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Any of the abovementioned disease processes may cause disequilibrium rather than vertigo if they do not involve the labyrinth itself but instead cause dysfunction with brainstem integration, cortical perception, or musculoskeletal function. In such cases, other cranial nerve or somatic deficits point toward the etiology of the problem. Common examples include loss of vibration sensation and joint proprioception in diabetic and hypertensive patients, poor muscle strength, and joint deformity in cases of severe osteoarthritis or rheumatoid arthritis and the wide-based ataxic gait of patients with cerebellar cortical disease.

Medications are common causes of imbalance and disequilibrium, especially in the elderly (14). Gentamicin toxicity may cause vertigo in the acute setting, but a patient's compensatory ability and symmetric vestibular loss may prevent this symptom from persisting. A patient may first manifest this after recovering from an acute illness enough to begin ambulating, sometimes with the most prominent long-term sequela consisting of difficulty walking in the dark (15). Furosemide is another medication that may be given in the context of systemic disease that can cause imbalance. Cisplatin is a common cause of disequilibrium in patients receiving chemotherapy. Amiodarone was once a common cause for vertigo or imbalance in patients with cardiac disease (16), but lowered doses now favored by cardiologists seem to have decreased the rate of this complication somewhat. Antipsychotics and anticonvulsants can cause instability and disequilibrium, symptoms that are often accompanied by eye findings such as spontaneous nystagmus.

Deficiency of vitamin B12 can be related to imbalance but only rarely to true vertigo. Subacute combined degeneration related to deficiency of the vitamin may be found in those with gastric disease or in vegetarians (17).

Migraine-associated dizziness is a common disease that manifests itself as headaches with nausea, photophobia, and dizziness of variable intensity, duration, and quality in young to middle-aged patients, manifesting more commonly in women than in men. A key to making this diagnosis is a high level of suspicion in younger, otherwise healthy patients with a personal or familial migraine history and light sensitivity during their dizziness (18).

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