Managing Persistent Dizziness: Insights from Neurology and Emergency Care

Recurrent dizziness?

Hello Dr.
Hong, I have been experiencing severe dizziness recently, accompanied by vomiting and diarrhea, which led me to visit the emergency department.
They assisted with blood tests and a CT scan of my brain (which showed no issues).
The dizziness and vomiting require treatment with antiemetics and analgesics (sometimes I experience headaches along with dizziness) before I can find relief.
I usually take Cinnarizine for dizziness; if that doesn't help, I add Nortriptyline and Betahistine.
If the symptoms persist, I seek emergency care.
I would like your opinion on whether any further tests are necessary based on the following blood test results before seeing a neurologist.
The brainstem examination showed no problems, and I was advised to perform canalith repositioning maneuvers.
However, I still experience significant dizziness about once a week, without a specific time of occurrence, and this has been ongoing for approximately 7 years.

Here are my blood test results:
RBC (Red Blood Cells): 4.12 (normal range: 4.2-5.4)
HCT (Hematocrit): 35.3 (normal range: 37-47)
Lymphocyte: 18.1 (normal range: 19-48)
Potassium (K): 3.2 (normal range: 3.6-5.2) --> but the ECG was normal, as confirmed in the emergency examination.
APTT (Activated Partial Thromboplastin Time): 31.8 (normal range: 32-45.1)
Thank you for your assistance!

Miss Hong, 30~39 year old female. Ask Date: 2021/07/09

Dr. Hong Weibin reply Neurology

Hello,
I apologize for the late response.
There are many causes of dizziness.
If you have already undergone imaging studies of the head and confirmed that there are no structural issues in the brain, a detailed medical history inquiry is necessary for diagnosis.
Generally, the causes of dizziness can be divided into central and peripheral types.
The central type is more commonly associated with recurrent dizziness due to migraines, known as migraine-associated dizziness, which often accompanies headaches but can also occur without them.
The peripheral type is usually related to issues with the inner ear vestibular system, such as benign paroxysmal positional vertigo (BPPV), labyrinthitis, Meniere's disease, and perilymphatic fistula, among others.
Each of these conditions has its own characteristics, and a thorough medical history is essential for accurate diagnosis.
Most of these conditions can be managed with medication to alleviate symptoms, but they may not completely resolve and can recur.
You may want to ask your physician if they can arrange for audiometry, brainstem auditory evoked potentials (BAEP), cervical vestibular evoked myogenic potentials (cVEMP), and videonystagmography (VNG), among other tests, which may be available at an ENT department in a medical center.
I hope you recover soon!
Best regards,
Hong Wei-bin

Reply Date: 2021/07/09

More Info

Managing persistent dizziness can be quite challenging, especially when it is accompanied by other symptoms such as vomiting and diarrhea. Based on your description, it seems that you have been experiencing dizziness for about seven years, with recent exacerbations that prompted emergency care. The fact that you have undergone blood tests and a CT scan of the brain, both of which returned normal results, is a positive sign, but it does not completely rule out underlying issues that may require further investigation.

Understanding Dizziness
Dizziness can stem from a variety of causes, including vestibular disorders, neurological conditions, cardiovascular issues, and even metabolic imbalances. Given your symptoms of dizziness accompanied by vomiting, it is essential to consider both central (neurological) and peripheral (vestibular) causes.
1. Vestibular Disorders: These include conditions like Benign Paroxysmal Positional Vertigo (BPPV), vestibular neuritis, or Meniere's disease. The recommendation for ear stone repositioning exercises suggests that your healthcare provider suspects a vestibular cause. These exercises can help alleviate symptoms by repositioning the otoliths in the inner ear.

2. Neurological Causes: While your CT scan of the brain was normal, it is still important to consider other neurological evaluations. Persistent dizziness can sometimes be a sign of conditions affecting the brainstem or cerebellum, which may not always be visible on a CT scan.

3. Metabolic and Hematological Factors: Your blood test results indicate a slightly low hematocrit and potassium level. Low potassium (hypokalemia) can lead to muscle weakness and may contribute to feelings of dizziness. It is crucial to address this imbalance, as it can affect overall health and exacerbate dizziness.

Recommendations for Further Evaluation
Given your ongoing symptoms and the results of your tests, here are some recommendations:
1. Follow-Up with Neurology: Since dizziness can have complex causes, a follow-up appointment with a neurologist is advisable. They may recommend additional tests such as an MRI of the brain, vestibular function tests, or even an EEG if they suspect any seizure activity.

2. Electrolyte Monitoring: It would be wise to monitor your potassium levels closely. If they remain low, your healthcare provider may recommend dietary changes or potassium supplements.
3. Vestibular Rehabilitation Therapy (VRT): If BPPV or another vestibular disorder is confirmed, a referral to a physical therapist specializing in vestibular rehabilitation may be beneficial. They can provide tailored exercises to help improve balance and reduce dizziness.

4. Lifestyle Modifications: Staying hydrated, managing stress, and avoiding triggers that exacerbate your dizziness can also be helpful. Keeping a diary of your symptoms, including when they occur and any associated factors, can provide valuable information for your healthcare team.

5. Medication Review: Since you are taking medications like Cinnarizine and others for symptom management, it is essential to review these with your doctor. Sometimes, medications can have side effects that contribute to dizziness.

Conclusion
Persistent dizziness can be multifactorial, and it often requires a comprehensive approach to diagnosis and management. Given your history and current symptoms, it is crucial to continue working closely with your healthcare providers to identify the underlying cause and develop an effective treatment plan. Don't hesitate to advocate for yourself and seek further evaluations if your symptoms persist or worsen. Your health and well-being are paramount, and addressing these issues holistically will be key to improving your quality of life.

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