The Dizzy Doc's Blog

One of the most frequent comments made by patients is that they feel that their symptoms are seasonal as they experience flare-ups consistently around the same time each year.  As might be expected, their symptoms are blamed on allergies and their physician prescribes medications to alleviate the apparent allergic source of the patient’s dizziness.  Obviously, the allergy treatments did not succeed as these patients eventually find their way to me.

Over the years, I noticed an interesting trend – my clinic volume increases around the holidays, especially in November and December.  This pattern is also true for many of the aforementioned “seasonal” patients.  As strange as it sounds, the holidays are actually to blame for most of these patients!  To understand this, let’s step outside the box and think about what happens during the holidays. 

First, people travel to visit family and friends.  As exciting as travel may be, it is tiring and stressful.  Hours are spent in the car navigating heavy traffic, sitting in airports waiting for delayed flights, or stopping at multiple stations if riding the train or bus.  For many, travel for the holidays takes the better part of a day and can take an additional day or two of rest to recover.  Unfortunately, the holidays are about visiting, shopping, dining out – anything but rest!  For patients that are prone to dizziness, their vestibular system is highly dependant on their vestibular compensation system to suppress dizziness.  As mentioned in an earlier post, fatigue decreases the effectiveness of the vestibular compensation system and puts the patient at risk for dizzy spells.

What else happens during the holidays?  We have family dinners where huge meals are cooked.  If traveling, the odds are good that we’ll have to eat out because leftovers can be tolerated for only so long.  The bottom line is that our eating habits change during the holidays, often pretty dramatically.  For many, this is not a big deal.  However, for patients prone to hydrops or Meniere’s disease, dietary intake of sodium is critical.  Fast food, fine dining, and family feasts are all known for bombarding us with salt – as a result, persons susceptible to hydrops are placed in a bad situation during the holidays because their sudden increase in sodium consumption causes them to retain water, which in turn may trigger hydrops, leading to a full-blown Meniere’s episode.

Another aspect of the holidays to consider is alcohol consumption.  Even people that rarely drink will imbibe a holiday cocktail or add some brandy to their egg nog.  As with fatigue, alcohol can severely impair a patient’s vestibular compensation system and lead to dizzy spells and falls.

While any of these factors during the holidays can impair the vestibular system, it is important to keep in mind that many people experience a combination of these factors, which produces an additive effect.  I always encourage my patients to keep these factors in mind during the holidays and remind them to get plenty of rest, allow for recovery time after traveling, be mindful of their sodium intake (if hydrops is a concern for that patient), and consider the ramifications of consuming alcoholic beverages.

Patients who suffer from dizziness and vertigo often report that their symptoms fluctuate on a daily basis.  That is, the severity of symptoms is not constant and can range from “good days” to “terrible days”.  It makes sense that for some pathologies (i.e. Meniere’s Disease) that this is to be expected due to the transient nature of the underlying cause of the symptoms.

However, there are factors independent of the pathology that can contribute to the fluctuation of symptoms.  Such factors include, but are not limited to: fatigue, anxiety/stress, and malaise.

When you think about it, fatigue is a huge factor in whether anyone has a good day or not.  If you are not well rested, it’s difficult to find the energy to get through the day, and chances are that you’ll become irritable.  The same is true when you are stressed or dealing with clinical anxiety.  After all, how likely is it that you’ll remain calm and deal with issues when you have an important deadline staring at you in the face?  Malaise, or not feeling often has the same affect – how likely are you to wake up with a stuffy nose and headache and exclaim “wow, today’s going to be a good day!”?  Not very likely.

Most people will agree that these factors can influence how one feels about their day – but how does it influence vertigo/dizziness?  Well, at any given moment, a patient’s central vestibular system is fighting to suppress the sensations of vertigo/dizziness; however, it also has to manage all of the body’s function (don’t ask me why but maintaining a heartbeat and respiration are a priority).  On top of this, you have to juggle tasks, drive a car, remember the honey-do list, and go about your day with a smile on your face.  This is multitasking at it’s finest, and generally, the brain does a great job at multitasking.

The problem is that the brain’s ability to multitask is limited by the amount of reserve capacity that a patient’s brain has – that is, amazing as the brain it, it does have it’s limits and can only multitask to a certain extent.  When you have a brain that is managing the everyday tasks and then ask it to suppress vertigo or dizziness, the brain is challenged – often to its limits.  Now, this is considering a best-case scenario.  What do you think happens when the brain is fatigued because you couldn’t sleep last night?  Or, how about when you are stressed about losing your job because of the time that you have had to take off because of your dizziness?  How about when your head is stuffy and all you can think of is crawling back in bed?  The answer is pretty simple – multitasking takes a hit and the brain is less able to supress the vertigo and dizziness symptoms.

So, lack of sleep, anxiety, stress, depression, and illness can influence the severity of perceived dizziness/vertigo.  They are not the cause, per se, but rather, are compounding factors.

When people get dizzy or experience attacks of vertigo, what do they do?  If the episode is characterized by severe vertigo, many people will seek help from the emergency room out of fear that something serious is going on (i.e. stroke).  If the episode isn’t severe enough to warrant a ride in the ambulance, patients often opt instead to see their primary care physician ASAP.  Regardless of which route patients take, the end result is often the same – a prescription for vestibular suppressant medications (e.g. Meclizine, Antivert).  What these medications do is suppress the areas of the brain that receive and process the vestibular input from the inner ear.  A good example is giving a boy who has just come outside on a sunny day a very, very, very dark pair of sunglasses.

Previously, I discussed that vertigo spells have two phases – acute and sub-acute.  The acute phase is the worse period and often includes true vertigo, nausea, and sometimes even vomiting.  The acute phase typically lasts one to several days and then transitions to the sub-acute phase.  The sub-acute phase is not as severe as the acute phase; however, patients continue to get very dizzy with head motions.  Hopefully, with a little more time, the sub-acute phase gradually subsides and things return to normal.  For the boy, the acute phase is the sensory shock upon walking outside where he can’t keep his eyes open.  The sub-acute phase is when his eyes start to adapt and he is able to open his eyes for progessively longer periods of time.

Vestibular suppressant medications are very useful during the acute phase in diluting the severity of the vertigo.  The problem is that many physicians have been trained to treat vertigo and dizziness with these medications until the symptoms improve.  Why is this a bad thing?  Well, let’s talk about what happens during the sub-acute phase.  This is a period of recovery during which the areas of the brain responsible for balance assess the status of the components of the vestibular system (eyes, ear, legs, etc.) and makes adjustments.  Think about it – how well do you think the brain can accomplish this recovery if it is bogged down by vestibular suppressant medications?  You got it – not very well.  In the sun-glasses example, each time the person takes off the sunglasses he complains that it’s too bright – so, he puts the sunglasses back on.

Now, let’s take things a step further – if the vestibular suppressant medications impede the recovery process, how will the dizziness go away?  If the patient is lucky, it can happen but often takes a lot longer; however, the reality for most is that the dizziness persists.  Since the dizziness has not improved completely, the patient continues taking the vestibular suppressant as instructed by the physician.  Sometimes, the physicians respond by prescribing even higher doses of the same medication, or even writing a prescription for stronger suppressants.  In our example, the boy is able to play with his friends as long as he wears the sunglasses.

Here’s another thought – what about the patients that experience complete and/or near complete recovery while taking vestibular suppressant medications?  They tend to be mostly functional, but will experience problems if they try to increase their activity level.  Hmmm – wouldn’t they be a lot better off if we take them off of the vestibular suppressant medications?  In the long run, most likely yes because we’ll give the brain a chance to recover like it is supposed to.  However, if the patient has been on the medications for a while, things are obviously going to get worse as the brain deals with an onslaught of vestibular information from the ears that it has ignored while on the medications.  How do you think the boy is going to react if we yank the sunglasses off of him and ask him to read a sign in direct sunlight?

The sad thing is that a lot of these times when patients take vestibular suppressants for prolonged periods, their central vestibular system has deteriorated so much that it is equivalent to a Herculean task for them to get back to normal.  Many patients are unable to do so on their own.  These patients can be very difficult to manage because it is difficult for them to accept that coming off the medications is best for them in the long run because in doing so, they feel worse than they have ever felt.  This is especially true for patients who have taken vestibular suppressants daily for years.  Fortunately, vestibular rehabilitation with a well-trained physical therapist can do wonders for a lot of these patients – once they overcome their dependency on the drugs.

If someone has been taking vestibular suppressants more than 3-5 days, a red flag should go up.  That person needs to see a vestibular specialist to determine the root problem of the vertigo/dizziness and most likely a vestibular rehabilitation specialist to maximize recovery.  Bottom-line – there are no magic pills for vertigo or dizziness.

Interestingly, many people have heard of Meniere’s disease – they don’t know what it is, but they have heard of it somewhere.  Briefly, Meniere’s disease is a metabolic disorder that affects the inner ear and results in excessive fluid build-up in the inner ear (the medical term for this is hydrops).  It is unclear if it is an issue with excessive fluid production, inadequate drainage of the fluid from the inner ear, or a combination of both factors.  At any rate, when the fluid builds up in the inner ear, it exerts pressure on the sensory structures of the ear resulting in both vertigo and tinnitus (noise in the ear).

Diagnostically, Meniere’s disease is frequently a garbage can term, meaning that when physicians can’t figure out what the source of a patient’s dizziness it, they pass it off as another case of Meniere’s.  I can’t tell you the number of patients that I have seen over the years that were diagnosed with Meniere’s disease only to find out with proper testing that it wasn’t Meniere’s after all!

The classic Meniere’s patient will experience episodes of vertigo lasting up to several hours in durations (sometimes longer) accompanied by nausea/vomiting.  A low-frequency roaring tinnitus typically accompanies the spells, and sometimes will precede the spell.  Many Meniere’s patients will tell you that they know a spell is coming because they perceive an increase in their tinnitus prior to the onset of vertigo.  Diagnostically, these patients often present with sensorineural hearing loss in the lower frequencies and evidence of damage to the vestibular system per vestibular assessment.  Usually, spells are less severe at the onset of the disease and progressively worsen with time in that they increase in severity, frequency, and the length of the episodes.  It is not a pleasant experience at all.

If there is a silver lining for Meniere’s patients, it would be the fact that a fair number of patients obtain relief by greatly reducing their salt intake and/or the use of a diuretic (akak water pill because it makes you eliminate water).  The basic premise of the reduced sodium diet and diuretic interventions is that they both reduce the amount of water your body retains, which hopefully also acts to counter the effects of the hydrops.

For patients that do not respond to the reduced sodium or diuretic interventions, other interventions are available; however, these interventions are invasive and/or cause damage to the inner ear and thus should not be undertaken without good diagnostic data from a reliable vestibular assessment.