Podcast: Why Am I Feeling Dizzy?

Dr. Louise Klebanoff:  I caution my patients when they feel lightheaded as if they’re going to faint, that they should sit down or lay flat. That’s not the type of symptom that you can push through and just feel like I’m just gonna tough it out. Because if your brain isn’t getting enough blood, it is going to faint. Because that’s how it gets you down to the ground to use gravity to get the blood.

Courtney:  Welcome to Health Matters, your weekly dose of health and wellness from NewYork-Presbyterian. I’m Courtney Allison.

Today, we’re visiting a topic that many of us have experienced at some point in our lives—dizziness. It’s a symptom that can range from mildly irritating to completely debilitating. But what exactly causes dizziness? To help us navigate this complex topic, we talked to Dr. Louise Klebanoff, a neurologist from NewYork-Presbyterian and Weill Cornell Medicine.

Dr. Klebanoff will help us understand the various types of dizziness, their underlying causes, and ways to manage dizziness when it occurs.

Courtney: Dr. Klebanoff, thank you so much for being here today.

Dr. Louise Klebanoff: Thank you. My pleasure to join you.

Courtney:   So when someone says they’re feeling dizzy, what does that mean to you as a doctor? How do you try to figure out what they’re experiencing?

Dr. Louise Klebanoff: So when a patient comes in and their chief complaint, what brings them into the doctor’s office is dizziness, the first thing I do with the patient is try to figure out what they actually mean by dizziness. And there are three big baskets that we have. We’ve got lightheadedness, as if you may faint, which is often a cardiac problem.

There’s vertigo, which means a sense of motion that either the patient is moving or the world is moving around them. And then the third one means instability, gait instability, which means difficulty walking.

Courtney: Okay.

Dr. Louise Klebanoff: And some patients have more than one. Some patients have all three. But it’s really helpful for me to define the type of dizziness they’re complaining of, so I know what else to do.

Courtney: And how do patients commonly describe their dizziness?

Dr. Louise Klebanoff: Well, it depends on the type. So some people, you know, and when I give them, sort of, these categories, they can often figure out what kind of dizziness they have. But really the big thing, do you feel like you were gonna faint? Did you feel like you were moving or the world is moving? Or is this a walking problem?

Courtney: Mm-hmm.

Dr. Louise Klebanoff: And often they can figure out which type, and then I go through more historical details and more exam details once I have the type of dizziness defined.

Courtney: So let’s spend some time talking about these different types. I think the first one you mentioned was lightheadedness. Maybe that feels, like, woozy.

Dr. Louise Klebanoff: Right.

Courtney: What might cause these sensations and what are the treatments or how can people manage the symptoms?

Dr. Louise Klebanoff: So a sense of lightheadedness as if you’re going to faint usually means that your blood pressure has dropped. And that could be from a number of different things. So if patients are dehydrated, their blood pressure can drop. If they have a big emotional stress and that triggers a reflex where their blood pressure drops, vasovagal syncope, so they faint because there’s a reflex that makes their blood pressure and their heart rate drop.

But usually when you feel lightheaded as if you faint, especially if it’s followed by an actual faint on occasion or if it improves when people lie flat, that to me indicates that the patient should probably be seen by a cardiologist. ‘Cause that’s usually a cardiac issue. The blood isn’t pumping enough, or there’s an abnormal heart rhythm, and the heart isn’t able to really push the blood out.

And then some patients have orthostatic intolerance or what people call pots, postural orthostatic tachycardia syndrome. And that’s when they stand up, their heartbeats really fast, and the longer they stand, the more it beats fast. When the heart’s beating really fast, it doesn’t effectively push the blood to the brain, and then people feel very lightheaded.

Courtney: And now I realize this might be more of a cardiology question in terms of what are the treatments or how can people manage these symptoms? Does that kind of then depend on the journey they take then going to see a cardiologist?

Dr. Louise Klebanoff: Correct. The basics are still sort of the same. So I caution my patients when they feel lightheaded as if they’re going to faint, that they should sit down or lay flat. That’s not the type of symptom that you can push through and just feel like I’m just gonna tough it out. Because if your brain isn’t getting enough blood, it is going to faint. Because that’s how it gets you down to the ground to use gravity to get the blood.

So that’s number one. Number two, stay hydrated. And we also check people’s blood pressure. If their blood pressure tends to run a little bit on the low side, you can add a little salt to your diet as well as staying hydrated.

Change positions gradually. You know, if you tend to get lightheaded when you stand up, then you need to go from laying to sitting and sitting to standing kind of gradually. And then to watch for other symptoms, like do you actually have chest pain when you feel lightheaded, do you feel like your heart’s really racing?

Because that’s something that’ll be helpful for the cardiologist.

Courtney: I appreciate how you described fainting, too. I don’t know if I ever really thought about it that way, that it’s gravity. It wants the blood to get there. That’s really interesting.

Dr. Louise Klebanoff: Yes, the brain is gonna do what it needs to do to get blood, and that means it’s going to go to ground.

Courtney: Wow. Go to ground. So the next one you mentioned I think was spinning.

Dr. Louise Klebanoff: Yeah, so a sense of motion. A sense of motion with either you feel like you are spinning or the world is spinning around you is vertigo. Vertigo in and of itself is a symptom. It’s not a diagnosis. There are many things that cause vertigo. So when someone tells me they have a sense that the world is moving around them or they have a sense that they’re moving, then I need more details.

When does it come on? Does it come on particularly when you put your head in one position or when you roll over in bed? ‘Cause that’s highly suggestive of benign positional vertigo, which is a really common cause of vertigo.

Courtney: So in the limited amount I know about vertigo, I’ve heard about ear crystals. Can you explain what these crystals are and what are they for?

Dr. Louise Klebanoff: So with benign positional vertigo, what happens is the small calcium crystals that are in our inner ears, those are called otoconia. They’re supposed to be in certain positions. Sometimes they get dislodged and they’re free floating in this fluid, or they attach to the wrong membrane inside the inner ear.

Now, this is deep inside the skull in your temporal bones. This is not something that we could see by looking at your ears from the outside. But part of the way we figure out where our heads are in space is through these small crystals inside our inner ear. And when they’re dislodged, if you put your head in one position, you spin. Usually that spinning is relatively intense but relatively brief. So if you take your head out of the position, it stops. But if you put your head back in that position, it comes on again. So these are patients who get spinning dizziness when they are trying to, like, park their car and they turn their head around, or when they roll over in bed, or when they first get outta bed in the morning.

And one of the ways we treat benign positional vertigo is doing these maneuvers with the patient’s head where you put their head in a symptomatic position. So usually the patients are lying on the table and you hold their head in your hands, you bring them back and to the side and you watch for eye movements and you see if the patients have symptoms of vertigo.

If you put the patient’s head in the right position, they will feel very uncomfortable with vertigo, and you could actually see their eyes jiggle, which is called nystagmus, and that’s diagnostic of benign positional vertigo. And one of the ways you treat the condition is through vestibular therapy, which is some of these exercises to get the crystals back in the right place.

Courtney: If you could, just for people not familiar, what does vestibular mean?

Dr. Louise Klebanoff: The vestibular system is our equilibrium system. It tells us where our heads are in space and where they’re moving in space. Are they moving forward? Are they moving to the side? It really helps us keep our balance and know where we are in space. That’s the vestibular system.

Courtney: The third one you mentioned about the way dizziness can be described was gait instability. Is that right?

Dr. Louise Klebanoff: Correct. So some people say that they feel dizzy, but when you, I really talk to them, it’s that they’re unsteady when they walk. And that dizziness is not gonna occur when they’re standing still, when they’re sitting or when they’re laying flat. It’s a walking problem. And that can be caused by a lot of different things.

Anything from a stroke to hydrocephalus or water on the brain to problems in going on in the neck to really bad lumbar stenosis to neuropathy. Things like multiple sclerosis can all present with difficulty walking, which if the patients describe it as dizziness, they’re gonna see probably a general neurologist for dizziness.

And then we have to figure out what’s really going on.

Courtney: Switching gears a little bit, is there a connection between migraines and dizziness?

Dr. Louise Klebanoff: Excellent question. There is a big connection between migraines and dizziness. First of all, more patients with migraines have motion sickness than the general population. Lots of patients with migraine have vestibular symptoms, and these are the patients that tell me they have all three kinds of dizziness: lightheadedness, vertigo, and gait instability that come and go. Sometimes worsened with head movement, but no single position that really brings it on. Sometimes they could feel a little nauseous. Sometimes they’re unsteady walking. but these are patients who have a history of migraine headaches, you know, moderately to severe headaches, often on one side of the head, often pulsatile, associated with sensitivity to light and noise, nausea and vomiting and worsening when you move.

And about a quarter of the patients with migraine will have a visual aura. They’ll get blind spots or have zigzag lines that obscure their vision before the headache. But to make a diagnosis of vestibular migraine, which is migraine with a lot of vestibular symptoms, the patients have to have a history of migraine.

Courtney: Yeah. Can you talk about PPPD, or I hope I pronounce this correctly, persistent postural perceptual dizziness.

Dr. Louise Klebanoff: Yes, PPPD is a relatively newly defined condition where patients kind of, by definition will have at least three months of relatively constant dizziness and not room spinning vertigo but unsteadiness. And there’s no other real cause. We’re not entirely sure what causes this phenomenon. It often responds to medications that we use to treat anxiety like certain SSRIs or SNRIs.

But it can be very disabling. These patients feel really uncomfortable and are often functionally impaired and even bedbound because of the symptoms.

Courtney: Wow.

Dr. Louise Klebanoff: And it’s very frustrating because the exam is normal and the imaging is normal. There’s not a blood test that gives you a diagnosis. It’s really a clinical diagnosis that can take some time to come up with.

Courtney: So I think dizziness can also be very scary symptom to feel.

Dr. Louise Klebanoff: Yes.

Courtney: If a patient is concerned about the worst outcome, like their dizziness could be a sign of a brain tumor. What’s important for the patient to know?

Dr. Louise Klebanoff: In terms of really serious medical problems, unless there’s a real heart issue that needs to be addressed, most dizziness is symptomatic and functionally impairing, but is not necessarily medically dangerous. So that’s something to keep in mind. Most patients, the vast majority of patients with dizziness are not gonna have a brain tumor or a stroke or multiple sclerosis, which tend to be the leading concerns that patients come in with dizziness.

You know, if I cannot reassure a patient by taking a history and doing a really detailed neurological exam, or if there’s anything I’m concerned about, I’m certainly gonna get an imaging study on the patient.

Courtney: And so for those who are struggling with dizziness, but maybe they’re not sure where to start, is there anything they can do today to better manage and understand their symptoms?

Dr. Louise Klebanoff: Really think about what the symptoms are and when they come on, and then talk to your primary care doctor. Always best to start with primary care ’cause they help you coordinate your care. If they’re really not sure what the dizziness is caused by, you’re coming to me, you’re coming to neurology.

Courtney:  Dr. Klebanoff, thank you so much for being with us here today and talking us through all the various types of dizziness and what we can do about it.

Dr. Louise Klebanoff: It was great to be here. Happy to come again.

Courtney: Our many thanks to Dr. Louise Klebanoff. I’m Courtney Allison.

Health Matters is a production of NewYork-Presbyterian.

The views shared on this podcast solely reflect the expertise and experience of our guests. To learn more about Dr. Klebanoff’s work with patients, check out the show notes!

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