Effective help for dizziness, first of all, depends on correct diagnosis and identifying the true causes of dizziness. Dizziness is the second reason after headache for visiting a neurologist. It occurs in more than 80 different neurological, cardiac, mental and other diseases. To successfully treat dizziness, it is necessary to correctly determine the true causes of these symptoms.
To identify the causes of dizziness, it is necessary to correctly carry out differential diagnosis. We pay special attention to diagnostics. Experienced doctors at the clinic will be able to correctly assess a person’s condition, select the right treatment for dizziness, and carry out it efficiently.
Unique hospital replacement methods of rehabilitation therapy used in the Brain Clinic allow you to quickly restore the functions of the nervous system and stabilize a person’s condition.
Call!
We help in the most severe cases, even if previous treatment did not help! There are four main types of dizziness.
Types of dizziness
- Vestibular vertigo
- Feeling lightheaded
- Feeling of impending loss of consciousness
- Instability
Dizziness in diseases of the nervous system
Vestibular vertigo is a sensation of imaginary rotation of objects around the patient or the patient himself in space.
This dizziness is caused in most cases by damage to the vestibular apparatus.
Other types of dizziness are symptoms of other diseases, such as orthostatic hypotension, polyneuropathy, anxiety disorders, etc.
Vestibular vertigo is caused by damage to the cerebral or peripheral parts of the vestibular system. V.G. more often it is paroxysmal, episodic, often accompanied by nausea, vomiting, noise and ear congestion, decreased hearing and loss.
Vestibular disorders are among the most common in clinical practice. According to a recent study conducted in the United States, clinically obvious or hidden vestibular disorders are observed in 35% of Americans over 40 years of age [1]. The most characteristic manifestation of vestibular dysfunction is vestibular vertigo (VV) - the illusion of movement or rotation of surrounding objects or the patient himself in space. Vestibular, or systemic, dizziness, although inferior in frequency to non-systemic, is nevertheless quite common: its prevalence among adults reaches 5% [2].
Vestibular vertigo can be divided into acute and chronic. Acute VH is usually combined with more or less pronounced autonomic disorders in the form of nausea, vomiting, increased or decreased blood pressure, sweating, pallor, etc. In addition, acute dizziness is accompanied by instability and nystagmus. The duration of acute dizziness ranges from a few seconds to several days, but in practice it rarely exceeds 6–12 hours.
Chronic VH is manifested to a greater extent by instability, while the illusion of movement of surrounding objects mainly occurs briefly in response to turning the head or eyes.
Acute VH is caused by sudden damage to the vestibular analyzer at any level. Damage to the vestibular analyzer at the peripheral level (labyrinth of the inner ear or vestibular nerve) is most often caused by benign paroxysmal positional vertigo (BPPV), Meniere's disease and vestibular neuronitis. Damage to the vestibular analyzer at the central level (vestibular nuclei of the brain stem and numerous connections of the vestibular nuclei with other parts of the vestibular analyzer) in most cases is a consequence of migraine, as well as stroke or transient ischemic attack in the vertebrobasilar system.
Chronic VH can be a continuation of acute (in such cases it is caused by insufficient vestibular compensation) or arises primarily due to the gradual development of a pathological process (for example, due to neuroma of the vestibular-cochlear nerve) or bilateral symmetrical damage to the vestibular analyzers (as in bilateral vestibulopathy caused by the action of ototoxic substances ).
The principles of drug and non-drug treatment of acute and chronic dizziness differ significantly.
Pharmacotherapy of acute dizziness
Regardless of the cause of acute dizziness, representatives of two main groups remain the drugs of choice: vestibular suppressants and antiemetics.
Vestibular suppressants include antihistamines, anticholinergics, and benzodiazepines. The main vestibular suppressants are listed in table. 1.
Antihistamines
For vestibular vertigo, only those H1 blockers that penetrate the blood-brain barrier are effective. These drugs include dimenhydrinate (Dramina 50–100 mg 2–3 times a day), promethazine (Pipolfen 25 mg 2–3 times a day orally or intramuscularly), diphenhydramine (Diphenhydramine 25–50 mg orally 3–4 times a day). day or 10–50 mg IM) and meclozine (Bonin 25–100 mg/day in the form of chewable tablets). All of these drugs also have anticholinergic properties and cause corresponding side effects [3].
Anticholinergics
These drugs inhibit the activity of the central vestibular structures. Scopolamine or platyphylline are used. Side effects of these drugs are mainly due to the blockade of M-cholinergic receptors and include dry mouth, drowsiness and accommodation disorders. In addition, amnesia and hallucinations are possible. Scopolamine should be prescribed with great caution to the elderly due to the risk of developing psychosis or acute urinary retention.
It has now been proven that anticholinergic drugs do not reduce CH, but can only prevent its development, for example, in Meniere’s disease [4]. Because of their ability to slow down vestibular compensation or cause compensation to fail once it has already occurred, anticholinergics are increasingly used less frequently in peripheral vestibular disorders.
Benzodiazepines
The inhibitory transmitter of the vestibular system is gamma-aminobutyric acid, and benzodiazepines enhance the inhibitory effects of gamma-aminobutyric acid, which explains the effect of these drugs in VH. Even in small doses, benzodiazepines significantly reduce dizziness and associated nausea and vomiting. The risk of drug dependence, side effects (drowsiness, increased risk of falls, memory loss), as well as slower vestibular compensation limit their use in vestibular disorders. Lorazepam (Lorafen) is used, which in low doses (for example, 0.5 mg 2 times a day) rarely causes drug dependence and can be used sublingually (at a dose of 1 mg) for an acute attack of dizziness. Diazepam (Relanium) at a dose of 2 mg 2 times a day can also effectively reduce GV. Clonazepam (Antelepsin, Rivotril) has been less studied as a vestibular suppressant, but appears to be as effective as lorazepam and diazepam. It is usually prescribed at a dose of 0.5 mg 2 times a day. Long-acting benzodiazepines, such as phenazepam, are not effective for vestibular vertigo [5].
Vestibular suppressants slow down vestibular compensation, so their duration of use is usually limited to 2–3 days [6].
Antiemetics are often used in the same circumstances as vestibular suppressants. Moreover, most vestibular suppressants are also antiemetics. Among the most common antiemetics are phenothiazines, in particular prochlorperazine (Meterazine 5–10 mg 3–4 times daily) and promethazine (Pipolfen 12.5–25 mg 3 times daily orally or IM). Metoclopramide (Cerucal 10 mg IM) and domperidone (Motilium 10–20 mg 3–4 times a day orally) are peripheral D2 receptor blockers that normalize gastrointestinal motility and thereby also have an antiemetic effect [7]. Ondansetron (Zofran 4–8 mg orally) is a serotonin 5-HT3 receptor blocker that also reduces vomiting in vestibular disorders.
Antiemetics, like vestibular suppressants, can slow down vestibular compensation, so the duration of their use for vestibular disorders is limited to 2-3 days. There is evidence that ondansetron has no effect on central vestibular compensation [8]. Drugs with predominantly antiemetic activity are presented in table. 2.
Pharmacotherapy of chronic dizziness
Vestibular suppressants and antiemetics are ineffective in chronic VH. Moreover, since many cases of chronic dizziness are caused by insufficient vestibular compensation, drugs that depress the vestibular system may aggravate the patient's condition and delay recovery.
The basis for the treatment of chronic vestibular dysfunction is non-drug methods, primarily vestibular rehabilitation. The goal of vestibular rehabilitation is to accelerate vestibular compensation and create conditions for rapid adaptation to damage to the vestibular system. Vestibular gymnastics is based on exercises in which movements of the eyes, head and torso lead to sensory mismatch [5, 9]. These exercises stimulate central vestibular compensation. Clinical studies have shown that improvements in vestibular function and stability as a result of vestibular rehabilitation are observed in 50–80% of patients. Moreover, for a third, compensation is complete [10–12].
The possibilities of drug stimulation of vestibular compensation are currently limited. However, studies of various drugs supposedly stimulating vestibular compensation are ongoing. One such drug is betahistine dihydrochloride. By blocking H3 receptors in the central nervous system, it increases the release of neurotransmitters from the nerve endings of the presynaptic membrane, exerting an inhibitory effect on the vestibular nuclei of the brain stem. Experimental studies have shown that Betaserc accelerates vestibular compensation [13, 14]. Betahistine dihydrochloride is used in a dose of 24–48 mg daily for one or several months.
There is evidence of acceleration of vestibular compensation in diseases of the peripheral part of the vestibular analyzer under the influence of Ginkgo biloba extract [15, 16]. The drug is prescribed at a dose of 120 mg/day orally for one or several months.
Another drug believed to improve the speed and completeness of vestibular compensation is piracetam. This drug changes the speed of spread of excitation in the brain, improves metabolic processes in nerve cells, normalizes connections between the cerebral hemispheres and synaptic conduction in neocortical structures. It is believed that piracetam affects the vestibular and oculomotor nuclei of the brainstem, accelerating vestibular compensation [17]. Piracetam is recommended primarily for dizziness caused by damage to the central vestibular structures. Piracetam is prescribed orally at a dose of 2400–4800 mg/day; Duration of treatment – from one to several months.
Pharmacotherapy of the most common vestibular diseases
Benign paroxysmal positional vertigo
The basis of treatment for BPPV is not drugs, but special exercises and therapeutic maneuvers that have been actively developed over the past 20 years [18–21].
Drug treatment is used only in the most acute period, when it is necessary to reduce the severity of episodes of positional vertigo, and as a premedication during positional maneuvers. In these cases, vestibular suppressants and antiemetics are used. In addition, there are limited data indicating the ability of betahistine dihydrochloride to increase the effectiveness of therapeutic positional maneuvers for BPPV [22] and reduce the duration of the period of instability after a successful positional maneuver [23].
Meniere's disease
To date, Meniere's disease remains an incurable disease. The goal of treatment is to reduce the frequency and severity of dizziness attacks [24–26]. For this purpose, diuretics are prescribed (acetazolamide or hydrochlorothiazide in combination with triamterene). However, to date, no convincing data have been obtained indicating the effectiveness of diuretics in Meniere’s disease [27].
Another drug that can reduce the frequency and severity of dizziness attacks in Meniere's disease is betahistine dihydrochloride. It is usually prescribed at a dose of 48 mg per day and taken long-term – for several months and sometimes years [14]. Recently, data have appeared on the effectiveness and safety of the use of high doses of betahistine in Meniere's disease [28].
Vestibular neuronitis
Drug treatment of vestibular neuronitis mainly consists of the use of symptomatic drugs: vestibular suppressants and antiemetics. Recently, evidence has emerged indicating the effectiveness of corticosteroids in vestibular neuronitis, but these data have not been confirmed by a meta-analysis [29].
Migraine-associated dizziness
The treatment of migraine-associated dizziness generally uses the same approaches as the treatment of regular migraine. However, due to the current lack of consensus regarding the diagnostic criteria for migraine-associated dizziness and the very fact of the existence of this pathology, there have been almost no controlled studies of the effectiveness of certain therapeutic approaches. To relieve an attack of migraine-associated dizziness, as with any other acute VH, vestibular suppressants and antiemetics are used. Preventive therapy is indicated for frequent (2 or more per month) and severe vestibular migraine attacks [30, 31].
The drugs of choice are beta-blockers (propranolol or metoprolol), tricyclic antidepressants (nortriptyline or amitriptyline) and calcium antagonists (verapamil). In addition, valproate (600–1200 mg/day) and lamotrigine (50–100 mg/day) are used. The starting daily dose of verapamil is 120–240 mg/day; the maximum daily dose should not exceed 480 mg. The starting dose of nortriptyline is 10 mg/day; if ineffective, the dose is increased to 10–25 mg/day, while the maximum daily dose should not exceed 100 mg. The starting dose of propranolol is 40 mg/day; if this dose is ineffective and the drug is well tolerated, the daily dose is gradually (weekly) increased by 20 mg, but so that it does not exceed 240–320 mg. There is also evidence of the effectiveness of topiramate as a means of preventing migraine-associated dizziness [32].
Thus, the possibilities of drug therapy for vestibular vertigo are quite large. There are a sufficient number of drugs for both symptomatic treatment of dizziness and pathogenetic therapy. Correctly selected and timely prescribed medications can significantly improve the quality of life of most patients with various diseases of the vestibular system.
Causes of dizziness
The main causes of dizziness are benign paroxysmal positional vertigo, Meniere's disease, vestibular neuronitis, vestibular migraine, vascular diseases of the brain (stroke, transient attack in the arteries of the vertebrobasilar system). A carefully collected anamnesis, analysis of the patient’s complaints, and instrumental studies will help diagnose these diseases. There are several common causes of dizziness.
Common causes of dizziness
- Vascular pathology (congenital or acquired);
- Brain concussion;
- Trauma to the cervical and thoracic spine;
- Osteochondrosis of the cervical and thoracic spine;
- Physical inactivity;
- VSD syndrome;
- Toxic and discirculatory encephalopathy;
- Intervertebral hernia;
- Listez;
- Birth injury
- Various mental disorders.
Causes of severe and prolonged dizziness
Constant dizziness in women and men, unlike rare ones that occur during sudden movements, poisoning or alcohol intoxication, can be caused by serious diseases, so it is necessary to know their symptoms and treatment.
Neurological causes
Frequent attacks of dizziness can occur due to damage to the nerve endings, as well as the circulatory system of the brain. Systemic vertigo causes migraine, meningitis, encephalitis, tumors of various origins, multiple sclerosis, epilepsy, strokes in the brain stem structures and in the cerebellum, vertebrobasilar syndrome, which occurs due to insufficient blood flow to the brain tissue.
ENT pathologies
Chronic dizziness causes inflammation of the vestibular apparatus, which occurs in the hearing organs or nearby nerve fibers. In these cases, chronic nausea often occurs. These are pathologies such as injuries to the internal organs of hearing, ischemia of the vessels of these organs, purulent processes in them, Meniere's disease and others.
Cardiovascular disorders
Frequent dizziness in women can be caused by menopause or menopause. In addition, there are common cases when constant vertigo occurs due to diseases of the heart and blood vessels, arrhythmia, diabetes, thyroid dysfunction, and sudden jumps in blood pressure.
Psycho-emotional disorders
Psycho-emotional reasons are hidden in external factors. This is stress, great excitement. An overly emotional woman, for example, may feel dizzy several times a day, becoming chronic. This condition is often aggravated by tachycardia, rapid breathing, and weakness of the arms and legs.
Diagnosis and help for dizziness
Accurate diagnosis of the causes of dizziness makes it possible to choose the most adequate treatment tactics.
Every person has experienced it at least once in their life. Dizziness usually takes us by surprise; it can happen while driving, on public transport, or while working.
Differential diagnosis
Depending on the medical history and examination collected by the doctor, a number of examinations are prescribed to identify the cause of dizziness. Among the examination methods used for dizziness in a patient are MRI of the brain in T2 mode or with intravenous contrast, ultrasound of blood vessels, MRI or x-ray of all parts of the spine, electroencephalography, electromyography. Treatment After undergoing a full examination and identifying the real cause of dizziness, you can begin to treat it.
Help and treatment for dizziness
There are general principles of treatment, prevention and first aid for dizziness:
- Drug therapy, which usually includes angioprotectors (drugs that improve vascular function), neuroprotectors and neurotrophic drugs. In case of severe dizziness or fainting, it is better for the patient to immediately call an ambulance team and receive treatment in a hospital setting.
- Physiotherapy is equivalent in effect to drug therapy and is indicated for dizziness. It is usually prescribed in parallel with neurometabolic therapy, which significantly enhances the therapeutic effect in the treatment of dizziness and reduces the risk of recurrence of the disease. Significantly relieves the condition in a few sessions. Typically, a rehabilitation therapy doctor prescribes a course of ten procedures that must be attended daily or every other day.
- Neck massage and manual therapy can also sometimes be prescribed for dizziness.
- Osteopathic correction is prescribed with caution, as it may have contraindications for some disorders.
- Acupuncture - prescribed with caution, as it has many contraindications in the presence of dizziness.
- Contrast shower - as prescribed by a doctor.
- Exercise therapy - under the supervision of a doctor.
- Aerobic physical activity is strictly dosed.
Dizziness has become the norm today for city dwellers. The reason for this is most often not hereditary or vascular pathology, but our lifestyle and high psychophysical stress (stress). In addition, a sedentary lifestyle plays a big role in the development and manifestation of dizziness; computers, TV, smartphones, tablets and cars have become our constant companions.
Definition and Features
It is necessary to distinguish between true dizziness, in which there is a feeling of objects moving in space. Such symptoms may be normal if they occur after prolonged rotation around its axis (on a carousel), but in other cases they indicate a malfunction of the vestibular apparatus. The difficulty in diagnosing this condition is that the doctor has to rely only on the patient’s testimony. Many people also mean other symptoms by this term: impaired visual acuity, headaches and others. In reality, dizziness should be understood as a feeling of movement of environmental objects in relation to a person, while the body position is felt as stable. Most often these are circular movements (objects rotate around a person’s axis), but they can also be linear (a feeling of falling or rising in height, various shocks).