Dear Dr. John,

Our little 14-year-old dog developed a head tilt in the last day or two. She is walking with some difficulty and having trouble getting her balance. Could she have had a stroke? We have an appointment with my vet in two days since we are traveling home, but should we be more concerned? Our vet told us that based on what we said it could likely wait. She is still eating, going to the bathroom, and responds to us with a wag in her tail. If this is not a stroke, what else could be the cause of her head tilt and what might be done for her to restore her balance? L.W.

Dear L.W.,

From the sound of things, I believe that waiting until your veterinarian evaluates your dog should suffice but typically, I recommend that dogs with a sudden onset head tilt be seen as soon as possible. Yes, your dog could have had a mild stroke but there are other possibilities as well.

Cases with a head tilt and imbalance are referred to as being caused by vestibular disease. In humans, think of vertigo as a good analogy. These can be peripheral with possible damage to the eardrum or infections and inflammation of the middle and inner ear, central originating from the brain from a stroke, inflammation, or cancer, or idiopathic which means the cause is not known and is what is usually seen in older dogs such as yours. Strangely enough, even hypothyroidism can cause these vestibular signs.

Your veterinarian will examine her and run some bloodwork. Typically, but not always, a dog with a stroke has a nystagmus in which the eyes move slowly in one direction and then quickly back in the other. A fair amount of these dogs end up with nausea and vomiting and a medication might be given to help with that. Additional testing may also be needed such as imaging with CT or MRI or other tests depending on the working diagnosis. Her head tilt and ataxia may turn out to simply be an old age thing with no specific causative agent and her balance may come back on its own over a few days or weeks as she adjusts. Good luck!

Dr. John de Jong is President of the World Veterinary Association. He owns and operates the Boston Mobile Veterinary Clinic and can be reached at 781-899-9994.