COVID related dizziness is a huge epidemic. Since the era of COVID began in early 2020, my private physical therapy practice has never been more busy. I’ve seen a huge uptick in new cases of dizziness and vertigo, especially in young people.
I’ll share some of my observations in this blog and things I’ve learned, but I am certain we will all need to continue to learn more about this condition over time. I am definitely not claiming to be an expert on the topic of COVID related dizziness, but I feel compelled to share my observations since I am seeing so many new patients with similar issues.
If something I mention in this blog rings true for you, I suggest you discuss it with your personal doctor or do your own detailed research since COVID related dizziness is a relatively new problem.
Total Number of Exposures
Many new complaints of dizziness or vertigo are starting after a COVID shot or a COVID infection.
In my practice, I’ve observed COVID related dizziness and vertigo for many different reasons. I’m finding basically the same type of clinical presentation and patterns in the cases, regardless of whether the symptoms started after a COVID shot or a COVID infection.
I’m mostly seeing COVID related dizziness in people with 3+ total COVID exposures, that is combined exposures to COVID as calculated by adding up total shots and total infections.
Although these symptoms can occur after only one COVID exposure. Many patients report some dizziness after an initial exposure which resolved within a few days to weeks. Then after subsequent COVID exposures, the persistent dizziness or vertigo started for which they are now seeking my care.
Multidisciplinary Team Approach and Extended Treatment Plan
These patients have required a multidisciplinary approach with multiple specialists and a prolonged treatment plan to have a full recovery.
COVID related dizziness is probably the most difficult and complex type of patient case I have ever seen, but I think it’s also been more challenging since it’s all so new in the last few years.
All healthcare providers are trying to figure out what to do and how we can help.
I will include certain types of providers I refer to for various root causes as I go along. At the end of this blog, I will also share other generally helpful referrals for these patients.
Many patients are acquiring immune deficiency syndromes. This seems to be causing more viral vertigo presentations than I’ve ever seen before. The COVID exposure itself can be a source of viral vertigo symptoms.
Also in many cases, other viruses besides the COVID spike protein are becoming active in the body again after the COVID exposure. Many of these patients have a history of cold sores or fever blisters (herpes simplex virus), chickenpox (herpes zoster virus), mononucleosis aka Mono (Epstein Barr virus), etc.
These old viruses had already been defeated by the immune system and had been inactive or dormant for years. After the COVID exposure, these old viruses may begin to resurface or re-activate causing a new onset of viral vertigo.
Viruses can cause vertigo by attacking the vestibular system and cranial nerve VIII, the vestibular nerve. This is called vestibular neuritis if hearing is spared and vestibular labyrinthitis is hearing is affected.
These patients generally benefit from vestibular physical therapy.
Impaired Immune Function
Impaired immune function may be detected by WBC and lymphocyte counts that are normal with blood work while the patient has a viral infection.
The labs look like they are in normal ranges and are therefore not flagged on lab results as out of range, so this may be overlooked. But perhaps those lab values should be elevated to show the body is having a normal immune response and actively fighting an infection.
Insufficient immune response is a common aspect of this patient presentation, so these patients often report getting sick more frequently since their COVID related dizziness started. They may have frequent colds, flu, pink eye, strep throat, etc. This is especially noticeable in patients who used to rarely get sick.
Patients with an inadequate immune response can experience recurrent viral vertigo attacks. These patients may need immune system support in addition to vestibular physical therapy.
Viral activity in the body can cause recurrent BPPV.
In fact, head trauma and active virus are the top two known causes of BPPV. Most other cases are considered idiopathic BPPV.
I’m seeing a lot of recurrent BPPV in patients with COVID related dizziness, likely due to a heightened viral load from an impaired immune response. Vestibular physical therapy can be helpful in treating BPPV with maneuvers, but the ultimate long-term solution needs to come from defeating the virus and strengthening the immune response.
If the total viral load in the body can be reduced, the recurrent BPPV related to viral activity often ceases. Therefore, these patients often need to take antiviral measures and strengthen their immune system, in addition to vestibular physical therapy.
Since the BPPV can result from the viral activity in the body, this root cause may not occur until weeks or months after the COVID exposure.
BPPV may recur repeatedly until all viral activity in the body is stabilized and settled.
Heart and Lung Problems
Heart and lung problems causing COVID related dizziness would be best evaluated and managed at a hospital-based Long Haul COVID clinic.
These patients may benefit from medical management by a cardiologist or pulmonologist. They may also benefit from cardiac or pulmonary rehabilitation with a physical therapist or respiratory therapist.
Dysautonomia is an underlying cause of orthostatic intolerance that is contributing to COVID related dizziness.
These patients often get lightheaded and dizzy after standing up. This may happen right away, or it may increase over time as patients are upright longer and longer. This type of dizziness is often relieved by lying down.
One of the most common forms of dysautonomia is POTS. This is when the blood pressure goes down and the heart rate goes up after standing per specific diagnostic criteria, often causing lightheadedness with standing.
Learn more about POTS <- click here
Interestingly, I’ve just seen my very first patient with the POTS variation called hyperadrenergic POTS. In this case, the heart rate remained normal and the blood pressure actually went up after standing, staying unusually high while standing which caused lightheaded dizziness over time.
Learn more about hyperadrenergic POTS <- click here
Upper Cervical Dizziness
When people have dysautonomia as I described above, they usually feel relief from their dizziness while lying down. Therefore, many people with dysautonomia, such as POTS or some other form of orthostatic intolerance, spend a lot of time lying down.
However, at the same time, they are also usually on their phone, tablet, or laptop researching their health condition and trying to figure out what to do next. Working on their phone, tablet, or laptop while lying down on the couch or lying in bed can eventually cause upper cervical dizziness.
In fact, poor ergonomics while working on electronic devices is a common root cause of chronic or recurrent upper cervical dizziness.
In some cases, this can eventually develop into a pulsating dizziness due to the upper cervical bones coming out of alignment. Due to the sequence of events and timing, the pulsating dizziness can develop weeks to months after the COVID exposure.
Upper cervical dizziness may then start to heighten baseline dizziness symptoms at all times, in all positions until it is treated.
Upper cervical dizziness can directly cause dizziness or vertigo. Upper cervical dizziness can also cause dizziness or vertigo indirectly. This neck problem may contribute to Meniere’s syndrome and chronic tension headaches, intractable migraines, or daily vestibular migraines.
These additional causes of dizziness and vertigo can pile on top of the dizziness that initially starts after COVID exposure, creating absolute misery. The dizziness keeps getting worse over time!
This is an example of a domino effect that can cascade into multiple root causes of dizziness and vertigo:
- Dysautonomia can start after COVID exposure. To get relief from dizziness, patients with dysautonomia spend most of their time lying down.
- Upper cervical problems can start after lying down most of the time, especially if the patient is working on electronic devices while lying down.
- Upper cervical problems can directly cause dizziness and vertigo. This issue can also be exacerbated if the patient is participating in vestibular physical therapy.
- Upper cervical issues can also cause dizziness indirectly by triggering vertigo attacks from Meniere’s syndrome or migraines.
All of the root causes in this cascade need to be addressed for the best outcomes, whether directly triggered by COVID exposure or part of a domino effect that was set off by the COVID exposure.
Gut Problems and New Food Sensitivities
Many of my patients with COVID related dizziness have also developed new digestive issues and food sensitivities concurrently.
New food sensitivities may or may not show up on food allergy testing, because the threshold for food sensitivities is lower than food allergies.
Many of my patients have gotten tested for food sensitivities and their symptoms have improved after making dietary changes. I refer my patients to a nutritionist who uses biofeedback testing to determine food sensitivities. That way the recommendations are individually prescribed.
In addition to individualized dietary recommendations, I have seen two general dietary changes that seem to help people with COVID related dizziness.
Anti-inflammatory diet changes have helped many of my patients, which means cutting down on sugar, dairy, gluten, and nightshades.
Reducing high histamine foods has been the final breakthrough for many of my patients with COVID related dizziness.
Cutting out all foods that are high in histamines or cause histamines to be produced has helped many of my patients with COVID related dizziness.
Eliminating high histamine foods was the final breakthrough for a few of my patients who used an elimination diet approach.
The surprising part was that they did not test positive for histamine-related food sensitivities using biofeedback or food allergy testing. The patients just chose to “try it” using an elimination diet type of strategic approach.
Learn more about high-histamine foods <- click here
Mast Cell Activation
I’ve heard some speculation that the new histamine food sensitivities are related to mast cell activation that is occurring in some patients with COVID related dizziness.
For assessment and management of potential mast cell activation issues, I refer my patients to a Naturopath or Functional medicine practitioner. They have strategies to assess and treat this type of issue.
Re-Activation of Old Post-Concussion Dizziness
The most surprising findings that has come up in many patients with COVID related dizziness is the re-activation of dizziness that presents as if it is post-concussive during the oculomotor and vestibular exam.
This means that eye movements while the head is still trigger the dizziness and the patient does not tolerate complex visual patterns well. This visual vertigo and nausea build up, getting worse as oculomotor and visual testing goes on.
Near point convergence distance is excessive, a cardinal sign of concussion related dizziness. I have been able to categorize three scenarios for this issue:
- Some of these patients had past concussions that were diagnosed and documented, but had already fully recovered in the past with a complete resolution of symptoms – sometimes many years ago.
- Other patients in this group had a history of head trauma, but had never previously been diagnosed with a concussion or never experienced dizziness after the old, initial head trauma.
- Finally, the third group of patients in this category had no history of concussion or head trauma but had played specific sports that cause repeated micro-head trauma over time such as soccer. For these patients, I also involve two other types of specialist practitioners: Neuro-Optometry and Orthopedic Manual Physical Therapy.
I’ve been trying to figure out why patients with COVID related dizziness are presenting like post-concussion patients.
Viruses active in the body can attack the cranial nerves III, IV, and VI which are responsible for the visual oculomotor system. That is one possible explanation.
Another possible explanation for this pattern is brain inflammation or neuroinflammation.
Brain inflammation could affect the central processing of visual input and other sensory information. Post mortem research conducted through autopsy has detected the presence of COVID spike protein lodged in the brain tissue of cadavers. In theory, patients with spike protein lodged within their brain tissue may not test positive for COVID viral activity in the serum through blood tests.
There is no way to test for spike protein lodged in the brain while a patient is still alive but it is a theory that could explain some of the dizziness and visual vertigo in patients with COVID related dizziness.
I have also heard this called neuroinflammation or neurological inflammation.
The term spikopathy is also being used to indicate the spike protein is causing brain problems long term. Symptoms associated with this include fatigue, cognitive impairment, and psychiatric issues.
Some of these patients present with a lower threshold of tolerance to stimuli such as loud sounds, strong smells, and visually complex environments like the grocery store.
One theory is that the inflammation in the brain caused by spike protein lodged within brain tissue is causing CNS sensitization. This theory is due to hypersensitivity of their central nervous system which is overreacting to environmental stimuli.
Neurological management with certain medications to suppress the CNS may be helpful, so many of my patients consult a neurologist.
Chronic Vestibular Migraine
For these cases with CNS sensitization where the brain is overreacting to environmental stimuli at a lower threshold than ever before, it can present as a chronic vestibular migraine.
Headaches are a common complaint in patients with COVID related dizziness. These headaches may also present as migraines or vestibular migraines.
Learn more about vestibular migraine <- click here
In these cases, I teach many self-care strategies since I’ve suffered from migraines and vestibular migraines for most of my life.
Gut issues and upper cervical issues can be a deeper root cause of chronic migraine in many cases.
I also typically refer out for consultations for dietary triggers, for upper cervical care, and to neurology for migraine management.
Microclots in Blood Vessels
I would be remiss if I did not mention the higher rate of microclots than I have ever seen before, even in young people.
Typical risk factors for microclots include advanced age, high blood pressure, high cholesterol, obesity, tobacco smoking, and diabetes.
However, this potential cause of COVID related dizziness is on my radar now more than ever before, especially in younger patients without the typical cardiac or stroke risk factors.
I have met people who were diagnosed with a microclot within a vein of the retina inside their eyeball, in their lungs, or in their legs. Truly the microclots can be found anywhere!
Microclots are especially important to rule out in patients with persistent cognitive deficits, brain fog, and respiratory problems. When these affect the brain, they may be called cerebral microemboli.
Learn more about cerebral microemboli <- click here.
It is recommend for patients who are suffering from long COVID to get a D-dimer blood test, according to this article.
Analysis of D-dimer levels and C-reactive protein (CRP) levels in the blood may help predict patients who are likely to experience microclots after COVID.
In theory, microclot could affect vestibular system and the hearing apparatus – really anywhere with small sized blood vessels.
A microclot in certain blood vessels within the brain or vestibular system could present with a new onset of dizziness or vertigo, with or without hearing loss.
I’ve had people contact me with severe tinnitus or sudden onset of deafness post COVID, which requires an automatic referral to neurology for a full work-up.
Therefore, screening all patients with COVID related dizziness for clinical signs of microclots is extremely important.
Medical management is beneficial in these cases with a referral to the appropriate medical specialist.
I think it goes without saying that many people with COVID related dizziness develop health-related anxiety.
They are uncertain where to turn for help and what to do.
This can turn into a constant and overwhelming feeling of worry or nervousness that disrupts their daily life and interrupts their sleep.
I’ve written extensively on the link between anxiety and vertigo.
I’ve also written about strategies to alleviate anxiety.
Some patients develop depression or other psychological problems. I’ve written about the link between depression and dizziness here.
I refer to a psychologist, a neuropsychologist, or other licensed mental health counselor as needed for these cases.
COVID Specialty Providers
For my patients that need specific protocols for detoxifying from COVID exposure and spikopathy, I do refer to clinics and professionals who have developed specialized protocols and run medical practices that offer specific care for COVID related health problems.
For patients who are looking for a more natural medicine approach, I might suggest checking out:
I hope that this information is helpful. Research is gradually coming out regarding this topic of COVID related dizziness, but the published research is limited since it’s all so new.
This blog is provided for informational purposes only. The content and any comments by Dr. Kim Bell, DPT are not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. The details of any case mentioned in this post represent a typical patient that Dr. Bell might see and do not describe the circumstances of a specific individual.