Persistent Dizziness: Possible Causes and Next Steps

Dizziness and an unsteady sense of balance?

Hello Doctor, I have been experiencing dizziness for over a month.
I have consulted with a neurologist, an otolaryngologist, and a cardiologist, and all tests have come back normal.
However, my symptoms have not improved with medication.
The symptoms seem to be best described as a sensation of weightlessness, primarily characterized by: 1.
When standing still, I feel as if my center of gravity is constantly shifting beneath my feet.
2.
When lying down, I have a sensation of almost falling off the bed.
3.
While sitting or lying down, I occasionally feel my body swaying, with a frequency that matches my heartbeat.
4.
I do not experience feelings of lightheadedness or pressure in my head; it is mainly a physical sensation.
5.
When walking, I feel a floating sensation, but it does not lead to instability or falling.
6.
The above symptoms have been persistent without interruption.
7.
Upon waking in the morning, the symptoms slightly improve for a period of time.
I would like to ask the doctor: 1.
What could be the possible causes of my dizziness? 2.
Is this dizziness classified as lightheadedness or vertigo? Since the otolaryngology examination showed no issues, I have a sensation of vertigo where my body feels like it is swaying, making it difficult to distinguish.
3.
Should I continue to seek treatment from a neurologist and an otolaryngologist, or should I consider seeing a psychiatrist?

Wang, 20~29 year old female. Ask Date: 2023/06/20

Dr. Jiang Junyi reply Neurology

Hello Mr.
Wang,
You mentioned that "the symptoms improve slightly after getting up in the morning...
and the body feels like it's swaying." This may indicate proprioceptive abnormalities caused by cervical spine issues.
Often, this is related to muscle fascia tightness and degeneration of the cervical spine.
Symptoms may include pain at the affected site, discomfort, muscle stiffness, or a sensation of heaviness in the head and neck.
Additionally, autonomic nervous system dysfunction should also be considered.
Generally, when experiencing dizziness, it is important to rule out anemia or dehydration, which can lead to insufficient cerebral circulation.
Symptoms may improve with hydration and electrolyte replenishment.
Blood tests can assist in evaluating dizziness.
These tests should include screening for possible complications such as anemia, hyperthyroidism/hypothyroidism, diabetes, recurrent vestibular neuritis, autoimmune diseases, neurosyphilis, and central nervous system disorders.
I recommend that you consult a neurologist to discuss further examination and treatment options.
Thank you for your inquiry, and feel free to reach out with any related questions!
Wishing you good health, peace, and happiness.
Dr.
Jiang Junyi, Department of Neurology, Taoyuan Hospital

Reply Date: 2023/06/20

More Info

Persistent dizziness can be a perplexing and distressing symptom, especially when it has lasted for over a month and has not improved with medication. Your description of the symptoms provides valuable insights into the nature of your dizziness, which seems to be more related to a sensation of imbalance rather than traditional vertigo. Let's break down your concerns and explore possible causes and next steps.

Possible Causes of Your Dizziness
1. Vestibular Disorders: Although you mentioned that ENT specialists found no issues, vestibular disorders can sometimes be subtle. Conditions like vestibular neuritis or benign paroxysmal positional vertigo (BPPV) might not always be easily diagnosed. These conditions can cause sensations of imbalance or a feeling of "floating."
2. Neurological Causes: Given that you've already consulted with neurologists, serious conditions like multiple sclerosis or transient ischemic attacks (TIAs) may have been ruled out. However, other less common neurological issues could still be at play, such as migraines that can cause vestibular symptoms without the typical headache.

3. Orthostatic Hypotension: This condition occurs when blood pressure drops significantly upon standing, which can lead to dizziness. It might be worth monitoring your blood pressure in different positions (lying down, sitting, and standing) to see if there are significant changes.

4. Anxiety and Stress: Psychological factors can manifest physically, leading to sensations of dizziness or imbalance. Anxiety can create a feeling of unreality or detachment, which might explain the "floating" sensation you describe.

5. Medication Side Effects: If you are taking any medications, it’s essential to review them with your healthcare provider, as some can cause dizziness as a side effect.

6. Inner Ear Issues: Conditions affecting the inner ear, such as Meniere's disease, can cause persistent dizziness and a sensation of fullness in the ear, although you mentioned no findings from ENT evaluations.

Differentiating Between Dizziness Types
Your symptoms seem to align more with a sensation of imbalance rather than true vertigo, which is typically characterized by a spinning sensation. The fact that you do not feel lightheaded or faint suggests that your dizziness might not be due to a drop in blood pressure or dehydration. Instead, it could be related to vestibular dysfunction or even a somatic symptom disorder where physical symptoms arise from psychological factors.

Next Steps
1. Follow-Up with Specialists: Given that your symptoms have persisted and you have seen both neurologists and ENT specialists, it may be beneficial to revisit these specialists with your updated symptoms. You might also consider asking for specific tests like a vestibular function test or a more comprehensive neurological evaluation.

2. Consider a Psychosomatic Evaluation: If no physical causes are identified, consulting a psychiatrist or psychologist could be beneficial. They can help assess whether anxiety or stress might be contributing to your symptoms.

3. Physical Therapy: Vestibular rehabilitation therapy (VRT) can be helpful for many patients experiencing balance issues. A physical therapist specialized in vestibular disorders can provide exercises to help improve your balance and reduce dizziness.

4. Lifestyle Modifications: Keeping a symptom diary may help identify triggers or patterns related to your dizziness. Additionally, ensuring adequate hydration, managing stress, and avoiding caffeine or alcohol might be beneficial.

5. Further Testing: If your symptoms continue without resolution, further testing such as MRI or CT scans might be warranted to rule out any underlying structural issues in the brain or inner ear.

In conclusion, persistent dizziness can stem from various causes, and it often requires a multidisciplinary approach to diagnose and manage effectively. Continue to advocate for your health, and don’t hesitate to seek further evaluations if your symptoms persist.

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