Pressure in head and dizziness anxiety

Phobic postural vertigo

“Phobic postural vertigo” (PPG) is understood to be a clinical syndrome that includes, firstly, dizziness described by patients as “fog in the head”, unsteadiness, a feeling of intoxication, which are usually associated with special conditions (downstairs, walking along a busy street, at night) or situations that are perceived by the patient as provoking factors (being in the subway, a public place, driving a car), secondly, anxiety and autonomic reactions (nausea, vomiting , lability of pulse and blood pressure) and, thirdly, avoidance behavior in relation to these situations in the absence of objective clinical signs of organic neurological disorders.

PPH is typical of obsessive-compulsive individuals and usually develops after significant irritation of the vestibular apparatus (especially in benign paroxysmal positional vertigo, vestibular neuronitis) or stress.

Clinic

PPH is characterized by attacks of imbalance, fear that occur without episodes of real falls (falls are possible that precede the formation of secondary PPH), but with the formation of avoidant behavior.

The severity of symptoms is reduced by distracting the patient, as well as after taking small doses of alcohol, in some patients during sports. The quality of life of patients with PPH significantly decreases with the generalization of vegetative-somatic symptoms and the increase in the patient's social maladaptation. In the premorbid character structure, predominantly obsessive traits and perfectionism are revealed, predisposing to the formation of stable obsessive-compulsive disorders and psychogenic depressions.

The manifestations of PPH largely correspond to the structure of panic disorder, including periodic anxiety attacks, an obsessive fear of a recurrence of an attack accompanied by dizziness, and avoidance behavior. However, it should be borne in mind that the fear of repeated dizziness with avoidant behavior can also be observed in patients with vestibular dysfunctions, which makes it possible to distinguish between primary and secondary panic disorder that develops on the basis of otological pathology.

Diagnostics. For differential diagnosis, it is important to conduct a comprehensive examination of such patients (brain MRI, consultation with a neurologist, ENT doctor), exclude possible concomitant somatic pathology (endocrine disorders, anemic syndrome, arrhythmias, etc.), convince the patient of the benign nature of his disease. After all, sometimes such patients find themselves without the help of specialists: otorhinolaryngologists exclude their pathology, therapists and neurologists also do not find any significant deviations, which fixes the patient even more on his own experiences, forming a feeling that he has a “rare, incomprehensible” disease with a dubious prognosis for recovery. Criteria for the diagnosis of PPG are given in the table.

Treatment

Treatment of patients with PPH should be based on a combination of medicinal and non-drug (psychotherapy, vestibular and respiratory gymnastics) methods of treatment. First-line drugs are antidepressants (selective serotonin reuptake inhibitors - paroxetine, venlafaxine - and tricyclic antidepressants - amitriptyline). Benzodiazepines (phenazepam, diazepam, alprazolam, etc.) are also used. In some cases, a positive effect in the treatment of anxiety disorders is achieved with the use of "small" antipsychotics (sulpiride, tiapride, thioridazine). As an additional therapy, the drug betahistine is used, which reduces the excitability of the vestibular apparatus and is effective for all types of dizziness, including psychogenic. Mandatory is the treatment of underlying somatic and neurological pathology, which leads to a deterioration in postural and vestibular functions (for example, treatment of diabetes mellitus, vitamin B12 deficiency, hypo- or hyperthyroidism).

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Causes, symptoms and treatment of vertigo

Vertigo is a misperception of one's body in space. This is a fairly common symptom of both neurological and mental, somatic diseases. An average of 15-35% of the population experiences dizziness in their lifetime. Most often these are people after 60 years - 20%, after 70 - 30% and after 80 - 50%.

Regular bouts of dizziness when standing up markedly impair quality of life and can lead to injury due to falling. This is especially dangerous for the elderly. For people of working age, such manifestations in the body often cause a temporary loss of the opportunity to work fully.

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There are 5 main types of vertigo:

• vestibular;
• lipothymic;
• postural;
• cervicogenic;
• psychogenic.

Vestibular vertigo develops due to damage or physiological stimulation of the peripheral vestibular apparatus and central autonomic structures. As a rule, difficulties with orientation in space arise when the head is rotated. All this passes with loss of balance, periodic falls, nausea and other unpleasant manifestations.

Lipothymic vertigo occurs in pre-syncope after excessive use of insulin or insulinoma. A characteristic symptom is "fog" in the head. A similar condition can occur after taking drugs that depress the central nervous system. For example, tranquilizers.

Postural vertigo is due to various gait disorders.

Cervicogenic dizziness is provoked by diseases of the cervical spine. Dizziness in this pathology is the result of pain and limited mobility of the neck.

Psychogenic dizziness is characteristic of people with neuroses and personality disorders. Such attacks are manifested due to feelings of anxiety, panic attacks in various situations. This type is usually described as a feeling of unsteadiness, the presence of heaviness in the head, a feeling of intoxication. Oscillatory eye movements in this case are absent, but, unlike other varieties, depression may occur afterwards. Treatment of dizziness in women and men includes psychotherapy, vestibular exercises, antidepressants.

SYMPTOMS OF VERTIGO AND BALANCE

People who experience dizziness are more likely to describe their condition as follows:

• sensation of body movement;
• loss of balance and body tilt to one side;
• feeling of tightness, constriction in the head;
• fall for no reason;
• unsteady gait or loss of her confidence.

Symptoms may only get worse with changes in body position or head rotation. Dizziness can come on suddenly and be so severe that you have to sit up or lie down abruptly. It can last a day or even several, although it is often limited to a few minutes.

CAUSES OF Dizziness

There are many causes of dizziness, from diseases of the inner ear to taking certain medications. The most serious are determined by pathologies of blood circulation in the brain, as well as tumors or brain damage after falls or strong blows.

In many situations severe vertigo causes diseases of the inner ear, benign paroxysmal positional vertigo, Meniere's disease. Also often the basis is infectious diseases of the ear.

Less common causes are vertebrobasilar insufficiency, stroke or intracerebral hemorrhage, multiple sclerosis, vestibular migraine, acoustic neuroma, orthostatic hypotension, hypoglycemia (low blood sugar), anemia (low iron), medication.

Inner ear infections

Vestibular neuritis and labyrinthitis are disorders that result from infections. They cause inflammation of the inner ear, or the nerve that connects the inner ear to the brain. After that, the transmission of sensory information from the ear to the brain is disrupted. The result is hearing loss and balance problems.

Inner ear infections are caused by viruses or bacteria. You can find out about the presence of viruses in the body by the symptoms of an infection of the internal respiratory tract. Its manifestations are noted a few weeks before the onset of dizziness. You can get an infection at any age.

Anatomy of the ear

The inner ear consists of a system of tubes and sacs that are filled with fluid. All this is called a labyrinth, the functions of which are hearing and balance. Sound signals from the labyrinth are transmitted to the brain via the vestibulo-cochlear nerve with two branches. One transmits messages from the organ of hearing, and the other from the organs of balance.

The brain processes balance signals sent through the vestibular nerve from the right and left ear. When one party is infected, it sends false signals. This is how information is presented that does not correspond to reality, which leads to dizziness.

Vestibular neuritis (nerve inflammation) affects the balance branch. This leads to dizziness, a disturbed sense of oneself in space, a sharp movement of the eyeballs with a fast phase, but there is no transformation with hearing. It may seem to a person that objects are moving around, and when performing coordination exercises, he will usually be mistaken.

Experts also use the term "vestibular neuronitis" (damage to the sensory neurons of the vestibular ganglion). Its symptom is severe, rapidly developing, paroxysmal dizziness. It is often characterized by vomiting, imbalance. Often development symptoms of dizziness precedes SARS. Sometimes, a few weeks before the developed clinical picture, patients may notice short bouts of loss of balance.

Labyrinthitis (inflammation of the labyrinth) occurs when an infection affects both branches of the cochleo-vestibular nerve. Then the hearing changes, attacks of dizziness occur. Even with small turns of the head, the symptoms become more pronounced. Therefore, some people are forced to support their heads with their hands.

Benign paroxysmal positional vertigo (BPPV)

BPPV is one of the most common causes of vertigo which manifests itself with sudden movements and head waving. The duration of the state is limited to a few seconds or minutes. It occurs when calcium crystals (otoliths) in the inner ear begin to move. Because of this, there is a sensation of rotation of the body.

The causes of BPPV are a history of traumatic brain injury, as well as otitis media. Often, the cause of the disease cannot be identified. Then the diagnosis is confirmed by taking a Dix-Hallpike sample. To do this, the patient quickly lies down from a sitting position and slightly lowers his head, turned 45 degrees. The test is positive if, a couple of seconds later, an attack of dizziness and nystagmus occurs.

Between 20% and 28% of patients with BPPV report symptomatic relief on their own up to a month after the onset of vertigo. The disease is benign and recurs within the first 12 months in only 15% of cases.

Treatment of BPPV

Treatment includes the Epley maneuver. It allows, with the help of head manipulations, to shift the otolith (crystal) into an insensitive zone - the vestibule of the inner ear.

If the effectiveness of such treatment is low, the patient is additionally prescribed a set of exercises to perform at home. This is Brandt-Deroff gymnastics, according to the method of which you need to practice 2-3 times a day from 1 to 3 weeks. Taking medication in this case usually does not give positive dynamics.

Operations are performed when repositioning techniques fail. Surgical interventions carry the risk of complications in the form of injuries of the facial nerve and hearing loss.

Among the possible operations:

• obstruction of the posterior semicircular canal;
• removal of the vestibular nerve;
• labyrinthectomy;
• selective neurectomy.

Meniere's disease

A disease characterized by repeated attacks of rotational vertigo. They last several hours and are not without noise in the ears, their congestion or bursting, as well as hearing impairment. It occurs in about 0.2% of the population, usually in people from 40 to 60 years old. The disease is based on the expansion of the endolymphatic system in the inner ear, which leads to the degeneration of the labyrinth receptors.

The disease has the following manifestations:

• dizziness;
• unsteady gait;
• hearing impairment;
• problems with perception of sounds;
• nausea and vomiting;
• ringing in the ears.

Treatment of Meniere's disease

An attack is treated with vestibulosuppressants. Prevention of the disease necessarily includes a low-salt diet, avoidance of alcohol and caffeine, the use of betahistine and diuretics.

If the chosen therapy does not lead to positive dynamics, more serious treatment is required. These can be injections of drugs directly into the ear or surgery.

Diagnosis in case of dizziness

In case of dizziness, patients undergo Halmagi tests to determine the level of the vestibulo-ocular reflex. Its violation speaks of central and peripheral lesions.

The Halmagi test does not require the use of additional equipment and lengthy preparation. The patient needs to stop looking at the bridge of the nose of a specialist who sits opposite. At the same time, the doctor holds the patient's head with both hands and turns it from side to side by 15 degrees. With a normal vestibulo-ocular reflex, the eyes remain looking at a given point. If there is a violation, then the gaze turns along with the turn of the head.

Severe dizziness with repeated bouts of vomiting lasts up to 3-4 days, after which the patient improves. Recovery can take up to several months. In older people, it is usually delayed and often incomplete. If positive dynamics is not observed within a month, then an MRI of the brain and audiometry should be performed to rule out Meniere's disease.

WHEN SHOULD YOU SEE A DOCTOR?

The alarm should be sounded if dizziness becomes regular or prolonged. Immediate help is needed if you experience severe dizziness and unsteadiness in combination with the following symptoms:

• sudden headache;
• pain in the retrosternal region;
• difficult breathing;
• numbness or weakness of limbs;
• fainting;
• rapid or intermittent heartbeat;
• slow or slurred speech;
• problems with coordination;
• ongoing vomiting;
• convulsions;
• sudden hearing loss;
• numbness or asymmetry of the face.

TREATMENT OF VERTIGO

• Treatment of vestibular neuronitis At diagnosis, the patient is hospitalized, but sometimes outpatient treatment is acceptable. In either case, treatment should be aimed at reducing the degree of dizziness, stopping vomiting, and accelerating vestibular compensation. Symptomatic therapy includes the use of vestibular suppressants. When vomiting, injectable forms of drugs are used. The duration of treatment is determined by the complexity of the manifestations of dizziness. However, in most cases they are taken no longer than 3 days. An additional effect is given by a course of corticosteroids and antiviral drugs for middle ear infections. The vestibular apparatus is best stabilized through special gymnastics. At first, it can negatively affect the well-being, but after 2-3 days, therapy should stabilize the condition. You need to repeat gymnastics at least twice a day.
• Tumors of the cerebellopontine angle (acoustic neuroma) Quite a rare cause of vertigo. It manifests itself as a slowly progressive hearing loss and tinnitus. Rotational vertigo is rare, but unsteadiness is often noted. For some time, vestibular disorders may be the only symptom of the disease. After that, hearing disorders begin to be observed. People with a similar problem should have an MRI of the brain with IV contrast. This will help check the patient for the presence of a tumor in the posterior cranial fossa. When a tumor is found, patients need to consult a neurosurgeon for referral for surgery.
• Vertebrobasilar insufficiency and cerebrovascular diseases It is distinguished by the development of a reversible dysfunction of the brain stem, cerebellum and other structures that receive blood through the main and vertebral arteries. Ischemic attacks may occur due to violations of their patency. The reason is atherosclerotic changes, vascular hypoplasia. A little less often, inflammation, extravasal compression of the vertebral artery (with a neck injury) or dissection of the artery become a prerequisite. A key cause of loss of coordination during dizziness is a malfunction in the work of small arteries with high blood pressure, diabetes, or two diseases together. According to statistics, cerebrovascular accidents account for about 6%. The cause of dizziness at normal pressure can be a malfunction in the functioning of both the labyrinth itself due to problems with blood circulation, and a violation in the area of ​​​​various brain systems. Most patients with vertebrobasilar insufficiency are diagnosed with other neurological symptoms. Separately, dizziness with problems with blood vessels is very rare. In such situations, further diagnosis is required to remove other concomitant factors. You should not associate bouts of dizziness when changing the position of the head with compression of the vertebral arteries. Often, the rapid development of severe dizziness, along with nausea, vomiting and increased pressure, can be perceived as a signal of the development of a cerebrovascular disease. But usually it rises due to severe dizziness and stress. If a stroke is suspected, a person must be urgently hospitalized for examination and immediate treatment. The hospital performs an MRI of the brain, which in a stroke will show a focal lesion of the cerebellum or brain stem.
• Vestibular migraine Vestibular migraine is relatively rare, although it is regarded as a common cause of recurrent non-positional vestibular vertigo. Its manifestations are dizziness of varying severity, combined with migraine and weakness. It can occur both during the migraine attacks themselves, and in the intervals between them. The duration of such attacks - from 3-5 minutes to 2-3 hours, sometimes days. They are not accompanied by noise or ringing in the ears, as well as hearing loss. Such attacks usually recur. The diagnosis of vestibular migraine is made on the basis of the typical clinical picture, as well as in the presence of migraine and after the exclusion of other possible causes of dizziness in women and men. Treatment of the disease, as with ordinary migraine, includes 3 stages: elimination of provoking factors, relief of an attack and preventive measures. Anti-migraine drugs or analgesics, as well as vestibular suppressants, are taken to eliminate vestibular migraine. Prevention is necessary for regular and severe attacks of vestibular migraine. Then specialists prescribe β-blockers and tricyclic antidepressants.
• Treatment of multiple sclerosis The most important thing in the treatment of this diagnosis is the elimination of life-spoiling sensations and related disorders: difficulties with coordination, hearing or vision. Treatment is determined by the cause of dizziness in men and women and the mechanisms of its development. It is important to guarantee the almost complete independence of the patient in everyday life, try to avoid sources of stress and minimize the risks of falls and injuries. Relief of symptoms includes the use of vestibulolytics. The time of their intake should be short and discussed with the doctor, because the inhibition of nerve formations does not allow compensatory changes to develop. The effectiveness of treatment increases with regular gymnastics, as well as exercises to restore the stable functioning of the vestibular apparatus. Therapy is also important to improve coordination, stabilize gait, and develop skills in a person to avoid balance problems in the future. Usually, physiotherapy exercises are used for this, which not only reduces discomfort, but also gives independence when moving.

Demyelinating disorders (multiple sclerosis)

People with demyelinating lesions of the CNS, especially those with multiple sclerosis, may be diagnosed with vertigo. Diagnostic difficulties may occur when dizziness develops at the onset of the disease without other manifestations or with their moderate severity. Dizziness in this case can be of a mixed nature, and also be characterized by a persistent course. To confirm the diagnosis, the patient needs to undergo an MRI of the brain with intravenous contrast.

HADASSAH MEDICAL MOSCOW PERFORMS DIAGNOSIS AND TREATMENT OF VERTIGO

• CT of the temporal bones and MRI of the brain;

• Ultrasound of neck vessels;

• Audiometry;

• Neurologist appointment;

• ENT doctor's appointment;

• General practitioner appointment;

• Diagnostic tests to verify BPPV and vestibular neuronitis.

Sources

• Diagnosis and treatment of balance disorders in diseases of the nervous system. Clinical guidelines, Moscow, 2017.
• Jahn K, Kressig RW, Bridenbaugh SA, Brandt T, Schniepp R. Dizziness and Unstable Gait in Old Age: Etiology, Diagnosis and Treatment. Dtsch Arztebl Int. 2015 Jun 5;112(23):387-93. doi: 10.3238/arztebl.2015.0387.
• Neurology: A Practitioner's Handbook / D.R. Shtulman, O.S. Levin. - 6th ed., add. and perab. — M.: MEDpress-inform, 2008. —— 1024 p.
• Brandt T., Dieterich M., Strupp M. Vertigo: per. from English. // M.: Practice, 2009.
• Parfenov V.A., Zamergrad M.V., Melnikov O.A. Dizziness: Diagnosis and Treatment, Common Diagnostic Mistakes: A Study Guide. // M.: MIA, 2009.
• V. Parfenov, N. Bestuzheva. Diagnosis and treatment of dizziness in outpatient practice // Vrach, 2012
• Neurology. National leadership. Brief edition / ed. E. I. Guseva, A. N. Konovalova, A. B. Gekht. — M.: GEOTAR-Media, 2018 — 688 p.

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Davidov
Natan Rashbilovich

Neurologist, Ph.D.

Work experience: 10 years

Published: 04/10/2023

The information provided on the site is for reference only and cannot serve as a basis for making a diagnosis or prescribing treatment. Internal consultation of the expert is necessary.

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