Dizziness is one of the most common reasons adults see a doctor, and one of the most frustrating symptoms to live with. The word covers several very different sensations, from the room spinning to feeling faint when you stand up, and each one points toward a different set of causes. Most dizziness turns out to come from the inner ear, blood pressure, medications or fluid balance and is very treatable. A smaller share comes from the heart or the brain, and those causes are the ones a careful evaluation is designed not to miss.
At NYMD Center our internal medicine physicians approach dizziness by first pinning down what kind of dizziness you have. That single step does more to narrow the workup than any test, because it tells us whether to look first at the inner ear, the circulation, the heart rhythm or the nervous system. From there we use in-office testing to confirm or rule out the likely causes and build a treatment plan around what we find.
Types of dizziness and what causes them
We sort dizziness into four broad categories. Vertigo is a false sense of motion, usually spinning, as if you or the room is turning. It most often comes from the inner ear. The most common cause is benign paroxysmal positional vertigo (BPPV), in which tiny calcium crystals in the inner ear drift out of place and trigger brief spinning spells when you roll over in bed, look up or bend down. Vestibular neuritis, an inflammation of the balance nerve often after a viral illness, causes a longer, severe bout of vertigo that settles over days. Migraine and Meniere's disease are less common inner ear and neurologic causes.
Lightheadedness is a woozy, heavy-headed or foggy feeling without true spinning. Presyncope is the stronger version, the sense that you are about to faint, often with dimming vision, sweating or nausea. Both usually mean the brain is briefly getting less blood flow or fuel than it needs. Common causes include orthostatic hypotension (a drop in blood pressure on standing), dehydration, blood pressure and other medications, anemia, low blood sugar, and heart rhythm problems that make the heart beat too fast, too slow or irregularly. Less often, a weakened heart muscle (cardiomyopathy) or a narrowed valve is responsible. Anxiety and panic can also cause lightheadedness, but we reach that conclusion only after the physical causes have been checked.
Imbalance is unsteadiness on your feet, usually worse when walking, without a spinning or fainting feeling. It can come from nerve damage in the feet, joint problems, weak vision, the lingering effects of an inner ear injury, certain medications, or neurologic conditions. The Mayo Clinic's overview of dizziness groups these causes in a similar way. Many people, especially older adults, have more than one type at once.
How we evaluate dizziness at NYMD Center
The visit begins with a detailed history. We ask you to describe the sensation without using the word dizzy, and we ask when it happens, how long each spell lasts, what brings it on and what comes with it. Spells triggered by rolling over in bed point to BPPV. Spells on standing point to blood pressure. Spells with a racing or pounding heart, or that come on without warning while seated, point toward the heart rhythm. We review every medication and supplement, since blood pressure pills, diuretics, sedatives, sleep aids and some antidepressants are frequent contributors.
We then check orthostatic vital signs, measuring your blood pressure and pulse lying down and again after standing, to look for a meaningful drop. We do a focused neurologic exam covering eye movements, coordination, strength, sensation and gait. When the history suggests positional vertigo, we perform the Dix-Hallpike maneuver, in which we move you from sitting to lying with your head turned and watch for the characteristic eye movements that confirm BPPV and tell us which ear is involved. The MedlinePlus entry on benign positional vertigo describes this test.
An ECG (EKG) is done in the office to look for rhythm problems, conduction disease and signs of heart strain. Blood work usually includes a complete blood count for anemia, blood sugar, and electrolytes and kidney function, with thyroid and other tests added when the picture calls for them. If your spells suggest an intermittent rhythm problem, we place an ambulatory ECG (Holter) monitor in our office, which you wear at home to capture your heart rhythm during symptoms. An echocardiogram, hearing and balance testing, or brain imaging are arranged when the findings point that way.
Treatment options
Treatment follows the cause, and most of it starts with simple, low-risk measures.
Repositioning maneuvers for BPPV
BPPV is treated by moving the loose crystals back where they belong with a series of guided head and body positions, most commonly the Epley maneuver. MedlinePlus notes that this approach has the best cure rates of the available treatments. It can often be done in the office in a few minutes, and we can teach you home exercises for recurrences. The spells may return months or years later, but the same maneuver usually works again. Medications that dull vertigo are sometimes used for a few days but are not a substitute for repositioning.
Fluids, salt and medication review
For dizziness from dehydration or orthostatic hypotension, we focus on adequate fluids, standing up slowly, and adjusting medications that lower blood pressure. Many patients improve simply by changing the dose or timing of a blood pressure pill, a diuretic or a sleep aid. When high blood pressure treatment is the cause, we work to keep your blood pressure controlled without overshooting.
Treating medical causes
Anemia, low blood sugar, thyroid problems and electrolyte disturbances are treated directly once identified. Vestibular neuritis is usually managed with short-term symptom relief and balance exercises, and vestibular physical therapy can speed recovery from lingering imbalance.
Heart rhythm and heart disease
If monitoring shows an arrhythmia, treatment depends on the type. Some rhythms respond to medication; others need referral to cardiology or electrophysiology for procedures such as ablation or a pacemaker. Our page on changes in heart rhythm explains these options. We coordinate the referral and stay involved in your care.
What to expect at your visit
Plan for a conversation, an examination including orthostatic blood pressures and a neurologic check, an ECG and usually a blood draw. If positional vertigo is suspected, we may perform the Dix-Hallpike test and treat BPPV at the same visit. Bring a complete list of your medications, including over-the-counter products, and a short diary of your spells if you have one: when they happened, what you were doing and how long they lasted. Many patients leave with a working diagnosis and a first step, whether that is a repositioning maneuver, a medication change or a heart monitor.
When to seek care urgently
Call 911 for dizziness that comes on suddenly with facial droop, weakness or numbness on one side, trouble speaking, confusion, loss of vision or double vision, a sudden severe headache, chest pain, shortness of breath, or fainting. Sudden dizziness or loss of balance can be a sign of stroke, and the CDC advises calling 911 right away rather than driving yourself. Dizziness with a very fast, very slow or irregular heartbeat also needs same-day emergency care.
Questions patients ask
What is the difference between vertigo and lightheadedness?
Vertigo is a false sense of motion, usually spinning, and most often comes from the inner ear. Lightheadedness is a faint, woozy or heavy-headed feeling without spinning, and usually reflects a brief drop in blood flow or fuel to the brain, from causes such as low blood pressure on standing, dehydration, medications, anemia or a heart rhythm problem. Telling us which one you feel shapes the whole evaluation.
Can dizziness be caused by a heart problem?
Yes. Heart rhythms that are too fast, too slow or irregular can reduce blood flow to the brain and cause lightheadedness or near-fainting, as can a weakened heart muscle or a narrowed valve. That is why we do an ECG at the visit and may place a Holter monitor in the office if your spells come and go, especially when they happen with palpitations or without warning.
What is BPPV and can it be treated in the office?
Benign paroxysmal positional vertigo happens when tiny crystals in the inner ear move into the wrong canal, causing brief spinning spells with head movements such as rolling over in bed. We confirm it with the Dix-Hallpike test and can often treat it in the same visit with a repositioning maneuver such as the Epley. We can also teach you exercises in case it returns.
Could my medications be making me dizzy?
Often, yes. Blood pressure medications, diuretics, sedatives, sleep aids, some antidepressants and several other drugs can cause dizziness, especially when doses change or several are combined. We review everything you take, including supplements and over-the-counter products. Please do not stop a prescribed medication on your own; we will adjust it safely with you.
When is dizziness an emergency?
Call 911 if dizziness comes on suddenly with facial droop, weakness or numbness on one side, trouble speaking, vision loss, a sudden severe headache, chest pain, shortness of breath or fainting. These can be signs of a stroke or a serious heart problem. Do not drive yourself, and do not wait to see whether the symptoms pass.