What are the next steps to diagnose and manage my persistent dizziness and lightheadedness, given normal bloodwork, sleep study, and pending cardiac tests?

Evaluation and Management of Persistent Dizziness/Lightheadedness

Your persistent dizziness/lightheadedness requires evaluation by a vestibular specialist, as it is likely related to a peripheral vestibular disorder rather than cardiac causes based on your symptoms and initial workup. 1

Symptom Analysis and Classification

Your symptoms suggest a specific pattern that helps narrow the diagnosis:

• 24/7 symptoms that only subside with focused attention (TV, computer)
• Movement-triggered worsening
• Normal bloodwork and sleep study
• Symptoms persisting for 6-7 months

These features point toward a vestibular system issue rather than cardiac pathology, which aligns with the initial findings from your Faint/Fall clinic evaluation 2, 1.

Diagnostic Considerations

Key Differential Diagnoses

1. Peripheral Vestibular Disorders:

   • Vestibular neuritis/labyrinthitis (persistent symptoms after acute phase)
   • Benign Paroxysmal Positional Vertigo (BPPV) - though typically more episodic
   • Ménière's disease - though would typically have hearing fluctuations 2
   • Persistent Postural-Perceptual Dizziness (PPPD) - fits with your constant symptoms

2. Orthostatic Disorders:

   • Initial or delayed orthostatic hypotension 2
   • Postural Orthostatic Tachycardia Syndrome (POTS)

3. Medication-Related Dizziness:

   • Review of current medications for potential side effects 1

Next Steps in Evaluation

While awaiting your cardiac tests (heart monitor and stress test), the following evaluations should be pursued:

1. Vestibular Function Testing:

   • Videonystagmography (VNG) or electronystagmography (ENG) to evaluate vestibular function 2
   • Dix-Hallpike maneuver to assess for BPPV 1, 3

2. Orthostatic Vital Sign Assessment:

   • Lying-to-standing test with BP and heart rate measurements at 1,3, and 5 minutes 2
   • Tilt table testing if orthostatic symptoms are suspected but not confirmed with simple testing 2

3. Detailed Medication Review:

   • Evaluation of all current medications, including over-the-counter and supplements 1

4. Audiometric Testing:

   • Hearing evaluation to assess for associated auditory symptoms 2

Management Approach

Based on your symptoms and pending test results, management should follow this algorithm:

1. If BPPV is identified:

   • Canalith repositioning procedures (Epley maneuver) 3

2. If vestibular hypofunction is found:

   • Vestibular rehabilitation therapy (VRT) - specialized physical therapy to retrain the brain to compensate for vestibular deficits 3
   • This is particularly effective for persistent dizziness even when the exact cause isn't identified

3. If orthostatic issues are identified:

   • Increased fluid and salt intake
   • Compression stockings
   • Possible medication (alpha agonists or mineralocorticoids) if severe 4

4. If medication-related:

   • Gradual tapering of suspected medications using a hyperbolic schedule (25% reduction every 1-2 weeks) 1

5. If PPPD is suspected:

   • Combination of vestibular rehabilitation and possibly selective serotonin reuptake inhibitors (SSRIs) 3

Important Considerations

• Avoid vestibular suppressants (meclizine, diazepam) for long-term use as they can impair central compensation and prolong symptoms 3
• Maintain physical activity as prolonged inactivity can worsen vestibular compensation
• Keep a symptom journal noting triggers, severity, and associated symptoms to help identify patterns

When to Seek Immediate Medical Attention

Seek emergency care if you develop:

• New neurological symptoms (facial drooping, limb weakness, speech changes)
• Sudden severe headache
• New hearing loss or severe ear pain
• Fainting episodes

While awaiting your cardiac tests, pursuing vestibular evaluation is the most appropriate next step given your symptom pattern and initial normal findings. The persistent nature of your symptoms that worsen with movement strongly suggests a vestibular system disorder that would benefit from specialized vestibular assessment and rehabilitation.