Are dizziness and headaches symptoms of carotid stenosis?

Dizziness and Headaches Are NOT Typical Symptoms of Carotid Stenosis

Isolated dizziness and headaches are explicitly NOT attributable to extracranial carotid artery disease and should prompt evaluation for alternative diagnoses. 1

Why These Symptoms Are Not Carotid-Related

The 2011 ACC/AHA/ASA guidelines explicitly state that "nonfocal neurological events, including transient global amnesia, acute confusion, syncope, isolated vertigo, nonrotational dizziness, bilateral weakness, and paresthesia, are not clearly attributable to ECVD [extracranial carotid and vertebral artery disease]." 1 This is a critical distinction that prevents unnecessary workup and inappropriate attribution of symptoms.

Common pitfall: Clinicians frequently misattribute nonspecific symptoms like dizziness and headaches to carotid stenosis found incidentally on imaging, leading to inappropriate revascularization decisions. 1

What ARE the Actual Symptoms of Carotid Stenosis?

Focal Neurologic Deficits

• Motor deficits: Isolated paresis of the hand, arm, arm and face, or less commonly the leg, contralateral to the stenotic artery 2
• Sensory deficits: Numbness or tingling affecting the same side of the body, contralateral to the culprit carotid artery 2
• Visual symptoms: Amaurosis fugax (transient monocular blindness) caused by temporary reduction of blood flow to the ipsilateral eye 1, 2
• Speech disturbances: Aphasia or dysarthria when the dominant hemisphere is affected 1

High-Risk Presentations

• TIA: Focal neurologic deficits lasting <24 hours, with stroke risk up to 13% in the first 90 days 1
• Completed stroke: Symptoms lasting >24 hours 2
• Retinal emboli: May be detected on fundoscopic examination even in otherwise asymptomatic patients 2

Important Exception: Vertebrobasilar Disease

While carotid stenosis does not cause dizziness, vertebral artery and posterior circulation stenosis can present with dizziness and vertigo. 3 The distinction is anatomically critical:

• Vertebrobasilar symptoms include: Dizziness, vertigo, diplopia, perioral numbness, blurred vision, tinnitus, ataxia, bilateral sensory deficits, and syncope 3
• High-grade inferior cerebellar artery stenosis requires urgent evaluation due to high stroke risk 3
• Vertebral artery atherosclerosis accounts for approximately 20% of posterior circulation strokes 3

The Hearing and Headache Controversy

While some research suggests associations between carotid stenosis and hearing changes or headaches 4, 5, these are considered non-specific symptoms that may indicate ischemia but are not diagnostic of carotid disease. 4 The guidelines do not support using these symptoms as indicators for carotid evaluation. 1

One study found that carotid stenting improved dizziness in patients with severe stenosis who complained of this symptom 6, but this does not establish causation and contradicts guideline-level evidence that explicitly excludes isolated dizziness as a carotid symptom. 1

Clinical Algorithm for Symptom Attribution

When evaluating dizziness/headaches in a patient with known carotid stenosis:

1. First, assume these symptoms are NOT from the carotid stenosis 1
2. Look for focal neurologic deficits (weakness, numbness, speech changes, monocular vision loss) that would indicate true carotid territory ischemia 2
3. If dizziness is present with other posterior circulation symptoms (diplopia, ataxia, bilateral deficits), consider vertebrobasilar disease instead 3
4. Evaluate alternative causes: Vestibular disorders, medication effects, cardiac arrhythmias, orthostatic hypotension, migraine, tension headaches 1
5. Only attribute symptoms to carotid disease if there are clear focal deficits in the appropriate vascular territory 1, 2

When to Image for Carotid Disease

Appropriate indications for carotid evaluation include: 1

• Hemispheric TIA with focal deficits
• Amaurosis fugax
• Completed stroke in carotid territory
• Cervical bruit in asymptomatic patients
• Multiple atherosclerotic risk factors requiring vascular assessment

Inappropriate indications:

• Isolated dizziness without focal deficits 1
• Isolated headaches 1
• Nonspecific neurologic complaints 1