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Dizziness and Balance Problems

It may not be clear what a patient or parent means when they describe being unsteady or having poor balance. If the symptom affects ambulation and is progressive in nature, it may represent ataxia, a feature of mitochondrial disease, although the intensity of the symptom may vary.

Fatigue when pronounced can be associated with an increase in "clumsiness" resulting in balance problems, tripping and falling. Patients may show more energy in the morning; as fatigue increases over the day, they may experience difficulties with walking.

If the symptom is more akin to lightheadedness, and is transient in nature and intermittent in occurrence, it may actually be a manifestation of autonomic dysregulation, specifically vascular dysautonomia associated with a fluctuating heart rate and blood pressure (see AUTONOMIC DYSREGULATION). This may be triggered by inadequate fluid or calorie intake, and may be worse when fluid requirements increase (as with infections of fever, or in ambient heat). It can also worsen with fatigue or following exertion (see FATIGUE). Other signs of autonomic dysfunction include heat or cold intolerance, diminished sweating, spontaneous pallor/flushing/mottling without cause, or abnormal gut motility or bladder function, and these can occur in mitochondrial disease (Zelnik, 1996; Axelrod, 2006). .

Episodic lightheadedness or poor balance might also be a manifestation of seizures, migraine (see HEADACHES), and stroke-like episodes (see ACUTE NEUROLOGIC DETERIORATION).

Mitochondrial cardiac disease - arrhythmia, cardiomyopathy, cardiac failure- may also be the cause of dizziness (see CARDIAC).

Mitochondrial Differential Diagnosis

1. Mitochondrial disease

2. Dehydration

3. Inadequate nutrition

4. Fatigue

5. Autonomic dysfunction (vascular dysautonomia)

6. Neurologic causes -

a. Migraine

b. Seizures

c. Stroke-like episode

7. Cardiac causes -

a. Arrhythmia

b. Ventricular dysfunction

Assessment and Recommendations

Tease out the nature of the symptom - dizziness, vertigo, unsteadiness of gait, generalized weakness.

1. Dehydration and/or inadequate nutrition:

a. Determine the patient's hydration history and status.

b. Assess the patient's nutrition, specifically calorie intake.



2. Fatigue:

a. Is the problem more linked with the patient's energy level?



3. Autonomic dysregulation:

a. Assess for autonomic dysfunction and those factors that can cause autonomic dysfunction: temperature dysregulation, abnormal (usually low) basal body temperature, heat and cold intolerance, abnormal sweating patterns, tachy- and bradycardia, dizziness, and bladder dysfunction.


1. Evaluate for vascular dysautonomia, and look for orthostatic changes in heart rate and blood pressure which can cause fatigue and dizziness.

2. If fluid or calorie intake is low, encourage fluids and/or calories. A trial of IV fluids might improve symptoms and support an autonomic etiology.


4. Migraine as a cause:

a. Is there a past or family history of migraine? Are episodes associated with headache, or sensitivity to light or noise, or aura prior to symptoms?



5. Seizures or stroke-like episode as a cause:

a. Is there an altered mental state, loss of function, focal findings, or an asymmetry to the physical exam suggesting a neurologic event like a seizure or a stroke-like episode? Is there a history of seizures?



2. Refer to the ER or to a neurologist depending on the urgency of the situation.

6. Cardiac causes (e.g., arrhythmia, ventricular dysfunction):

a. Are there other signs of cardiac involvement?


1. Chest x-ray, EKG.

2. Refer to the ER or to a cardiologist depending on the urgency of the situation.



Axelrod FB, Chelimsky G, Weese-Mayer DE. Pediatric autonomic disorders. Pediatrics 2006;118:309-21.

Zelnik N, Axelrod FB, Leschinsky E, et al. Mitochondrial encephalomyopathies presenting with features of autonomic and visceral dysfunction. Pediatr Neurol 1996;14:251-4.

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