Epilepsy & Dizzy Turns

Dizzy turns are often difficult to assess, taking the right story can be time-consuming & in some circumstances the importance of a good witness account cannot be over-emphasised. People tend to use the terms giddiness, dizzy, light-headed, muzzy & peculiar interchangeably and it is essential to pin these descriptions down. It is particularly important to distinguish clearly between a seizure of some type and syncope – fit vs.faint. The complaint of vertigo must contain some sense of rotation or movement, either of oneself or the environment.

1. Epilepsy

Epilepsy can be difficult to diagnose and the "story" of the attack is essential and the importance of a first-hand witness account cannot be overemphasised. Bring the 'witness' with you or at least ask them to write down what they saw. Contact numbers for the 'witness' are valuable so that an account can be obtained via e-mail, telephone or fax. Epilepsy is very poorly understood. It is not a disease - it is merely a threshold phenomenon. Loss of consciousness typically occurs without warning, lasts minutes and is followed by a period of confusion, sleepiness and headache which may be prolonged. Broadly divided into generalised and focal types, the former conform to the "grand-mal" type with a convulsion often associated with tongue-biting and incontinence. More focal types of epilepsy are preceded by a spreading warning which may be a jerk of a hand, foot or the face, tingling & numbness, flashes of light, funny smells or feelings of depersonalisation, deja-vu or fear. Frequently no cause for epilepsy is found, though generalised types often run in the family. Tests include MR Imaging of Brain, Electroencephalography (EEG), Electrocardiogram (ECG) and blood analysis. Treatment is usually drug-based and is often long term. Rarely neurosurgery is required.

2. Syncope

This means loss of consciousness resulting from lack of blood in the head. There is usually a long warning extending over minutes comprising a light-headed "faint" feeling, fading of vision from the periphery, muffled hearing, nausea, shivering & sweating. Loss of awareness tends to be short-lived, there may be a few jerks and colour is usually described as "deathly" white, grey or green often turning red on recovery. There is minimal confusion afterwards although people often feel very tired and physically drained for many hours or even days. The usual cause is a simple faint (or 'vasovagal' attack) due to pooling of blood in the large veins of the pelvis and thighs, 'starving' the heart of the blood it needs in order to pump. These attacks usually start in early adolescence and are often triggered by pain, the sight or thought of blood (eg 'video nasties') and standing in hot stuffy environments (pubs, restaurants, discos etc). Management is with reassurance. At the very first inkling of an impending attack, lying flat with legs propped up is the way to avoid the embarrassment of a fully developed attack. A sinister cause, seen more often in middle-aged & elderly people, is heart disease, either a disturbance of rhythm where people may complain of palpitations, or disease of the heart valves or coronary arteries where attacks may be exertionally-triggered. Tests in syncope need to be directed not at the brain but at the heart and include ECG, a 24-hour ECG tape and an echocardiogram (heart ultrasound).

3. Vertigo

This is a poorly used term but must involve some sense of movement. Classically rotatory, it may be described as being on a rocking boat with either a side-to-side or to-and-fro motion and sometimes people describe a 'magnetic pull' to one or other side. Broadly, vertigo can be divided into peripheral (outside the brain, in the ear) and central types. Peripheral causes are very common and are associated with ringing or buzzing in the ears, deafness and a feeling of fullness in the ears. Rarely there may be a tumour on the hearing nerve but more common explanations include benign positional vertigo, "labyrinthitis", Meniere's Disease, migraine, trauma and ear infection. Central vertigo tends to be more prolonged and is often caused by prescription drugs and of course is common with alcohol! When associated with double vision, unsteadiness, slurred speech or facial numbness, there is usually a more sinister cause such as multiple sclerosis or stroke. Investigations include testing of hearing and peripheral vestibular function, evoked potential studies and MR Imaging of Brain. Cawthorne-Cooksey exercises may be helpful in management. Vestibular sedatives should be avoided.

4. Hypoglycaemia

This is the most important metabolic cause of dizziness, funny turns and blackouts. Symptoms include palpitations, sweatiness, tremor, pallor and confusion occurring in episodes often overnight or before breakfast and are helped by sugar. There are some rare tumour causes of hypoglycamia but diabetics overtreated with drugs or insulin is a more typical scenario.