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I am a 31 year old male, average build, maybe considered a little over-weight.  For the last 3 months,  I have been experiencing some diziness or a light headed feeling.  Some of the time, it is accompanied with a odd headache, in the back of my head(where the spine connects with the skull) and sometimes in my sinuses. I originally thought it was due to me being out of shape, so I started to run on the treadmill, play hockey, basketball, etc.  There are time when I am doing physical activity, these spells get worse. Two months ago, I went to the family doctor and had my blood pressure, blood sugar, and EKG done... all normal.  The doctor thought it may have been an inner-ear infection because this feeling started around the time of a head cold.  I was put on antibiotics, finished the Z pack and two months later, still have the problem.  I dont know where to start...  ENT, Neurologist... do I need blood work done?  Any help would be greatly appreciated.
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Thanks for using the forum. I am happy to address your questions, and my answer will be based on the information you provided here. Please make sure you recognize that this forum is for educational purposes only, and it does not substitute for a formal office visit with your doctor.

Without the ability to examine you and obtain a history, I can not tell you what the exact cause of your symptoms is. However I will try to provide you with some useful information.

It sounds like you have been experiencing dizziness and light-headedness. The causes for these symptoms are highly variable.

If you experience only light-headedness (without a sensation of vertigo, or room-spinning), then a central nervous system process (brain or spinal cord problem) is unlikely. The more likely cause is a systemic one: causes could include low blood pressure such as due to dehydration or autonomic dysfunction, cardiac problems, and several other non-neurologic causes. Anemia can cause light-headedness as well.

One neurologic cause of light-headedness is a problem in the autonomic nervous system may be a cause of light-headedness. The autonomic nervous system is the part of the nervous system that controls blood pressure, heart rate, and other functions. It is not located in one specific part of the brain or other body part but is rather made up of several different components: a region in the brainstem, certain receptors located on blood vessels and in the heart, and small nerves in our skin, among other areas. Dysfunction of the autonomic nervous system due to whatever cause can lead to a variety of symptoms including but not limited to orthostasis (which means symptoms or signs resulting from assuming an upright posture), light-headedness with drops in blood pressure when sitting up or standing up (this is an example of orthostasis), syncope (passing out), constipation, diarrhea, sweating abnormalities etc. If there is a problem in the small nerve fibers, what is medically termed a small fiber neuropathy, in addition to these symptoms, burning/tingling in the feet and hands or mild sensory loss may also occur.

Normally, there are specific blood pressure and heart rate responses that an individual mounts in response to changes in posture. Often, these include a small drop in blood pressure and an increase in heart rate when one assumes a standing posture. In individuals with a problem somewhere within the autonomic nervous system, these responses are abnormal. Diagnosis of autonomic dysfunction includes a tilt table test and tests for peripheral neuropathy.

One type of autonomic dysfunction is POTS syndrome, a condition with no known definitive cause in which the heart rate goes up inappropriately, leading to palpitations and light-headedness, and this is treated with medications that prevent these heart rate increases such as beta blockers.

I can not tell from your description above if you are experiencing room-spinning vertigo. If you are not having room-spinning vertigo, then an ENT cause to your symptoms is less likely. However, if you are having actual vertigo, then an ENT evaluation is defnitely warranted. The causes of vertigo (room-spinning dizziness) could be either the inner ear or the brain. Inner ear causes of vertigo most commonly include benign positional vertigo (BPPV), which is due to small particle in the inner ear that moves out of place, and can be repositioned with simple head maneuvers. The symptoms often include vertigo that occurs with turning of the head, often while turning over in bed. Another cause, if your symptoms are associated with tinnitus (ear ringing) and hearing loss is called Meniere’s disease and can be treated with medications and sometimes surgery. And so on, several other causes from inner ear problems exist.

Less commonly, vertigo can also be due to problems in the brain. The most common is a benign (not cancerous) tumor called a schwanoma (also called acoustic neuroma). This is diagnosed by MRI of the brain. Thyroid problems can also lead to vertigo. A type of migraine called basilar migraine can cause vertigo as well.

Given that your symptoms worsen with exertion, this may imply a cardiac problem or autonomic problem. I recommend that you see your regular doctor before seeing a specialist. A cardiac evaluation is warranted. If you had just a regular ECG and it was normal, but you were not having symptoms, this does not say much. In some cases, a holter monitor, which is a monitor you wear at home to see if it picks up any heart rhythym problems is warranted. Also, specific measurements of blood pressure (lying down, seated, standing) are more accurate than just one blood pressure measure in the setting of light-headedness. After these evaluations, referral to a specialist can be made. if a cardiac cause is suspected, then evaluation by a cardiologist is warranted. Suspicion by your doctor for autonomic dysfunction related to a neuropathy would warrant referral to a neurologist.

Thank you for this opportunity to answer your questions, I hope you find the information I have provided useful, good luck.
I had very similar symptoms to yours for over a year.  Finally, my doctor found a B12 deficiency.  It's not something they would suspect in someone your age, but not my age either (and they still don't know what caused mine).  Treatment was simple with OTC tablets.  It's a blood test.  It took three months of treatment before I noticed changes, but the dizziness is mostly gone.  I'll be on B12 supplements the rest of my life. I do still sometimes get dizzy for a short while (not on and off all day for weeks like before) when I'm walking or doing specific exercises for my neck.  

Your headache and tingling in the nose could also be related to upper spine problems. This might be something else to check. I'm currently in physical therapy for headaches and shoulder pain, and have had some relief from the McKenzie Method PT. To paraphrase my doctors, dizziness has a zillion possible causes and it took lots of visits and tests to rule out the dangerous (and obvious) stuff. I still don't have a definitive answer for my dizziness, but what I'm doing seems to be working.  Hang in there. Oh and by the way - my husband had two normal EKG's and a good blood pressure during a heart attack in January - I'm not so confident of those anymore. Luckily they checked his blood enzymes too.
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