In this article will consider a patient who complains of giddiness. Giddiness or vertigo is a subjective sensation of turning or rotation of the surroundings. The patient feel that he/she is rotating or that the surroundings are rotating, and finds difficulty in balancing, if he is standing or sitting. In severe cases, the sensation may occur even in the lying down position.
What to do first?
If a patient is feeling giddy, first make the patient lie down, and give a tablet of stugeron (Cinnarizine) or stugil (Domperidone + Cinnarizine) stat and 8 hourly. If Cinnarizine is is not effective try tab stemetil (Prochlorperazine) one stat and TDS. In severe cases, give injection stemetil (Prochlorperazine) 2cc IM stat. This should be supplemented with B complex injections and capsules. If the patient has cochlear symptoms, like tinnitus, ringing sounds in the ear or deafness, then prescribe tab Vertin (betahistine) 8 mg TDS. This was in short, the symptomatic treatment of giddiness.
How to approach a case of giddiness?
Now let us see, how to approach this patient who complains of giddiness and what to look for.
- The first thing to do is to make the patient lie down and check the blood pressure. Severe hypertension is one of the causes of giddiness if giddiness.
- If giddiness is only on standing up, then make the patient stand up and check the BP again, if BP becomes low on standing, then it is a postural hypotension causing giddiness.
- Patients on antihypertensive drugs especially calcium channel blockers (CCB) like nifedipine may experience giddiness due to postural hypotension. In these patients a different antihypertensive drug should be prescribed.
4.Internal ear pathology
- If giddiness appears on turning the head to one side, or if there is associated tinnitus or deafness then the cause in the internal ear is very likely. So examine the ears for perforation in the eardrum or ear discharge, suggestive of otitis media, for hard wax in the external ear canal. If there is ear problem, treat the patient symptomatically and then refer the patient to an ENT surgeon.
- If giddiness comes in episodes of sudden attacks of severe giddiness lasting for few hours with nausea and vomiting, but with no other physical finding then probably it is a case of meniere’s disease.
- Another common cause for giddiness is cervical spondylitis. If the patient has pain in the neck, or pain radiating to the shoulders and arms and if giddiness increases on looking upwards or making any neck movements then think of Spondylitis. An x-ray of the cervical spine will be diagnostic.
- Then you should also ask about history of taking any medicines. We have already seen that antihypertensive drugs especially when given in higher doses cause postural hypotension and giddiness on standing. Some drugs cause labyrinthitis or vestibular damage, and the patient gets severe giddiness. The most common example is streptomycin injections in the treatment of Tuberculosis, so also quinine in the treatment of Malaria and Salicylates in the treatment of Arthritis can cause labyrinthitis. When a patient complains of giddiness stop these drugs immediately and treat with stugeron (Cinnarizine) and B complex. If you continue to give the drug, the damage to the ear will become permanent.
- Patient with severe anaemia with hemoglobin is less than 4 or 5 gram per cent will also complain of Giddiness. The patient will be pale white and will require blood transfusion and haematinics.
9.Aortic stenosis or age related aortic sclerosis
- Auscultate the heart for harsh systolic murmur of aortic stenosis, which causes giddiness on exertion.
- If the patient is a diabetic, giddiness should alert your mind to hypoglycemia, especially with there is associated headache or sweating. Check the blood sugar immediately and if the patient is hypoglycemic, give oral or intravenous glucose immediately.
- If after thorough history and examination, no apparent cause is detected, get the eyesight checked for minor refractive errors, which if found should be corrected by glasses.
- Lastly we should be aware of two interesting causes. Firstly, giddiness maybe physiological, after a long travel, specially when you are sitting near the window watching outside, you may get giddiness for sometime. Physiological giddiness is also experienced by many, when standing at unaccustomed heights and looking down. This needs no active treatment.
- Secondly giddiness could also be hysterical. A young patient, specially a female, fluttering the eyes, seeking attention, should make you suspect hysteria, of course this is not true giddiness.
- Underlying infection or fever may release cytokines and may result in anemia of chronic disease resulting in giddiness.
At the end, let us revise the symptomatic treatment of giddiness.
- Make the patient lie down supine. Give one tablet of Stugeron (cinnarizine).
- If it is not effective, give a tablet of stemetil (prochlorperazine).
- In severe cases give injection stemetil (prochlorperazine) 2cc IM, also give injection neurobion (Vit B Complex) and oral B complex.
- If the patient has cochlear symptoms like tinnitus or deafness, give tab Vertin, that is betahistine 8 milligram TDS.