Clinical Consult: Dizziness

Dizziness: It’s more common than you may think

One in three 18-year-olds has fainted (syncope) at some point during their teenage years, and countless others have experienced dizziness without fainting. When a child or adolescent presents with “dizziness,” how do you figure out if there is a more serious clinical problem?

Evaluation and treatment

Patients often report that their symptoms occurred when they stood up after sitting or lying down for a long period of time. Nausea and vertigo (feeling like the room is spinning) are also commonly described. The experience is quite common in teenagers because their bodies are growing and changing very quickly.

The most effective way to combat dizziness is to drink extra fluids, relax for at least a few hours and recover from the environmental stimulus or minor illness that contributed to the experience.

Re-creating the situation that sparked the dizziness may help demonstrate how simple physical maneuvers can quell symptoms quickly. After performing a supine exam, ask the patient to stand up quickly. Then ask if she feels a little dizzy again. If so, instruct her to make a fist or stand in “first position” (a ballet posture many girls will recognize, in which the ankles touch and the feet open outward in a ‘V’ formation). Both movements require muscle tension, which often relieves dizziness.

In teenage girls, frequent and recurring episodes of syncope may be related to anemia or malnutrition, so it is important to obtain a comprehensive medical history.

Is an EKG necessary?

If the patient has a typical history and a brief neurological exam is unremarkable, an EKG is unnecessary. In fact, it may be counterproductive; it is quite unlikely that a minor EKG variation or abnormality would indicate an underlying cardiac issue related to dizziness.

When to refer to a specialist

In truth, dizziness rarely signifies a critical medical issue. For instance, among those patients referred to cardiologists, only between 5 and 7 percent require medical attention. Thus, nearly 95 percent of patients who have been evaluated by their primary care doctor and undergone further follow-up do not need any form of specialized care.

Patients who present with dizziness should be referred to cardiology if they are concurrently experiencing heart palpitations or if the dizziness occurs with exercise. If a patient experiences dizziness with hearing changes, she should be referred to an ear, nose and throat specialist.

Patients with findings on a neurological exam should see a neurologist. Such findings could include dizziness:

  • at rest, while the patient is lying down
  • that occurs in clusters for a few days, then remits for a few weeks only to start all over again
  • associated with headaches, nausea, vomiting, blurry vision, unsteadiness or alterations in mental status or memory

Patients should also be referred to neurology if they or their family have a history of head trauma, concussions, migraines or motion sickness.

However, it is important to remember that most patients presenting with dizziness do not require a specialist referral and can address their symptoms with home care and/or targeted muscle movements.