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It is always frustrating and also concerning when a variety of laboratory tests are normal and symptoms continue. It is true that the MRI, EEG, VNG, sinus X-rays and blood flow measurements did not indicate what was going on, but they also suggested that a number of potentially serious things are not going on, and this means that there is time to observe the symptoms and try various interventions, some of them quite simple and natural and inexpensive, to see if any improvement can be achieved. "Anxiety headache" is not a recognized diagnosis, but it is quite possible that this is a type of headache disorder and also that anxiety may be present. More information will be needed to confirm either of these, to decide between them and to clarify what kinds of treatment might be appropriate.

The symptoms seem quite consistent with sleepiness, and studies show that insufficient or ineffective sleep is very common. People with sleep apnea at night are sleepy during the day but also feel badly in many other ways. Individuals with fibromyalgia have a marked deficiency in the deeper stages of sleep and experiments in which subjects were awakened as soon as deep sleep was evident on a sleep recording soon developed the symptoms of fibromyalgia and fatigue, which in turn resolved when their sleep normalized. Many kinds of depression and anxiety disorders are also associated with nighttime sleep disturbance and problems functioning during the day. Patients have been described who do not have apparent epilepsy during the day, but who have bursts of abnormal electrical activity in an all-night EEG and wake up repeatedly, then are tired and achy during the day. Nonrestorative sleep may simply be a matter of exercising or eating or drinking alcohol too close to bedtime, a sleeping environment that is too warm or too noisy or has a little too much light. The planned 24-hour EEG will show the electrical correlates of seizures if they are there, but could also indicate restless nighttime sleep and frequent awakenings, in which case some further sleep evaluation would be appropriate.

An inner ear infection can certainly cause dizziness and constant lightheadedness, and sometimes headache too, but the dizziness is often pronounced and rotational (vertigo) or associated with ear pain, and in any case the negative ENT evaluation and VNG makes this unlikely. Sinus disease can cause head and face pain with dizziness, usually with sinus tenderness and not so often with spaciness and sleepiness; sinus X-rays are less useful than CAT scan of the sinuses, but if there were no mention of the sinuses in an otherwise normal MRI and there is no congestion or nasal drainage, a CAT scan will not add anything. The ultrasound and blood flow measurements make narrowing of cerebral arteries unlikely and the possibility of stroke much less.

MRIs are perhaps done more often than they need to be, but yours was quite reasonable as multiple sclerosis can cause persistent disequilibrium alternately perceived as spaciness and lightheadedness. In the apparent absence of other neurological signs like imbalance or altered speech, this is less likely, but sometimes a later MRI will be positive and visual evoked potentials may reveal inflammation of the optic nerve that is not clinically apparent. The negative MRI also argues against odd things like a colloid cyst of the third ventricle, which can have a ball-valve effect and intermittently cause acute enlargement of the ventricles of the brain with headache, lightheadedness and fainting or presyncope.

The right bundle branch block in the heart could produce faintness and feelings of lightheadedness and dizziness, and headache could result from compensatory dilation of cerebral blood vessels. There are usually palpitations or at least intermittent slow heart rate when this happens, so the ECG part of the 24-hour EEG may be helpful, and a cardiologist could be consulted down the line. A prolapsing or billowing mitral valve is another potential cardiac cause, a common and generally benign condition that is often associated with dysautonomia, abnormal function, usually overactivity, of the autonomic nervous system that regulates pulse, blood pressure, breathing and other vital functions without our conscious awareness. This results in the physical reactions of stress without any stressor being present, and is often associated with migraine or other headaches and with anxiety disorder. The prolapsing mitral valve is not the cause of the autonomic condition but is a marker for it, possibly on a genetic basis. The valve makes a characteristic sound on cardiac examination, a click and a soft murmur; if this cannot be heard, the prolapse may be seen on an echocardiogram, which is something else a cardiologist might in time propose.

The HSV2 is almost certainly unrelated, but the past anxiety may be a sign of a predisposition to anxiety, also perhaps on a hereditary basis. The term "chemical imbalance " has come often to mean about the same thing as "it's all in your head". In fact, if that is the problem it is in your nervous system and reflects an imbalance between serotonin and other chemical transmitters. Anxiety very often has associated physical symptoms of dizziness, lightheadedness and headache. It is often associated with migraine, which represents according to recent large surveys about 85 per cent of the headaches for which people seek medical attention. The normal MRI makes a structural cause for the headache, exceedingly rare in neurologically normal people, essentially impossible, and if the headache is pulsatile, interferes with activity at least some of the time and is present with similar features in first-degree relatives such as parents or siblings, then it is very likely to be a form of migraine.

The planned 24-hour EEG and then a cardiology evaluation, possibly with echocardiogram, or further study of sleep may well give an answer. There are further tests, some of them quite simple, of the autonomic nervous system like measurement of skin sweating, the electrical potential of the sweat glands of the skin or the beat-to-beat variability of the heart rate. These are giving an answer, and if the answer continues to be negative, then focusing on the treatment options for migraine and anxiety disorder would be in order.

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