What are the most common causes of long-term dizziness?

Most Common Causes of Long-Term Dizziness

The most common causes of chronic dizziness (lasting weeks to months or longer) are anxiety or panic disorder, medication side effects, posttraumatic vertigo, posterior fossa mass lesions, and cervicogenic vertigo. 1

Classification by Duration and Triggers

Understanding dizziness requires categorizing it based on timing and triggers, which helps narrow down the differential diagnosis:

Chronic Vestibular Syndrome (Long-Term Dizziness)

• Anxiety or panic disorder - Often the leading cause of persistent dizziness
• Medication side effects - Many medications can cause chronic dizziness
• Posttraumatic vertigo - Following head injury
• Posterior fossa mass lesions - Tumors affecting the cerebellum or brainstem
• Cervicogenic vertigo - Related to neck pathology

Other Important Categories (for comparison)

1. Acute Vestibular Syndrome (continuous dizziness lasting days to weeks)

   • Vestibular neuritis
   • Labyrinthitis
   • Posterior circulation stroke

2. Triggered Episodic Vestibular Syndrome (brief episodes triggered by position changes)

   • Benign paroxysmal positional vertigo (BPPV)
   • Postural hypotension
   • Superior canal dehiscence syndrome

3. Spontaneous Episodic Vestibular Syndrome (episodes lasting minutes to hours)

   • Vestibular migraine
   • Ménière's disease
   • Transient ischemic attacks

Detailed Review of Common Causes of Long-Term Dizziness

1. Anxiety or Panic Disorder

• Presents as persistent, vague dizziness without clear triggers
• Often associated with other anxiety symptoms
• May develop secondary to vestibular disorders as "chronic subjective dizziness"
• Responds to anxiolytics and cognitive behavioral therapy

2. Medication Side Effects

• Common culprits include:
  • Antihypertensives
  • Antidepressants
  • Anticonvulsants
  • Sedatives
• Mechanism often involves effects on blood pressure or central nervous system
• Improvement typically follows medication adjustment or discontinuation

3. Posttraumatic Vertigo

• Follows head trauma or concussion
• May involve multiple mechanisms:
  • BPPV triggered by trauma
  • Labyrinthine concussion
  • Perilymphatic fistula
  • Central vestibular dysfunction
• Often complicated by anxiety and depression

4. Posterior Fossa Mass Lesions

• Tumors affecting cerebellum, brainstem, or cerebellopontine angle
• Vestibular schwannoma (acoustic neuroma) presents with:
  • Chronic imbalance more than episodic vertigo
  • Progressive unilateral hearing loss
  • Tinnitus
• Other signs may include headache, ataxia, and cranial nerve deficits

5. Cervicogenic Vertigo

• Controversial diagnosis related to neck pathology
• Associated with neck pain, limited range of motion
• May involve proprioceptive dysfunction from cervical spine
• Often responds to physical therapy targeting the neck

Diagnostic Approach

When evaluating long-term dizziness, focus on:

1. Timing pattern - Continuous vs episodic symptoms
2. Associated symptoms - Hearing loss, tinnitus, headache, neurological symptoms
3. Triggers - Position changes, pressure changes, specific situations
4. Response to previous treatments
5. Medication review

Common Pitfalls to Avoid

1. Overlooking medication side effects - Always perform a thorough medication review
2. Missing central causes - Watch for neurological signs suggesting central pathology
3. Attributing all chronic dizziness to anxiety - While common, anxiety should be a diagnosis of exclusion
4. Focusing only on vestibular causes - Remember that cardiovascular, metabolic, and other systemic conditions can cause chronic dizziness
5. Failure to recognize multiple concurrent causes - Chronic dizziness often has more than one contributing factor

Special Considerations

• Elderly patients may have multiple contributing factors including age-related vestibular degeneration, polypharmacy, and cerebrovascular disease
• Patients with migraine history are more susceptible to vestibular disorders including vestibular migraine
• Multiple sclerosis can cause central vertigo through demyelinating lesions in the brainstem or cerebellum 2
• Persistent BPPV may be misdiagnosed as chronic dizziness when it's actually recurrent episodes

Remember that chronic dizziness significantly impacts quality of life and often requires a multidisciplinary approach for effective management.