How to manage dizziness in a patient with hypothyroidism (underactive Thyroid Stimulating Hormone (TSH) regulation)?

From the Guidelines

Managing dizziness in a patient with hypothyroidism requires optimizing thyroid hormone replacement therapy with levothyroxine and addressing potential underlying causes of dizziness. The primary treatment for hypothyroidism is oral T4 monotherapy (levothyroxine sodium) 1. To manage dizziness, patients should start with a dose of levothyroxine, typically 25-50 mcg daily for older adults or those with cardiac issues, or 75-100 mcg daily for most adults, with dose adjustments every 6-8 weeks based on TSH levels until reaching the target range of 0.5-2.5 mIU/L.

Some key points to consider when managing dizziness in hypothyroidism include:

• Dizziness often improves once thyroid levels normalize, which may take several weeks 1.
• During this adjustment period, patients should change positions slowly to prevent orthostatic hypotension, stay well-hydrated, and avoid triggers like caffeine or alcohol.
• If dizziness persists despite optimal thyroid treatment, consider other potential causes such as anemia (common in hypothyroidism), inner ear problems, or medication side effects 1.
• Patients should track dizziness episodes, noting timing, duration, and associated factors, to help identify patterns.
• Vestibular rehabilitation exercises may help if dizziness continues after thyroid levels normalize 1.
• The serum TSH test is the primary screening test for thyroid dysfunction, and multiple tests should be done over a 3- to 6-month interval to confirm or rule out abnormal findings 1.
• The USPSTF found no direct evidence that treatment of thyroid dysfunction based on risk level alters final health outcomes, but treatment is generally recommended for patients with a TSH level that is undetectable or less than 0.1 mIU/L, particularly those with overt Graves disease or nodular thyroid disease 1.

Overall, managing dizziness in hypothyroidism requires a comprehensive approach that addresses both the underlying thyroid condition and potential contributing factors to dizziness.

From the Research

Managing Dizziness in Hypothyroidism

To manage dizziness in a patient with hypothyroidism, it's essential to understand the underlying causes of dizziness and how hypothyroidism can contribute to this symptom.

• Dizziness can be a symptom of various conditions, including orthostatic hypotension, which is a common cardiovascular disorder characterized by a drop in blood pressure when standing from a supine to an erect position 2.
• Hypothyroidism, or underactive thyroid, can cause a range of symptoms, including fatigue, lethargy, cold intolerance, weight gain, constipation, change in voice, and dry skin 3.
• While the standard treatment for hypothyroidism is thyroid hormone replacement therapy with levothyroxine, some patients may experience persistent symptoms, including dizziness, despite normal thyroid function tests 3.

Evaluating Dizziness

Evaluating dizziness in a patient with hypothyroidism requires a comprehensive approach, including:

• A thorough medical history to identify potential triggers and underlying causes of dizziness 4.
• A physical examination, including orthostatic blood pressure measurement, a full cardiac and neurologic examination, assessment for nystagmus, and the Dix-Hallpike maneuver 4.
• Laboratory testing and imaging may not be necessary, but can be useful in some cases to rule out other underlying conditions 4.

Treatment Options

Treatment options for dizziness in hypothyroidism may include:

• Thyroid hormone replacement therapy to manage hypothyroidism symptoms, including dizziness 5.
• Non-pharmacologic strategies, such as increasing salt intake, wearing compression stockings, and avoiding dehydration, to manage orthostatic hypotension 6.
• Pharmacologic interventions, such as fludrocortisone or midodrine, to manage orthostatic hypotension 6.
• Vestibular rehabilitation and balance exercises to improve balance and reduce dizziness 4.