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Common Causes of Ongoing Dizziness

Interviewer: Feeling dizzy or off balance for a short time can be unsettling, but what happens when dizziness or vertigo becomes a constant struggle? For some patients, dizziness lingers for months and sometimes even years despite seeing primary care doctors and specialists. But nothing seems to work, so what's next?

To help share their expertise, we're joined by Dr. Judith Warner, a neuro-ophthalmologist at the John A. Moran Eye Center at the Ï㽶ÊÓƵ of Utah Health.

Dr. Warner, why don't we start with just kind of a basic understanding of chronic dizziness and vertigo? What are some of the more common causes that people might experience these symptoms for longer than just an acute situation?

Dr. Warner: The causes are numerous when it comes to acute dizziness, but there are just a couple of things that you need to worry about when you have chronic dizziness.

When we see patients with chronic dizziness, we ask that they see their primary care doctor to make sure that there's not a cardiac issue going on that's leading to more of a lightheadedness, to make sure that there's nothing neurological going on, such as seizures that might give an intermittent dizziness.

Inner Ear Injuries and Lasting Effects

But once the medical situation has been evaluated, what we like to do is to get a thorough examination of the patient themselves and also of their inner ear function. Sometimes people are chronically dizzy because of a prior injury that happened to their inner ear system, and sometimes they're dizzy because of a migrainous tendency. Those two are probably the most common causes of what we call chronic subjective dizziness.

So when we are seeing patients with chronic dizziness, we ask that they get a special test of their inner ear system to make sure that there hasn't been or isn't any ongoing inner ear damage. And we work really closely with our ENT colleagues in that regard.

Persistent Postural-Perceptual Dizziness

The most common chronic, all-the-time dizzy sensation is something called PPPD, persistent postural-perceptual dizziness. And that's a really interesting phenomenon that occurs . . . it's thought to be a poor recovery from an inner ear event. Sometimes that's a concussion, but a lot of times it's actually a real, honest-to-goodness spinning, dizziness thing that puts you right down.

But then, when you recover from that . . . most people recover and they spring back to normal. Some people do not recover properly, and they're left constantly dizzy. It's miserable.

Chronic Sensory Sensitivities Linked to Migraine

The other major group is people who have migraine, and people can have migraine affecting their dizziness in two main ways.

The first is vestibular migraine, which is migraine involving the inner ear system, where they will have attacks of vertigo, which are related to a history of or ongoing migraine headache.

The tricky thing is that a lot of people who have migraine will have a visual aura, and that's usually very tidily related to the headache. They'll have flashes and sparkles in their vision for 20 minutes, half an hour, and then they get a headache.

With vestibular migraine, the vertigo is often not time-wise associated with a headache. So people will get a headache once a month, and they'll have attacks of vertigo every day. Usually, that's a real vertigo.

The other thing that can happen to people with migraine is that they tend to be very, very sensitive to problems with their inner ear, and their vision is overly stimulating.

So, almost everybody with migraine tends to be a little more carsick than your usual person. Almost everybody with migraine tends to be a little more light-sensitive than a normal person. And they can also be very bothered by visual stimulation like stripes, flickering lights, and fluorescent lights.

But if you take that visual sensitivity of migraine, which exists all the time in migrainous people, not just when they're having the headache, and you ramp that up a couple of percentage points, then you can have a situation where every visual stimulation, like going to a big box store, or driving on a windy road, or just driving with all the cars going by and the lamp standards going by, can make you feel dizzy.

The Role of the Inner Ear in Balance Problems

Interviewer: So what is it about the inner ear and maybe a problem with the inner ear that causes maybe dizziness or this kind of vertigo sensation?

Dr. Warner: The inner ear is responsible for our brains being able to detect movement in every direction. And so if you have a problem, say, with one of the crystals in the inner ear or inflammation of the nerves of the inner ear, it causes an imbalance between the two inner ears, and that will set off vertigo.

Key Red Flags That Shouldn’t Be Ignored

Interviewer: What are some red flags? I mean, there are a bunch of different kinds of things that could be causing these symptoms of chronic dizziness or vertigo sensations. But are there any red flags that a patient who might be experiencing these symptoms should really be looking for to let them know, "Hey, you really should be going and getting this seen"?

Dr. Warner: Absolutely. Some of the really significant red flags are things like pressure in an ear, hearing loss in an ear when the vertigo is happening. That's very, very important. Double vision during the dizziness is very, very important. Inability to walk when you're dizzy, very important.

Intractable, ongoing nausea or vomiting. Now, almost all people who get dizzy will get nauseated with it, but if you are having just ongoing vomiting, that's a red flag.

In the other category of a more chronic dizziness, there's what we call ataxia. Ataxia is a problem where, with your arms and legs, you're uncoordinated. So when you reach for an object, you can't get your hand right on target, or as you're walking down the hallway, you might be staggering around like you're drunk.

One of the things that we do in neuro-ophthalmology, which is a critical part of this evaluation, is look for what we call central causes of dizziness. And if somebody has, for instance, a hereditary or an acquired disorder of their cerebellum, they may be very off balance.

They usually won't have spinning dizziness, but they can definitely feel dizzy in their head. And we're looking for any signs on the examination that point to a cerebellar disorder, some sort of a degenerative condition like that. Very, very important.

When to Seek Immediate Medical Attention

Interviewer: So with those types of symptoms that we really want to get checked out, is that something that's maybe emergent? Should they be going to an InstaCare or an ER, or is this something that we can kind of deal with just as we go to our day-to-day doctors?

Dr. Warner: If you've never had vertigo before and you have sudden vertigo where you can't function, you can't walk, and it goes on for more than a minute or two, you need to go to the emergency room. That could be a stroke. It could be life-threatening.

Treatment Strategies for Persistent Dizziness

Interviewer: So if they have any of these symptoms, if they've been experiencing dizziness for a long time, and they've worked with their primary care person, they've tried some of these basic first-line approaches, what kind of treatment are we looking with afterwards that could help a person get some relief from these symptoms?

Dr. Warner: It's so important because it can be very disabling. Interestingly, there are some very simple things that can be done. I would guide people to our website, the , which is not a brick-and-mortar school, but which is an actual informational website, because it gives lots and lots of information on how to treat and diagnose PPPD and vestibular migraine.

Vestibular Therapy, Medications, and Cognitive Behavioral Therapy

For PPPD, the treatment is a combination of vestibular therapy, so it's like physical therapy for the balance system, usually SSRIs or SNRIs, which somehow help to rebalance the body's ability to deal with dizzy sensations, and cognitive behavioral therapy.

Cognitive behavioral therapy is not psychotherapy where you're going in and talking about your early childhood experiences. It's very day-to-day practical, "How can I function with this dizziness so that it's not taking over my life?"

The problem with dizziness that I have experienced is that dizziness is very primal. When you feel dizzy or off balance, it brings out one of the most fundamental fears of humans, which is falling. And so it can cause quite a panicky-type reaction, and that just makes things worse. And so a lot of people with PPPD can help to temper their response to the disease sensation and reduce the worsening that happens with the fear it induces.

With regard to the second category, which is vestibular migraine, a lot of migraineurs will benefit from a special tinted lens called FL-41, which is widely available, as well as its more recent cousin called Avulux, which helps to reduce the visual input to the brain, which is known to be irritating to the migrainous brain.

It's screening out a certain wavelength that helps to reduce light sensitivity, and that can work brilliantly for big box stores, for computers, for fluorescent lights, for all that light sensitivity and brain irritation that comes with the migraine.

With regard to the actual vertiginous component of the migraine, that's actually treated just like migraine itself. And recent studies are suggesting that some of the newest migraine medications that are available, the CGRP inhibitor medications, can have great benefit for vestibular migraine in addition to our tried-and-true migraine treatments, all of which are outlined on the Dizzy School and also the Ï㽶ÊÓƵ of Utah's Headache School.

: A Patient Resource for Recovery

Interviewer: For those listening, we'll make sure to include the links to the Dizzy School in both the show notes and the description of this piece. That sounds like a great resource. How did it come to exist in the first place?

Dr. Warner: Well, about five or six years ago, as I was seeing my thousandth dizzy patient, I became frustrated because I didn't really feel like I had an organized approach to people with chronic dizziness.

And so I reached out to some colleagues who specialize in vestibular therapy and vestibular evaluation, some ENTs who are interested in inner ear function, as well as colleagues in neuro-ophthalmology. We had a series of meetings going over an evidence-based approach to chronic dizziness, and that was actually how the Dizzy School was born. I just can't thank those colleagues enough, because they're what made it happen.

Since then, I've been spreading the idea as well as possible, and even took this information to the Bárány Society, which is the inner ear portion of the ENT world. I was very pleased with how interested people were in this kind of resource for patients.

Hope After Chronic Dizziness: Regaining Control of Your Life

Interviewer: Wow, that sounds like a really cool resource. And again, we'll include the link so people can kind of go and check it out if they're curious about it.

But I did have one last question. If there is someone out there who is listening, or maybe a family member or a loved one of someone who is experiencing these types of symptoms, what is your advice to those people who feel like they've already exhausted the options available to them, and maybe they're still struggling?

Dr. Warner: I like to have an organized approach to this. The first thing is to make sure that you've had adequate testing of the central nervous system and inner ear system, and just make sure that everything is okay.

The next thing is to stop testing and start working on getting better. And if you bring information, for instance, from the Dizzy School to the people who are trying to help you, you can help educate them and help get you the resources you need.

These are things like talented vestibular therapists who can help with reducing the dizziness, your primary care doctor if there needs to be any medications, as well as all the resources at the Dizzy School.

I can personally attest that I've had many, many patients, once they feel like they have agency, once they feel like they have a direction to go, be able to get these symptoms under control and resume a normal life.