Chronic Dizziness

Chronic dizziness is a frustrating, persistent disorder that can significantly interfere with normal daily activities and prevent people from being able to do the things they want to do. Chronic dizziness can take a few different forms, depending on what the precipitating event was, the physical and psychological contributions to the disorder, and the symptoms that are experienced.

Chronic dizziness is often initiated by a precipitating medical event. For example, an inner ear infection called labyrinthitis can cause dizziness/vertigo that lasts for several weeks, but typically resolves fully. However, some people continue to experience persistent, fluctuating labyrinthitis symptoms, including dizziness (but not vertigo) and increased sensitivity to complex visual stimuli (e.g. driving in the rain, complicated patterns), that are made worse by passive and active movements (e.g. riding in a car and walking, respectively).

To meet criteria for chronic dizziness, symptoms must be present more days than not for at least 3 months. Most people have symptoms for several hours every day. In addition, the disorder must cause significant functional impairment or distress. Triggers usually include an upright posture (standing or walking) and moving visual stimuli.

Chronic dizziness is frequently associated with an anxiety disorder that worsens symptom severity. Common symptoms of an anxiety disorder include excessive worrying about life events, loss of ability to carry out routine tasks, and anticipatory anxiety in advance of a situation that may cause dizziness. People who are anxious about becoming dizzy actually increase their risk for a dizzy spell.

Dizziness

Before we get into a discussion on chronic dizziness, let’s briefly review dizziness types and mechanisms.

Dizziness is an umbrella term that includes the following subtypes:

• Vertigo: A spinning or tilting sensation; a sense of motion when you’re not moving
• Presyncope: Feeling like you are going to faint (fainting is called syncope); also called lightheadedness or giddiness
• Disequilibrium: A sense of imbalance or instability, often experienced when you are walking

The vestibular system is an important balance organ, and when it isn’t working properly, you will feel dizzy. Consequently, dizziness is sometimes called a “vestibular symptom,” and disorders that cause dizziness are known as “vestibular disorders.”

Vestibular disorders can be caused by structural (anatomical), functional (physiological), or psychiatric (particularly anxiety) abnormalities.

Structural and functional vestibular disorders are initially acute or episodic, but they can both transition to a chronic state. Psychiatric vestibular disorders are not considered to be acute or episodic, rather, they are chronic, progressive conditions.

Chronic dizziness treatment

The most effective treatment approaches to chronic dizziness emphasize a holistic approach that addresses both physical and psychological aspects of the disorder. In many cases, people with chronic dizziness have seen several doctors in a variety of specialties without ever being accurately diagnosed, and the standard dizziness treatments they are given are often ineffective. Many people who have unsuccessfully tried medications find that physical therapy is a more effective treatment strategy.

When treating chronic dizziness, it is important to understand what caused it and what contributes to it. For example, one person may have had an acute case of vestibular neuritis that transitioned into chronic dizziness without anxiety, while someone else may have a psychiatric vestibular disorder with high anxiety and panic attacks. Treatment plans for these people may look very different. Treatments should be tailored to suit the specific needs of each patient.

Vestibular rehabilitation therapy

Vestibular rehabilitation therapy (VRT) is the gold standard in treating structural dizziness. VRT is an exercise-based physical therapy program that can alleviate symptoms associated with many forms of chronic dizziness.

VRT leads to significant improvements in vertigo symptoms, fall risk, posture and balance, and overall emotional status in people who have vestibular forms of dizziness (i.e. inner ear dysfunction). One recent study found that 79% of VRT patients reported subjective improvements in their chronic dizziness symptoms.

VRT is has also successfully helped people with mild forms of psychiatric vestibular disorders, although more serious cases may be better treated by combining VRT with behavioral therapy and, if necessary, medications.

Importantly, maximum efficacy requires a commitment from the person being treated. People who are less than 75% compliant with their physical therapy regimen have poorer outcomes than people who are fully compliant.

Cognitive behavioral therapy

Cognitive behavioral therapy (CBT) is one of the most successful behavioral therapies for helping people manage chronic dizziness that has a significant psychological component. CBT identifies negative thought patterns and replaces them with positive ones. Over time, this can significantly reduce chronic dizziness symptoms and improve mood and outlook.

Chronic dizziness that has a structural origin (e.g. peripheral vestibular system disorder) or a functional origin (e.g. vestibular neuritis) may respond well to CBT, but physical therapy should also be used to address the physical aspects of the disorder.

Medications

Depending on the cause of your chronic dizziness, some medications may help you manage the symptoms:

• Selective serotonin reuptake inhibitors (SSRIs) are antidepressants that can be very helpful for people who have psychiatric vestibular disorders or anxiety with dizziness.
• Benzodiazepines are prescription anti-anxiety drugs that can reduce dizziness and anxiety, but they are for short term, intermittent use only, as they are associated with a high risk for developing physical and psychological dependence/addiction.
• If your chronic dizziness is related to vestibular migraine, anti-migraine drugs may reduce symptom severity and duration.
• Nausea and vomiting can be treated with prescription antihistamines or anticholinergics.

Although medications have their place in treating anxiety and dizziness disorders, in many cases physical therapy and behavioral therapy are as (or more) effective than pharmacological treatment options.

Central nervous system therapies

Until recently, it was thought that chronic dizziness was the result of impaired compensation after an injury. Compensation is the process of recovering normal function through central and peripheral nervous system reorganization; in other words, your nervous system adapts to overcome damages associated with the injury. Recent evidence suggests that the recovery process is even more complex and includes changes in the way the brain integrates and processes spatial information. If this is proven to be true, it suggests that a peripheral nervous system disorder can have long-term functional consequences in the central nervous system.

Treatment options that target the central nervous system are currently being tested, with some promising preliminary results. Transcranial cerebellar direct current stimulation (tcDCS) was shown to enhance the benefits that physical therapy provides, and repetitive transcranial magnetic stimulation (rTMS) treatment was shown to reduce the frequency and severity of dizziness spells.

Chronic dizziness and lightheadedness

Lightheadedness, also known as presyncope, is the feeling that you are about to pass out. Chronic dizziness and lightheadedness may be experienced together, especially if a dysautonomia (a disorder of the autonomic nervous system) or a dysrhythmia (abnormal heartbeat) is also present. Lightheadedness can also be caused by orthostatic hypotension (low blood pressure) that occurs when you stand up too quickly. 

Chronic dizziness and headaches

Vestibular migraine is a chronic headache disorder that often includes dizziness or vertigo. Vestibular migraine is characterized by light sensitivity, imbalance, nausea/vomiting, ringing in one or both ears, spatial disorientation, and intolerance to moving visual stimuli.

Chronic subjective dizziness

Chronic subjective dizziness (CSD) is a unique type of chronic dizziness. It is a progressive disorder that is characterized by disequilibrium and hypersensitivity to complex visual stimuli. CSD is not caused by vestibular dysfunction, and dizziness is linear, rather than vertiginous. Unlike some types of dizziness that are obvious to observers, the dizziness associated with CSD is called “subjective imbalance” because even though the person with CSD feels imbalanced, they would not appear dizzy or off-balance to an observer.

Why some people develop CSD is not yet clear. Evidence suggests that both physical and psychological factors contribute to CSD, and many CSD symptoms are emotional or behavioral. CSD was originally thought to be a “psychogenic” disorder; that is, a disorder of the mind, without any physical contribution. We now know that there are psychological and physical components to CSD, but the majority of people (~60%) with CSD also have an anxiety disorder.

There are three types of CSD:

• Otogenic CSD: Dizziness developed as a result of a temporary medical condition (e.g. vestibular neuritis) and there was no history of anxiety before the inciting event
• Psychogenic CSD: Dizziness develops in the absence of an apparent physical cause and coincides with the course of an anxiety disorder
• Interactive CSD: Dizziness developed after a transient medical condition in someone with a predisposition to, or a history of, anxiety disorders

In order to be diagnosed with CSD, the following diagnostic criteria must be met:

• Persistent dizziness without vertigo
• Hypersensitivity to one’s own movement and the movement of objects in the environment
• Symptoms of CSD are exacerbated by complex visual stimuli (e.g. driving in the rain, moving through a crowd)
• Symptoms must be present for at least 3 months
• No evidence of a vestibular disorder or another physical cause (e.g. brain lesion)
• Balance function test results do not identify the patient as having impaired balance

Treatment options for CSD are similar to those for other types of chronic dizziness, including VRT and physical therapy, cognitive behavioral therapy, and medications.

Chronic dizziness and fatigue

Fatigue is a key trigger of dizziness. Usually, fatigue and dizziness are transient symptoms that resolve with rest, but there are some chronic conditions that include fatigue and dizziness.

Chronic fatigue syndrome

Chronic fatigue syndrome (CFS) is a condition that is characterized by overwhelming fatigue, even after a good night’s sleep. In addition to dizziness, CFS symptoms include muscle pain, headaches, difficulty thinking or focusing, insomnia, rapid heart rate, and flu-like symptoms. The cause of CFS is unknown, but stress and anxiety may have a significant role in the development and persistence of CFS symptoms.

Postconcussional syndrome

Fatigue and chronic dizziness are common symptoms after head trauma or whiplash. Other common symptoms include irritability, mood swings, dysphoria, insomnia, weakness, headache, short term memory loss, and inability to focus. Postconcussional symptoms often resolve within a week or so, but they may persist for several weeks, depending on the severity of the trauma and the care received after the accident.

Other causes of dizziness and fatigue

• Low blood pressure and low blood sugar are two common causes of dizziness and fatigue, but they are usually temporary conditions. However, unmanaged diabetes, malnutrition, anemia, and obstructive breathing disorders (e.g. sleep apnea, emphysema) can cause persistent dizziness and fatigue.
• Vestibular migraine may also cause episodic fatigue and dizziness. Migraine frequency can vary from several attacks per year to near-daily attacks, and dizziness and fatigue may coincide with the migraine or may occur before or after the migraine.
• Somatic symptom disorder (SSD) is a poorly understood condition that is characterized by persistent physical symptoms (including dizziness and/or fatigue) that do not have an obvious medical explanation. People with SSD are preoccupied with their symptoms and find them to be very disruptive or distressing.

Dizziness and nausea

Dizziness and nausea are non-specific symptoms, meaning that there are multiple potential causes. Chronic dizziness is often associated with increased sensitivity to complex or moving visual stimuli, which can cause nausea and motion sickness, even if you’re not moving. If you regularly suffer from dizziness and nausea, you may want to make an appointment with your doctor to learn about your options. There are several medications that may reduce the severity of your symptoms.

Importantly, dizziness or vertigo that is accompanied by ongoing vomiting could indicate a serious, even life-threatening medical issue, and you should seek medical treatment immediately.

FYZICAL is a dedicated group of physical therapy providers who are highly trained and skilled in helping people manage symptoms related to chronic dizziness. Using a holistic, whole-body approach, we will work with you to develop an exercise program that can help you get your balance, and your life, back.

FYZICAL offers free assessments that can help you understand why you’re feeling dizzy and help you explore ways to resolve these symptoms and regain your life. Find a FYZICAL location near you and make an appointment today.

To learn more about how FYZICAL Therapy & Balance Centers can help you, download our free e-book.