As a rule, the main types of disturbances that we feel as humans that present to the clinician as one form of dizzy feeling or another, are vertigo: a sense of spinning; disequilibrium: a sense of imbalance; or dizziness: a feeling of being off, or disoriented.  Dizziness is the vaguest of the symptoms.  Let’s talk about it this week.

Dizziness is in the top three reasons why individuals present to their doctors office.  It is often a confusing constellation of symptoms which patients find difficult to describe, and clinicians find difficult to diagnose.

Oftentimes, vertigo and disequilibrium will manifest such that the patient would complain to the clinician about dizziness.  It is up to the clinician to ask the right questions to discern between them to correctly diagnose the patient and refer to the appropriate specialist for neurologic or vestibular rehabilitation therapy, (what I do), vs. to an ENT for a sinus infection or similar.

So what then is Presyncope?  Well, syncope, means in medical terminology to pass out.  So presyncope is the sensation just before passing out, without progressing into actually passing out.  Most patients with presyncope will be referred to a cardiologist, assuming of course that they were even correctly diagnosed in the first place, which is not necessarily always the case.  This is not a bad plan as it rules out any cardiac problems as being causative, however, the patient gets cleared from cardiology and is still symptomatic.

Well here’s the deal.  Syncope/presyncope is almost always a neurologic condition.  Yes, it is caused by the heart, however, the heart only does what the brain is telling it to do.  To make some sense of this, imagine you are standing up.  Your heart has to pump blood up to your head sort of like a small water tower.  Now imagine lying down.  As blood gushes into your head, baroreceptors in the carotid vessels tell your brain to tell you heart to slow down so you don’t shoot your head off.  Conversely, when you arise from lying down, your carotid baroreceptors tell your brain to tell your heart it had better pick up and fast to get blood back up to your brain, (like a water tower again).  When there is a problem with this regulatory system, you are going to experience presyncope.  As this problem worsens, you will actually experience syncope, (actually passing out).  The irony to all of this is that this is actually very easily fixed more often than not; these are the types of problems that I spend much of my day fixing for people. As syncopal problems worsen, it is not uncommon for simple head movements or turns, or visual stimulus from driving to provoke an attack.  This also often precipitates into panic disorder and panic attacks, not only because of the fear and anxiety associated with the symptoms, but also because of the sympathetic nervous system and its hard wiring.  (The whole “fight-fright-flight thing you learned in school).

Again, there are many causes of dizziness and presyncope is just one of them, but it is a fairly common problem and finding the right specialist early on can make a big difference in how far your symptoms will progress and whether or not they will progress into other conditions over time until properly treated.

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14 Responses

  1. Does neurology or cardiology have the answer for this?

    I have history of presyncope with strenuous exertion. Symptoms: vision dimming or blacking out, loss of balance, feeling like I might pass out. Reducing activity reduces the symptoms until they stop.

    8 months ago, I was doing push ups and extended my neck back and rotated to right to look at trainer. I had an intense attack of presyncope for an hour, then normal. Repeated a week later, same thing happened. A day later, I began to have spontaneous attacks. Then one day, woke up with the dizziness and it didn’t leave. Also, right arm weaker and slightly less coordinated and left eye feels as though curtain has come down on one side, as if my peripheral vision has lost some acuity.
    Intense headache followed (worsened by exertion, relieved by rest). Headache lasted for a few months, then went away. Physical therapist touched neck and headache came back for a few weeks than left again. Physical therapist refused to treat because thought it was dissection or artery problem.

    CT scan normal. brain/neck MRI normal. Cardiac stress test normal (wasn’t strenuous enough to induce presyncope). MRA TOF looking for neck artery dissection normal. Ultrasound looking at neck normal. No tests were done using contrast, or with neck extended/rotated or when symptoms intense. Romberg test failed when loss of balance at its worst, but passed when balance is better. Failed Underburger’s Test (romberg with neck extended/rotated) and nausea, loss of balance, vision blurring, and feeling faint increase and are extreme during, but mostly relieved when stopped (although loss of balance is somewhat worse than before).

    Underburger test was followed by an extreme spontaneous attack lasting 2 hours (yesterday) with extreme loss of balance (sometimes knees start to buckle even), nausea, vision blurred, feeling of immediate loss of consciousness, and difficulty staying alert. Nurse at Doctor’s office had difficulty taking blood pressure, but noticed noticed right hand is colder than left, and blood pressure is different as well. After symptoms were mostly relieved, EKG done and was normal.

    Muscularskeletal doctor worries that this is thoracic outlet syndrome or vertebrobasilar insufficiency, but Insurance denied further testing from Vascular Doctor (wanted MRI/MRA with contrast) so he wants to see if this is cervicogenic dizziness through physical therapy before trying to get more testing approved. Physical therapist may reject me as last one did. Previous to this, one Neurologist suspected a virus in the cerebellum, another thought it was a rare migraine and another one said, “I have no idea” after the MRA demonstrated no vertebral artery dissection on TOF MRI.

    Are the tests I have been given 100% surety?

    Is it possible this is still a neurology issue?
    Stress doesn’t have any effect on balance, only exertion and extension/rotation of neck. None of the migraine medicines worked, but a few weeks of high-dose aspirin cured the headache.

    After last spontaneous attack, headache started again, so beginning aspirin regiment again.

    Any ideas for further testing?
    Should I consult with a neurologist again?

    • Thanks for reading my post and for responding to it. That is quite a medical history. Unfortunately however, it does not constitute a thorough comprehensive neurologic physical examination. As such, I will attempt to answer your questions as best as possible.

      With regard to 100% surety, the tests are valid for what they are designed to test for. Tests don’t always yield a diagnosis. An example would be an MRI, which is essentially a picture. Trying to conclusively arrive at a diagnosis from a picture would be much like handing your mechanic a picture of your car to try and figure out why it won’t start.

      Yes, it certainly sounds like a neurology issue to me.

      Where do you live? My office customarily sees patients from all over the country. Let me know. You can email me directly as this thread is public, at

      Thanks again.


  2. Hi yes my name is bonita davis and my mother was diagnosed with presyncope how serious is this should I be very worried

    • Depends. Lets first assume that the diagnosis was indeed accurate, which is not always the case. Presyncope is better than syncope. Presyncope is a feeling as though you may pass out, without actually progressing to passing out. Without appropriate treatment, this may progress into syncope. It is difficult to say how bad it is without actually examining your mom as there are many causes for syncope, and without knowing what is causing hers, I couldn’t really say how bad it is. I have successfully treated many patients with syncope but again, it depends on what the cause actually is.


  3. I too have experienced several bouts of lightheadedness over the past few months, as well as experiencing what I call a blip, but think it’s more of a brain fog where I become disoriented for a split second. I did have a convulsion which prompted me to seek medical assistance. I had a brain MRI, Head CT, EEG, wore a halter monitor, just had a ENG (results not back as of yet). I saw a Neurologist, Cardiologist and my PCP, yet no one can tell me what’s up. I do have low blood pressure and I have increased my water intake, but this is getting old.

    • First, sorry to take so long to get back to you, I have been away.

      Where do you live? Perhaps you would consider coming in to see me for a complete evaluation. Unfortunately, the evals which you have had until now are typically to assess for diseases. There are may conditions which are not “named diseases” which can cause these types of symptoms and be completely overlooked as “shades of grey” when looking at things merely as “black ad white”.



  4. Ellen AntonakosSeptember 24, 2011 @ 3:16 pmReply

    I am very interested in your website b/c my sister has had to stop driving recently b/c of dissiness and she thinks it is presyncopy. She lives in Ohio, I live in Baltimore. She has had trouble with a diagnosis – has worn a heart monitor, but no real findings. Not sure what to do. HELP PLEASE!!

    • Good morning Ellen. I am apparently going to have to talk to my ISP, I did not see this comment, (and several others), until this morning.

      It is extremely common for presyncope to be overlooked as in the realm of normal in the absence of findings following a halter monitor. Most doctors are looking for disease processes and in their absence, your symptoms are simply dismissed. There are however many “shades of grey” and everything is not black and white. I would urge your sister to consider coming in for an examination with me, (if she is still experiencing symptoms).

      Again, I apologise for taking so long to get back to you.



  5. I have been having severe health issues for the past five years. I have been diagnosed with vertigo. I have had MRI’s and a CT scans done of my brain. I have also had an EMG done. All results were clean.

    I experience an array of serious symptoms but no doctor has been able to form a diagnosis. Among these are severe insomnia, muscle spasms, neck stiffness and pain where my neck meets my head, severe headaches, severe vertigo, sharp chest pain, involuntary eye movement (back and forth, rapidly) jaw pain, what feels like temporary paralysis, pressure in my head, especially behind my eyes, shakiness, muscle weakness, tremors, loss of fine motor function (esp. hands), brain fog and backaches.

    All of these symptoms occur in waves of intensity, but are now always present (except for the chest pain.) I have been experiencing most of the symptoms to some degree for the last five years. The severity of my condition has been steadily increasing over time but in the past few months the frequency and intensity has increased to the point to where most of my daily functioning has been drastically inhibited. It has become very difficult to read (words move around). I often cannot drive or have to pull over because I am so dizzy. Most of the pain radiates from just below the bump at the back of my skull where my neck meets my head, I have been told this bump is a normal variant, but regardless that is where the pain is located. I can often hear and feel my pulse in my jaw, neck and eyes (strong throbbing, esp. when I lay down).

    I am scheduled to have an EEG and a Cervical Spine MRI, but money and ideas are both running very thin.

    I apologize for the long-winded (and some-what disorganized) nature of this message, but all of the information given seems worth sharing. I know from my experience the last few years there is no easy answer, but I would be grateful for any ideas as to what could be going on, and/or where to go from here.
    Thank you,

  6. I have been having episodes of presyncope, and have been cleared by cardiology (wore and event monitor for one week). I continue to have symptoms, and have been unsuccessful in eliciting any response from my doctor. Anxiety has been ruled out as a cause. All my blood work was fine. You say that the problem is easily fixed, so what’s the fix? Do I need to see a specialist? How can I convince my doctor to give me a referral?

  7. Bonnie SturdivantFebruary 11, 2011 @ 1:25 pmReply

    I was involved in a car accident in Feb. of 2008 which resulted in a moderate Traumatic Brain Injury for me. This consisted of a 6mm bleed on the hippocampus of my brain. I have had MRIs and CT scans and I have been told that the bleed had shrunken down a bit in size but that it would probably never go away. And that otherwise my brain looked fine. But I keep having “episodes” where I get disoriented, my muscles seize up, tingling sensations, I feel dizzy, begin to panic, have trouble breathing, and usually fall. If it progresses further, which it usually does, I experience a complete loss of peripheral functionality. I remain conscious and am aware of my surroundings, but I cannot communicate whatsoever, or move my limbs or anything. I have seemingly lost consciousness. But the thing is I remember it all. According to EEG testing, I am not having seizures. So I have no idea what is happening to me. And I cannot seem to get any real professional insight on the matter. If you have any thoughts I would greatly appreciate it. Thank you very much.

  8. I have been having dizziness and presyncope for the past year. Heat, driving and sometimes physical exertion seems to be the main precursers to my dizzy spells. I get dizzy, diaphoretic, pale, palitations, nausous, weakness in extremities, and feel extremely hot even though my skin is cool to the touch. Now that the enviromental temps been decreasing the dizzy spells have been as well. Cardiologist said it was not my heart. Holter monitor showed my hr was increasing into 120-150 range on multiple occassions in 24 hours. I live in wv and insurance limits what doctors I can see. Any advice would be greatly appreciated!

    • Hi Trish, I have had problems with my ISP and am just now getting to this message. The fact that your heart is normal is good, however, it is only going to do what your brain tells it to do so that many of these “cardiac” problems are in fact neurologic problems. If you continue to experience symptoms and would like to discuss further, please contact me off list at




  9. Thanks for your reply, and a good question. First, is a thorough examination, which typically reveals diagnostic clues. Treatment is then determined by examination findings. Drugs don’t work in these instances as if the problem is on one side of your brain, the drug does not know to just go to that side. Does this make sense? So the treatment then would be through neurologic rehabilitation. This is not a canned approach and is very specific depending on your examination findings. I have wonderful success very quickly with these cases.

    If you are interested in pursuing treatment, please call Debbie at my office to schedule an appointment, (732) 229-5250. If you are coming from out of the area, (NJ), which is quite common for my practice, she can give you info on local hotels that are reasonable. As our office is a block from the ocean, it is not a bad place to stay for a few days!

    Yours in health,
    Dr. S.

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