Tuesday, June 4, 2013

An Answer for Dizziness and Headaches

A few days ago a patient of mine came in and had no dizziness or headaches. What's special about this is that when I saw her about ten months ago for her first visit she described headaches occurring every day for at least five years and intermittent dizziness causing vertigo and nausea and increasing in frequency.

All of this had gotten much worse a couple of years ago after she had been treated for lymphoma with chemotherapy. Fortunately the cancer was cured but her symptoms were disabling. Examination revealed a pleasant articulate and engaging young woman. She had moderate swelling of the nasal tissues. More revealing was that during a balance test, "Romberg Test", wherein she stands heel to toe with her eyes closed she kept falling off balance. This test is very sensitive for an inner ear balance disorder.

Because of her dizziness I ordered a specialized balance test, videonystagmography or VNG, to evaluate inner ear balance and because of the migraines and nasal swelling I ordered an allergy test. Of note, I have learned over the past 15 years that patients with poorly controlled migraines often have at least a partial allergy trigger. I learned this a number of years ago when I was treating patients with  allergies who also had migraine headaches and when they would come in for a recheck they would have dramatic improvements in both symptoms.

For this patient her VNG revealed significant weakness in one of her ears. We did an MRI of her brain which was  normal and I began to suspect a disorder called Meniere's Disease. Meniere's is an autoimmune type disorder of the inner ear that causes intense dizziness with hearing loss ringing and ear pressure. What was also interesting is my patient had other autoimmune diseases she was being treated for at the same time. The standard treatment for Meniere's is dietary restriction of salt, alcohol and caffeine. Which ironically is also important for migraine headaches. Another thing I have learned over the years is that patients with Meniere's may also have an allergy trigger. So I encouraged my patient to complete the allergy testing.

The allergy testing was positive to nearly everything.  So she initiated sublingual immunotherapy, which involves placing allergy drops under the tongue every day, and allergy medications.I think it's important to remember that she was still having her headaches and dizziness when she returned after completing her allergy testing.  Normally I see patient's 3 months into therapy but she did not schedule her 3 month appointment.

Therefore, I was surprised to see her a couple of days ago.  I was curious about her progress and I was happy to hear her reply to my questions. She hasn't had a headache or dizziness for several months! With a smile she told me she was moving out of the area to attend college. She was concerned about stopping therapy, but one advantage of using sublingual immunotherapy is that we can mail her drops wherever she lives. There might be a few changes in her sensitivities in her new home, but overall I have had very good luck maintaining successful therapy in patients who have moved away and maintain the sublingual drops.

This patient really illustrates for me that experience can truly lead to significant improvements in patient care. For example, I have noticed the trend over the past 10 or 15 years that patient's who undergo immunotherapy can have dramatic improvements in headaches and dizziness symptoms.  But there are very few studies that are available to confirm this.  And in a small practice such as mine developing a double blind placebo controlled study is nearly impossible.  Therefore much of my treatment is based upon experience and would be considered anecdotal.  Perhaps one-day I can look through my old charts and present some analysis that would be publishable. Until that day I will continue do my best to find creative answers to difficult problems.