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Ask Dr. Arun Phophalia Your Own Question
Dr. Arun Phophalia
Dr. Arun Phophalia, Doctor (MD)
Category: Health
Satisfied Customers: 34702
Experience:  MBBS, MS (General Surgery), Fellowship in Sports Medicine
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I'd like a second opinion regarding my vertigo from an MD,

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I'd like a second opinion regarding my vertigo from an MD, but am not sure how to select that option. Also, for the sake of accuracy, I will try to error on the side of too much information rather than too little.
About me:
* 32 year old male
* Healthy except for a history of migraines.
* Had a physical exam ~5 months ago that included general blood work with everything showing up fine
I am currently having a second episode of vertigo in three months. The first episode occurred three months ago and lasted about a week with severity of symptoms steadily reducing to zero as time went on. At the worst of it, in addition to feeling disoriented and off balance when I moved my head or changed orientations, the room would actually appear to spin. These first few days were completely debilitating. The second episode that began about a week ago was similar to the first, but not as severe and without the visual manifestations, though still initially debilitating. I would describe the feeling of this vertigo as a headrush from standing up too quickly. Compared to the first episode, the second made me feel much more sleepy and the vertigo had a more general feeling of dizziness. I also noticed very infrequent, minor pulses of pain in both ears. The severity of the symptoms has reduced and I now feel about 85% back to normal after a week.
Neither episode caused me to feel nauseas.
Other information:
* Between the two vertigo episodes I had the worst diarrhea of my life for 3 days. 2 days in I started taking Pepto-Bismol, which helped a lot and put an end to the worst of it. Still, for about two weeks after that my stools were much wetter than normal. This diarrhea happened a couple weeks before my second episode of vertigo.
* Three times between the two vertigo episodes I felt atypically sick-tired for a few days as if I were coming down with a cold, but then would not get sick. I was getting a reasonable amount of sleep (> 7 hours) and not under other external factors to explain this tiredness.
* One of these sick-tired episodes did actually lead to a cold. After feeling like I might be coming down with something for a week due to my sick-tired feeling, I finally did get sick with an oddly mild and slow progressing cold that lasted about two weeks. My symptoms were a scratchy throat and congestion that a week in lead to a cough.
* During my first episode of vertigo, I read the cause could be vestibular migraines, so as a normal migraine sufferer I took my migraine medicine (Zomig), which always clears my migraines, to see if it would help, but it did not.
* I saw my GP yesterday for the second time regarding my vertigo (I saw him after the first episode as well) and he performed a few basic tests which all turned out normal: he checked my ears (no fluid), had me follow his finger with my eyes and walk a straight line. Because I didn't fail any of these tests (I'm feeling 85% recovered, tho still occasional pulses of ear pain and spells of dizziness), he mentioned something about salt likely being the cause, gave me a prescription for Meclizine and told me to wait it out and come back a third time if/when the symptoms come back. I hypothesized that perhaps I had a bacterial infection that was in my ears given the other odd symptoms I describe above, but he rejected that on account of my not having fluid in my ears.
My question:
Is my doctor's plan to see him if/when I get severe vertigo again a good plan? I'd expected to be referred to a specialist or given more substantive tests. His response felt dismissive and I'd just like to confirm that his plan is reasonable. For example, I do not want to just accept this vertigo or treat the symptoms as they come, but get to the fundamental cause and try to manage it from there. If you were my doctor what would you prescribe or recommend as next steps? What could be the cause of my vertigo?

I am Dr. Arun and will be helping you today.

I am sorry that your question was unanswered for long.

Your doctor's plan for watchful waiting would not be considered as completely wrong. Though I would get an ENT specialist opinion and few investigative work up.

The causes of dizziness according to the decreasing incidence are;

1) Benign paroxysmal positional vertigo (BPPV) 20%

2) Vestibular 15%

3) Migraine and motion sensitivity 15%

4) Anxiety and depression 10%

5) Meniere's disease 7%

6) Cerebellar disease 6%

7) Transient ischemic attacks 5%

8) Orthostatic hypotension 4%

9) Other.

In your case I would have considered first four of the above causes as the culprit in your case. The diarrhea episode can be related as the virus or any other organism which caused intestinal infection may have affected the internal ear (vestibular infection).

Chronic dizziness associated with the floating, rocking and light headedness and is induced by eye movements (head being still) should be also investigated or correlated to anxiety and depression, if all the medical imaging, blood work and examination is negative. If you are on any medications, their side effects also should be ruled out for lightheadedness, as drugs are quite a common cause for this symptom. Dizziness may be provoked by only certain movements, such as standing up after lying down for at least 10 minutes in orthostatic hypotension, or may occur after vertical or oblique head movements, such as lying down, turning over in bed, or sitting up in benign paroxysmal positional vertigo (BPPV). Simply moving the eyes with the head stationary causes dizziness and there is no eye movement disorder (ocular misalignment or an internuclear ophthalmoparesis), then dizziness is likely to be the result of anxiety. When dizziness occurs without provocation (spontaneous) and is vestibular (ear disorder) in origin, it frequently is exacerbated by head movements.

Internal ear disease vertigo is termed true vertigo in which one feels rotational movement of self or the surroundings. The false vertigo or nonvertigo has feeling of light-headedness, unsteadiness, motion intolerance, imbalance, etc. You need to consult first an ENT specialist to exclude the diseases of internal ear. They will perform some clinical tests (vestibular diagnostic tests) to establish the cause. Often, dizziness can be a multisensory disorder due to any combination of peripheral neuropathy, visual impairment, and musculoskeletal disease. Many patients who have thyroid dysfunction can present with dizziness as an initial complaint. In individuals who have migraine, dizziness and vertigo can occur as part of the aura or separately. Spells usually last approximately an hour but can last several hours or days in patients who have severe symptoms. Most patients who have migraines have a long history of recurring symptoms. So that too should be re-assessed as a cause since you have a history of migraine.

If you have another episode of significant dizziness, your doctor should also get an MRI with gadolinium contrast.

Your primary care physician should refer your to a neurologist, cardiologist and ENT specialist for evaluation if the dizziness increase or another acute attack occur, as the causes can be divided on the system, which is involved;

1) Inner ear or internal ear disease

2) Central nervous system

3) Cardiovascular, or

4) Systemic diseases

That should be able to conclude for the diagnosis.

Acute dizziness and vertigo is usually managed with;

1) vestibular suppressants,
2) antiviral medication,
3) antiemetic medications
4) steroids

Vestibular rehabilitation can help which is an exercise program. Please read this resource for the exercises;

Exercises are graded in difficulty based on velocity of head and object motion and by progression of body positioning from sitting to standing to walking. The exercises are graded in difficulty by narrowing the base of support, making the surface uneven, or changing the surface from firm to soft. Varied walking exercises are graded in difficulty by changing direction, requiring performance with the eyes closed, increasing speed of ambulation, walking on soft surfaces, or navigating stairs. An aerobic exercise home program progressively increasing the time, speed, or distance that the patient could tolerate also can be initiated. But all of these may need supervision of a doctor if vertigo is severe.

Please feel free for your follow up questions.

I would be happy to assist you further, if you need any more information.

Thanks for using Just Answer.

Customer: replied 9 months ago.
Thank you for the excellent, detailed response! I have a few quick followup questions:
1.) What do you make of the infrequent ear pain I've felt? Although my doctor did not see fluid in my ears, I've felt the infrequent ear pain both before and after my doctor checked my ears.2.) Does my not having fluid in my ears when the doctor checked towards the end of my second vertigo episode or there being 3 months between my two vertigo episodes rule out vestibular infection? If not, is the infection likely viral or bacterial? Are antibiotics warranted?3.) Does my taking migraine medicine (Zomig) during my first vertigo episodes and having it not change my vertigo symptoms at all point to it not being migraine related? Usually Zomig will make any migraine I have completely disappear within an hour.

You are very welcome.

The infrequent pain in the ear can be due to internal ear infection (vestibular infection) which can be responsible for the dizziness.

No fluid in the ear does not rule out vestibular infection. Internal ear cannot be seen by physical exam and its infection needs certain tests by ENT to look for it. Usually this is viral infection. This may be self resolving or steroids are given.

Zomig not relieving the dizziness does not completely rule it out to be migraine related. Many times other medicine or two medicines of migraine may be needed.

It is privilege assisting you.

Please let me know if you have further queries or unanswered questions.

Please consider a positive rating if this interaction has been satisfactory, as this is the only way we experts are credited and compensated for the time and work. You are not charged again for giving a rating.

Thank you.

Wishing you all the very best in life.

Customer: replied 9 months ago.
Can I have a Medical Doctor to answer my question too? I need another opinion from a real Doctor. Thanks


I am a real doctor.

This is the reason I have given you customized answers to all of your queries.

You were very appreciative of my previous detailed reply.

Best wishes,
It was my pleasure to help you.
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Customer: replied 9 months ago.
This is exactly what I wanted to avoid. I'm sorry they passed on my e-mail to you. I asked them to still pay you and simply resubmit my question to another doctor for free, but it seems they misunderstood. You did give good answers and clearly spent time on the answers, which I appreciate, but I lost confidence when I saw you practice homeopathy, which has been shown to not be more effective than placebo in a number of studies. Maybe in India there are good med schools that teach homeopathy, but in the US none of the reputable medical schools do. I apologize if I have offended you, but since you e-mailed me I felt I should address the issue.

I am a general surgeon and sports medicine specialist. And I have been trained in modern medicine. I did my my post doctoral fellowship in one of the best hospitals in Paris / France. I am not a homeopath. I am attached to university of homeopathy as a professor of surgery which is part of their curriculum too and because I teach undergraduates, postgraduates and supervise the doctoral thesis (PhD) in the University.

I really appreciate your rating and time taken for the explanation.

I again wish you all the very best in all your endeavors.

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