The Basics - Dizziness

A systematic approach to management is needed, writes Dr Keith Barnard.

Problems with balance may be due to inner ear disease (SPL)
Problems with balance may be due to inner ear disease (SPL)

In an average practice a GP is likely to see at least 30 patients each year complaining of dizziness or vertigo.

Dizziness is best managed with a systematic approach, and practitioners should take heart in the fact that it is rarely a serious condition, with less than 5 per cent of patients needing a referral. Most cases can be managed with advice alone or with medication.

Understanding symptoms
When the patient first presents, it is vital to determine exactly what the patient is experiencing, because patients mean different things by the term 'dizziness'.

This can be done by direct questioning, or by asking the patient to describe what they are experiencing.

The patient may have a definite rotational sensation (vertigo), a balance problem, they may be feeling weak or light-headed, or it may be their way of saying they are emotional or distressed.

Possible causes of dizziness range from the Arnold-Chiari malformation to the subclavian steal syndrome, but in day-to-day practice the most common causes of true vertigo encountered are labyrinthitis or vestibular neuronitis, benign paroxysmal positional vertigo (BPPV), vestibular migraine, and Meniere's disease.

Acoustic neuroma, cerebro-vascular events and multiple sclerosis are rarer causes of vertigo.

Problems with balance without rotational symptoms may be due to inner ear disease, peripheral neuropathy, cerebral disease, alcohol and drugs, or general frailty due to old age, illness or a combination of both. Problems with balance in the elderly are particularly important, because of the risk of falls that may cause further incapacity.

Balance does not rely only on the functioning of the semi- circular canals. It requires vision, proprioception and vestibular input as well as an adequate musculoskeletal system.

Because all these functions may be compromised to some degree by ageing, it is not surprising that dizziness in some form is a common complaint among older patients.

If the patient does not have rotational symptoms or a clear problem with their balance, the symptoms are often described in a vague fashion that leads to the term 'light-headedness' or feeling faint.

There may be a specific cause for such symptoms, including orthostatic hypotension, anaemia, or cardiac arrhythmias.

Often vague complaints of feeling light-headed are due to anxiety. It is always wise to ask about any medications the patient is taking, because many information leaflets list dizziness as a side-effect, although rarely is the type of dizziness the patient may experience accurately described in the literature.

Although serious disease is rare, there are a number of red flag symptoms that demand attention and possible referral .

Treating dizziness obviously depends on the cause.

Anxiety-related
If the description is of light-headedness or feeling faint and there are no obvious causes such as severe anaemia or an arrythmia, it is important to stress to the patient that there is unlikely to be a serious physical illness.

They may be worried about an impending stroke or imagine they have a brain tumour and this anxiety only serves to compound the symptoms.

However, anxiety-related dizziness can be frustrating for the GP and the patient, as there is usually no quick fix.

The background needs careful exploration, and if there is obvious depression and anxiety, this can be treated appropriately with counselling, medication and cognitive behavioural therapy.

It may be tempting to dismiss symptoms of dizziness once an anxiety-related cause has been identified, but the patient must not feel that their symptoms are being ignored or imagined. Sympathy and support can be all-important in this situation.

Vestibular causes
Labyrinthitis and vestibular neuronitis have similar causes and symptoms and it can be difficult to distinguish them.

Vestibular neuronitis is not usually associated with any hearing loss, while labrynthitis may follow an URTI. In either case the patient experiences true vertigo and nausea, often with vomiting.

The symptoms are often self-limiting, but may be eased by prochlorperazine, promethazine or domperidone. If vomiting is severe, a preparation that is absorbed through the buccal mucosa or administered in the form of a suppository may be offered.

Referral is rarely necessary, but if the symptoms do not settle after a week or so, vestibular rehabilitation therapy that includes oculomotor, balance and gait exercises may help.

BPPV
BPPV is characterised by brief recurring episodes of vertigo triggered by a change in head position.

It is thought to be caused by displaced otoconial crystals (the calcium carbonate crystals normally embedded in the saccule and utricle) that stimulate hair cells in the posterior semicircular canal, creating the illusion of motion.

The symptoms may subside after several weeks, but can return. When persistent or troublesome, attempts at canalith repositioning may be effective. These techniques include the Epley and Semont manoeuvres.

A GP with a special interest in ENT may learn these techniques, but often referral is necessary.

Another method of treatment depends on the fact that BPPV symptoms are fatigable. The patient is taught to perform provocative manoeuvres early in the day in a safe situation. The symptoms are then much less troublesome or absent for the rest of the day.

Medication is rarely helpful in BPPV.

Meniere's disease
Meniere's disease is an important condition that can cause considerable disability. It is an inner ear disorder that produces vertigo, fluctuating sensorineural hearing loss, and tinnitus. About 1 in 1,000 people are affected, most commonly between the ages of 20 and 50.

It usually affects one ear, but about 40 per cent of cases are bilateral. There is no diagnostic test, and the diagnosis may only become clear over time as the typical pattern of recurrent episodes becomes clear.

Treatment depends on the severity of the symptoms. Betahistine, a specific histamine agonist, is thought to work by increasing the blood supply in the inner ear, resulting in a reduction in pressure in the endolymphatic space. Long-term use (six to 12 months) may reduce the frequency and severity of attacks. Diuretics or beta-blockers may also help.

More extreme techniques for intractable vertigo involve chemical labrynthectomy with injections of gentamicin, or surgical vestibular neurectomy.

Tinnitus
Persistent and severe tinnitus can be disabling and cause depression, and in these cases masking of the tinnitus or using distraction may help, as well as relaxation techniques.

Referral to a tinnitus clinic is an excellent option if there is one available.

  • Dr Barnard is a former GP in Hampshire.

Red flags in dizziness

  • Unilateral or bilateral hearing loss.
  • Severe tinnitus.
  • Aural pain or discharge associated with CNS symptoms including headache or blackouts.
  • Persistent or recurring symptoms.
  • Recurrent vomiting.
  • Inability to function at work/childcare/school.
  • Associated discernable muscle weakness or numbness.

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