When is the world seems to spin around you, there might be a a variety of different underlying causes from high blood pressure, inner ear problems to neurological disorders. It's both important and tricky to get the proper diagnosis for those underlying conditions. 

Patients who come to Yale Medicine with symptoms of dizziness will be given a comprehensive evaluation, using advanced diagnostic techniques, in order to identify the underlying cause.

“I spend a lot of time with each patient, trying to understand their symptoms in as much detail as possible,” says Dhasakumar Navaratnam, MD, director of the Hearing & Balance Program in Yale Medicine’s otolaryngology department. "That is the first and most crucial step on the road to recovery."

Typically, patient complaints fall into three broad categories and each points to a different underlying problem.

• Lightheadedness. Some people feel woozy, or as if they might black out—especially when they stand up, or sit up from a reclining position. Usually, these patients are suffering from problematically low blood pressure—either because of a blockage of blood vessels, or because of a fluctuation in blood pressure.
• Spinning. Some people describe their dizziness like spinning round-and-round—either that their body is spinning or that the world around them is. Usually, this sensation is caused by a problem inside the inner ear, so patients with these symptoms will be treated at Yale Medicine’s Hearing and Balance Center.
• Unsteadiness. Some people describe their dizziness as a sensation of unsteadiness, or drunkenness. This can be an indication of brain or nervous system dysfunction, including migraine and even stroke. Patients will usually be treated by the Yale Medicine Department of Neurology.

Dizziness can be mild or acute, depending on the cause and the severity of the underlying disorder. Some patients experience intense periods of dizziness that lead to nausea and vomiting.

Others have severe bouts of dizziness that can be very disturbing, out-of-body experiences. And while occasional dizziness is common, patients shouldn’t shrug off their symptoms. Frequent dizziness often signals a medical condition. Even mild dizziness could indicate a neurological disease.

The good news is that dizziness often can be treated without much disruption for the patient, Dr. Navaratnam says. “We try to do a lot of things to address the dizziness before we move to medication or other treatment options."

If lifestyle modifications do not correct the dizziness, clinicians will explore other options—such as a medication adjustment or even surgery—depending on the cause of the dizziness.

Some patients who complain about unsteadiness and lack of coordination are suffering from a disorder in the brain stem or cerebellum, the region of the brain that controls motor skills.

Patients who suffer from chronic migraines might also experience a drunken or swaying feeling. Other neurological disorders, including stroke, brain tumor, or an injury like concussion, might lead to a sensation of dizziness.

These conditions can usually be diagnosed with a brain scan and neurological evaluation. Once diagnosed, patients will be referred to the appropriate care center within Yale Medicine's otolaryngology department, where treatment will differ, depending on the underlying cause of the dizziness.

The inner ear is a complex network of tiny structures. Some of the structures control balance and our perception of head alignment. Others regulate fluid inside the ear and transform sound into electrical signals that are sent to the brain. Dysfunction at any point can cause dizziness. Common inner ear problems include:

• Benign vertigo. The fluid in the inner ear contains tiny crystals that influence our perception of gravity. If the tiny crystals become dislodged, they can move into a different part of the inner ear called the semicircular canal. This can cause short but intense periods of dizziness, or a spinning sensation—especially when a person is lying down. In a simple procedure, a physician will have a patient hold the body in a series of seated and reclining positions, which move the crystals back into their proper place. Patients are also given exercises to practice at home to ensure the crystal does not become dislodged again.
• Ménière's disease. The precise cause of Ménière's disease is unclear, but many researchers believe that it is caused by fluid buildup in the inner ear. Patients with Ménière's disease feel pressure in their ear similar to the pressure that builds up during an airplane’s descent. They might also experience hearing loss, or tinnitus, or ringing in one ear. The drug dyazide works to reduce these symptoms in some patients. Others might see benefit from the drug betahistine.
• Vestibular neuritis. Sometimes the inner ear can become inflamed, usually because of an infection. This can lead to a severe sensation of dizziness that builds up over several hours. For some patients, this dizziness causes extreme nausea, vomiting, and discomfort. The inflammation is treated with steroids, but it takes about two to three weeks for most symptoms to abate. It also takes up to six months for patients to achieve a more complete recovery.

Patients who experience lightheadedness and dizziness often have poor circulation. The sensations can be most apparent when sitting up or standing, particularly after having been seated or reclining for several hours.

Dizziness is also a common symptom of the blood pressure medications such as alpha channel blockers or calcium channel blockers, and prostate medication. If patients are taking those medications, the best treatment for their dizziness is to consult with their primary care physicians to determine if switching medication is possible. 

Another treatment approach is to educate patients about symptom management. Before standing up suddenly, for example, you can improve circulation by repeatedly contracting your thigh muscles. Or instead of immediately getting out of bed in the morning, try raising your head by about three inches, which increases the tone of blood vessels so pressure doesn't drop after standing up. Compression stockings also work to increase arterial pressure and reduce the chance of a sudden blood pressure drop.

Because dizziness can be caused by so many different underlying illnesses, patients might have to undergo several diagnostic tests to ensure a proper diagnosis. At Yale Medicine, most patients can have all those tests performed under one roof.

Yale’s Medical Campus has a joint clinic that combines the resources from the Hearing and Balance Center with its Otolaryngology (ENT) Center. Experts work closely with Yale’s Neurology Program for patients with potential neurological disorders. Physicians from each clinic are each trained to assess a patient’s symptoms in a slightly different way and they work together to identify the best possible treatment.