

• Ménière’s Research Fund, Inc.: https://menieresresearchaustralia.org

• Hearing Health Foundation: https://hearinghealthfoundation.org