Are these head-reeling episodes sue to stroke, seizure or syncope?

Hello Doctor,

I have consulted you earlier on this forum regarding my mother’s health (59 years), who is under treatment for hypothyroidism (Eltroxin 50 mcg), hypertension (Olmezest 20 mg), osteoarthritis (Gemcal D3, Kondro OD), and mild anemia [Hb 10.6 g/dL; normal: 11.5–15 g/dL] (Folvite). I would like to request your kind review of some of her recent symptoms, which I have summarized below along with a brief history.

Early this year, she had a fever (100–101°F) with a cold and was taking Calpol 650 and Cetirizine for a few days. One morning, right after breakfast, while sitting on a chair, she suddenly felt reeling of the head (giddiness) along with darkness in both eyes (temporary visual blackout). The symptoms resolved after she lay down. That evening, during the doctor’s visit for fever, her blood pressure (BP) was 130/80 mmHg (left arm, sitting position) with a pulse of 102 bpm. She also had a left-sided headache, which subsided over two to three days with Calpol 650.

Two months later – During a period of anxiety about her son’s health and lack of sleep for a couple of days, she also had stomach upset, antibiotics use, gastritis, and loss of appetite. One morning, she developed a runny nose and sneezing, for which she took two Cetirizine tablets. The next day, right after lunch, while sitting and talking about her son’s health, she again experienced reeling of the head and darkness in both eyes, followed by bending towards the left side with shaking of the left hand for 10–15 seconds. She was about to fall but was supported by others.

For about five minutes, she appeared confused and stared blankly (altered consciousness). When spoken to, she initially made strange sounds, then spoke a few normal words in a hoarse voice, and gradually returned to normal speech. She was emotional and crying but later stated that she had no memory of the event (amnesia for the episode) except the last part when her daughter-in-law was consoling her. She recovered completely within ten minutes but felt tired and sleepy for the next two weeks.

After five to six days, the medicine specialist classified this as a viral infection and noted BP 118/82 mmHg (right arm, supine position) and no history of convulsion. A week later, she had four bowel movements (not loose stools) in the evening and developed a headache afterward. The next morning, she reported heaviness in her head and legs (fatigue/weakness). The doctor advised checking serum sodium (138.4 mmol/L) and potassium (3.72 mmol/L), which were normal. With rest, her symptoms improved, and she resumed normal activities.

In the following few months, she had one brief episode of reeling of the head that resolved spontaneously. She also developed fever with cold and left-sided headache, lasting three to four days despite taking Calpol 650. Most of her BP readings during this period were 110/80 mmHg (left arm, sitting) and 120/72 mmHg (right arm, supine). Due to the lower readings, her doctor changed her antihypertensive to Stamlo 2.5 mg, but it was later switched back to Olmezest 20 mg due to mild pedal edema (swelling in feet).

About two months ago, her earlier complaints of gastritis, constipation, and multiple bowel movements (three to four times a day) recurred. One morning, she woke up early (4:30 AM) and experienced severe reeling of the head lasting around ten minutes, which resolved on its own. She again had a left-sided headache (possible migraine) lasting three days despite taking Calpol 650.

During her next doctor visit, BP was 132/82 mmHg (right arm, supine position). The doctor mentioned her headache symptoms resemble migraine (neurological headache associated with throbbing pain, often one-sided) and advised continuing Olmezest 20 mg twice daily, as her BP was slightly higher than earlier. He also suggested a Computed Tomography (CT) scan and 24-hour Holter monitoring if further episodes of giddiness, seizure-like activity, or presyncope (near fainting) occur.

Her past six months of test reports have been uploaded for your kind review. She has also recently developed mild to moderate pain in the mid-waist region (possible musculoskeletal origin).

Kindly review the entire history and advise:

• What could be the possible cause of these episodes?

• Was there any possibility of stroke, seizure, or syncope, or are these warning signs?

• What should be our next steps from here?

• As the family is anxious about CT and Holter tests, is there any alternative evaluation to rule out these conditions?

Your guidance will be greatly appreciated.

Thank you.

Hello Doctor,

Thank you for your kind feedback. Regarding the low hemoglobin (Hb) issue, we had performed a stool examination, which was occult blood negative (no hidden gastrointestinal bleeding). However, even after 4.5 months of Uprise XT and Folvite, her Hb improved only to 11.1 g/dL [normal: 11.5–15 g/dL], and it dropped again to 10.6 g/dL after four months of stopping the supplements.

We also conducted an iron profile, which showed the following:

• Serum Iron: 56 µg/dL.

• Total Iron-Binding Capacity (TIBC): 255 µg/dL.

• Unsaturated Iron-Binding Capacity (UIBC): 199 µg/dL.

• Transferrin Saturation Index (TSI): 22.5%.

• Ferritin: 83 ng/mL.

• Vitamin B12: 894 pg/mL.

• Serum Folate: 12.5 ng/mL.

• RBC Folate: 883 ng/mL.

Please advise what further investigations or steps we should consider to evaluate and manage this persistent mild anemia (low red blood cell count or hemoglobin level).

Regarding the neurological symptoms (episodes of dizziness, transient unresponsiveness, and limb shaking), do you see any risk of mild stroke or Transient Ischemic Attack (TIA)?

Also, do you agree with the recommendation to double the dosage of Olmezest 20 mg due to the BP rise from 120/72 mmHg to 132/82 mmHg?

I have also attached a copy of her recent electrocardiogram (ECG) report (though it is slightly old) to check if it indicates any cardiac abnormality. Her lipid profile (also from an older test) showed:

• Total Cholesterol: 155 mg/dL.

• High-Density Lipoprotein (HDL): 39 mg/dL.

• Low-Density Lipoprotein (LDL): 86 mg/dL.

• Triglycerides (TGD): 143 mg/dL.

Kindly review the above details and guide us on the next steps for both anemia management and neurological evaluation.

Thank you.

Hello Doctor,

Thank you for your detailed response. I wanted to get your opinion on the home blood pressure (BP) test that you had suggested earlier. Using a home BP monitor, I recorded her readings in three positions as follows:

1. Sitting: 124/75 mmHg (P: 66), 117/67 mmHg (P: 62)

2. Standing: 135/90 mmHg (P: 70), 131/83 mmHg (P: 69)

3. Lying down: 126/69 mmHg (P: 66)

I noticed that her standing BP readings were consistently higher than those in the sitting or lying positions. Could you please explain why this might be happening? Is this finding clinically significant (abnormal elevation of BP while standing) or something to be concerned about?

Also, could this postural BP variation be related to the episodes she experienced earlier (giddiness, transient blackout, and limb shaking)? However, I would like to mention that there was no change of position during either incident—the first occurred while sitting and the second while standing.

Kindly advise if any further evaluation or monitoring is required in this regard.

Thank you.

Hello doctor,

Our medicine doctor had prescribed Folvite for six weeks for anemia treatment and advised us to repeat the CBC after that. However, as he is currently out of town for a month or so, we are not sure if it is right to continue Folvite beyond six weeks. Considering her incidents, do you see any neurological (and/ or other in general) risk if she continues Folvite for another four to six weeks?

Please help.

Thank you.

Hello doctor,

Thank you for the reply.

We have recently done some of her periodic tests (reports attached) and request your kind review if her lipid profile or any other report is worrisome from a neurological perspective. Her current medications are

1. Hypothyroidism - Eltroxin 50 mcg.

2. Hypertension - Olmezest 20 mg.

3. Mild anemia (Hb 10.6 g per dL)

4. Folvite (for the past two months).

5. Osteoarthritis - Gemcal-D3 and Kondro OD.

Please help.

Thank you.