Dizziness and Its Symptoms
Why Would a Cardiologist Deal With Dizziness?
I see a lot of patients who are sent to me for evaluation of dizziness. On the surface you wouldn’t think a cardiologist would have much to do with a symptom that relates more to the head than the heart. However there is some logic to it—poor blood flow to the brain could lead to dizziness and, since blood flow starts in the heart, that could be the place to look.
While it is true that diminished (or occasional absence of) blood flow from the heart can render a person devoid of the faculties that allow for stable upright posture, true dizziness is rarely the result of impairment of the cardiovascular system.
Three Symptoms of Dizziness
In order to fully explain the possible sources of dizziness we first need to tease out what is meant by the term itself. In my experience people can imply vastly different symptoms when they use the term “dizzy,” but in most cases these symptoms fall into three general categories:
You may experience lightheadedness if you perform movements similar to crouching down near the floor, staying there for about a minute, and then abruptly jump back to the upright position. In many people this will produce a sensation of “graying out.” Fighter pilots feel this when they perform aerial maneuvers that result in excessive force tugging down on their bodies (“pulling Gs”). The vision narrows, light goes gray or even black, but normal sensation resumes within a moment. During those few seconds you may feel unsteady and could even fall down if it lasts longer.
Connection Between Diabetes And Lightheadedness
The sensation of lightheadedness you have relates to something called orthostatic or postural hypotension. In people (particularly people with longstanding diabetes) this can be debilitating, but in others it’s mild and quite natural. I’ve suffered from this for years, as do many tall and thin people. Virtually every time I stand up I can count on losing my vision for a second or two. This is why shorter, stockier people make better fighter pilots—they tend to “gray out” less when there is a shorter distance from the heart to the head.
To have this sensation when you go from a sitting (or crouching) to a standing position is somewhat natural, but to get it spontaneously when you are walking or sitting is very abnormal. A sudden but temporary lightheadedness in this scenario can indeed be a marker for some type of transient cardiac disorder, such as a rhythm disturbance, and your best bet is to start by testing the heart. This type of lightheadedness would probably be most correctly classified as pre-syncope, a term that implies the condition of near-fainting.
Let’s say your walking down your hallway at home and you start to get the perception that you’re tipping to one side. You stagger to right yourself, but even when you’re ramrod straight and steadied against the wall you can’t escape the feeling that the world is off-kilter. No, you’re not an extra in the movie Inception; you’re likely suffering from disequilibrium, a disorder that usually involves some part of the neurological apparatus that your body uses to help you tell what’s up and what’s down. Possible sources of the problem include impairment of the cerebellum of the brain (stroke, tumor), impingement of spinal cord nerves (cervical spondylosis), and generalized neurological disorders such as Parkinson’s disease.
This one’s pretty easy to mimic. Start by finding a local city park that has a well-lubed merry-go-round and a rowdy bunch of kids that want nothing more than to witness an adult reeling and vomiting. The rest will pretty much happen by itself.
The inner ear has an intricate mechanism, called the vestibular system, of keeping track of the movement of your head. I would go into elaborate detail explaining to you the anatomy and function of the semicircular canals, otoliths, and big words like proprioception, but, quite frankly, it’s been 20 years since I last took a physiology course and I can’t really remember how the whole thing comes together. Suffice it to say, it’s really complicated.
If you mess up the vestibular system you’ll feel as if you are spinning in a circle even when you are standing still. The most common cause of this impairment is benign positional vertigo (BPV). This is a disorder that comes as a result of calcium debris building up in the posterior semicircular canal (see what I told you?—big words). It typically manifests itself as a brief, sometimes intense, spinning sensation that accompanies rapid movements of the head. Laying one’s head down on the pillow of the bed seems to be a common inciting event.
Dealing With the Symptoms of Vertigo
One of my brothers is an ear, nose, and throat specialist and I had a conversation with him recently about BPV. He claims that there is an easy and effective treatment for this problem that comes in the form of a “maneuver” that is easily done in the office. What follows is a description of the Epley maneuver from Wikipedia:
“The procedure is as follows:
- Sit upright.
- Turn your head to the symptomatic side at a 45-degree angle, and lie on your back.
- Remain up to 5 minutes in this position.
- Turn your head 90 degrees to the other side.
- Remain up to 5 minutes in this position.
- Roll your body onto your side in the direction you are facing; now you are pointing your head nose down.
- Remain up to 5 minutes in this position.
- Go back to the sitting position and remain up to 30 seconds in this position.
The entire procedure should be repeated two more times, for a total of three times.
During every step of this procedure the patient may experience some dizziness.”
Of course, if you’re not the Circue du Soleil type you can always try medication. Call me skeptical, but I have a hard time believing that this sort of thing can provide relief from BPV. My brother swears by it (as do several of my patients) even if it seems like a throwback to the days of liniments and snake oils.
Who Should I See Depending on the Variation of Dizziness?
So, which is it? Lightheadedness? If so, start with a look at your prescription medications and think about asking your doctor to look at the heart. If it’s a balance problem you have, you may want to find a neurologist. For vertigo—when the room spins even when you don’t—you could end up in the office of an ENT. In one published study that tallied the various causes of dizziness in a primary care clinic, the breakdown was as follows: BPV 54%; lightheadedness (presyncope) 6%; disequilibrium 2%; and psychiatric 16%. It was multifactorial in 13% and unknown in 8%.
Whenever I see someone who complains of “dizziness” I try hard to quickly find out what the patient is really experiencing before I order a single test. Of course, if patients have difficulty understanding what I mean by the various types of dizziness, I don’t mind taking a few minutes to show them. After all, it’s not all that hard to find a well-lubed merry-go-round.
Original post date: Oct. 2010, Revised: May 2019
Wow, you guys are quite the team. Dr E. VDG, this is the same SVT guy from last month. Just want to say I really enjoy and learn plenty from your blogs. Thanks for being available. Ray
As Dr. Van De Graaff's "ear, nose, and throat brother" I feel I need to comment on this blog. I agree completely with his description of the three major forms of dizziness. I also agree that it is frequently difficult for people to place a finger on exactly what they mean by being dizzy. This can be difficult not only for patients but also for primary providers to ascertain unless they ask the right questions. Not infrequently I will see patients in my office referred for vertigo when in actuality the patient is lightheaded and needs to see someone else. Benign paroxysmal positional vertigo (BPPV) is a common cause for vertigo. It usually comes on for no reason, but can be associated with a head trauma. There are however many other causes for true vertigo. Thus it is important for patients with persistent vertigo to be seen by a specialist who understands vertigo so that the true cause can be determined. I have seen patients in the past who were given the diagnosis of Meniere's disease and placed on Meclizine, sometimes for years at a time. Several of these patients actually had BPPV and I was able to clear their symptoms with the Epley repositioning maneuver. One point on which I disagree with my brother is the efficacy of the Epley maneuver. Reports in the literature and in my experience place the success rate of the maneuver at over 90% in resolving the vertigo. It is not a "throwback to the days of liniments and snake oils." In fact, the patient is being rolled in the plane of their offending posterior semicircular canal; thus allowing the calcium crystals to drop out of the canal and be reabsorbed. The bottom line for a patient is that they should ask themselves if they feel lightheaded, off-balanced, or vertiginous. Once he/she has established an answer for that question, then he/she should seek out the right specialist who can help in resolving those symptoms.
Alright, Eric and Ryan, lets get a good fight going! Call me crazy but I'm going to side with Ryan when he says something about the ear, nose or the throat. I'll side with Eric when he claims expertise on the heart. Congratulations Ryan on your first comment. Now I want to see one on Arie's blog.