Published in InterAction 73, Autumn 2010
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Dear Doctor: Frequent dizzy spells
I have been suffering from M.E. as part of chronic Lyme disease (My GP failed to diagnose and treat the Lyme disease) for 12 and a half years. I am 71 years old and have felt very isolated in spite of great support from my family. My biggest problem at the moment is frequent dizzy spells. Do you have any ideas how to combat this?
Dr Alastair Miller replied:
I think your question raises two important issues. One is the relationship between Lyme Disease and M.E. and the other is the causes and treatment of dizzy spells. In this issue I shall concentrate on the treatment of dizzy spells.
The term ‘dizzy spells’ can mean a variety of different things to patients suffering from them and to health care practitioners being consulted about them.
Dizziness is an extremely common symptom for those with and those without M.E. In the vast majority of cases it is a completely benign and often self-limiting condition that does not indicate any serious underlying disease. However, if it is persistent or disabling then it should be evaluated more thoroughly by a doctor.
The important initial distinction is between vertigo and light headedness.
Vertigo is a very specific symptom which is defined as a disabling feeling that the body or outside environment is moving. Usually this means a sensation that one’s surroundings are spinning around but sometimes it may mean the feeling that the floor is tilting or becoming unstable.
Whilst these symptoms may occur in M.E. there are a number of other specific medical conditions that may cause them. Any new onset of vertigo requires careful evaluation initially by a GP, and potentially with referral on to an appropriate hospital specialist (in practice this usually means an ear, nose and throat surgeon, a general physician or a neurologist).
The main organs of the body that are concerned with balance and fine control of body movements are the organs of balance in the inner ear (variously known as the labyrinth or semi-circular canals) and the lower back part of the brain called the cerebellum. Damage or disease of either of these organs or their nerve connections can lead to true vertigo.
Symptoms that may frequently accompany vertigo include disturbances of hearing (deafness and tinnitus, a high pitched buzzing in the ears) and vomiting. When a doctor examines an individual with vertigo, they should look for an abnormality called nystagmus which is a rapid, lateral, ‘flicking’ movement of the eyes.
From the symptoms alone it can be difficult to distinguish between disease of the cerebellum and disease of the labyrinth, except to say that deafness and tinnitus would usually point towards labyrinth disease. The most common causes of labyrinth disease are benign positional vertigo and acute labyrinthitis.
Benign positional vertigo causes sudden onset of vertigo associated with head movements or holding the head in a specific position. It is thought to be due to movement of small particles within the labyrinth and can often be cured by specific head manoeuvres that can be performed by a GP or specialist.
Acute viral labyrinthitis seems to be due to a paralysis of the fluid in the canals caused by a viral infection. It may be associated with other features of a viral infection such as sore throat, ear ache etc. It is usually self limiting.
Ménière’s disease is another common cause of dizziness. It consists of a combination of vertigo, deafness and tinnitus and can be quite resistant to treatment.
However, vertigo may also be a feature of a benign brain tumour called an acoustic neuroma that can be cured by surgery (and of course, the earlier diagnosed, the better). So, as I have said above, any new onset of vertigo that does not settle rapidly requires medical evaluation.
The main cerebellar causes of vertigo are multiple sclerosis and stroke, and clearly these also need urgent evaluation.
If you suffer from vertigo and it is felt to be of benign origin then there are a variety of drugs that may improve the symptoms. These include drugs such as cinnarizine (Stugeron) or prochlorperazine (Stemetil) that are also frequently used for treating and preventing nausea, vomiting and seasickness.
Lightheadedness is a more difficult condition to define but I think we all know what we mean by the term and have probably all experienced it at one time or another. Again it may have a variety of causes and is not an uncommon symptom amongst those with M.E. In many situations, no specific cause or mechanism of the symptom is found in those either with or without M.E.
However, as with vertigo, occasionally light headedness can be a symptom of major disease such as abnormal heart rhythms or epilepsy, so once again new onset of this symptom or a change in its nature mandates medical evaluation.
A common cause of lightheadedness is postural hypotension, which is the blood pressure dropping significantly when an individual rises from the sitting or lying position. This can be easily diagnosed by taking lying and standing blood pressure measurements. It can be caused by a variety of conditions including overtreatment with blood pressure pills, diabetes, dehydration and occasionally reduced function of the adrenal glands (Addison’s disease).
Patients with recent onset of lightheadedness will require careful evaluation by a GP. This may be followed in some cases by further tests and/or a referral to a hospital specialist, probably a neurologist, a cardiologist or an endocrinologist.
If serious alternative diagnoses are excluded and the symptoms of dizziness are left attributed to the M.E., there are certain strategies that can improve the situation.
Often the realisation that this symptom does not suggest severe underlying disease may be all that is necessary, but if the symptoms themselves are disabling or distressing then a number of approaches can be tried.
It is helpful to rise slowly from a recumbent position. If the symptoms are caused by postural hypotension then that is especially important. It may help to increase salt intake and/ or wear compression stockings.
It may be important to consider if there are any drugs being used for the treatment of high blood pressure that could be stopped. It is always important to try and avoid situations where a sudden dizzy spell might lead to a serious injury such as when climbing ladders, driving or riding a bicycle.
Hopefully this review has given you some insight into the causes of dizziness and some practical tips on improving the situation.
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