What is the initial workup for a patient presenting with nausea, headaches, and dizziness?

From the Guidelines

The initial workup for a patient presenting with nausea, headaches, and dizziness should include a thorough history and physical examination, followed by targeted laboratory and imaging studies, prioritizing the assessment of vital signs, neurological examination, and laboratory tests to rule out life-threatening conditions such as aneurysmal subarachnoid hemorrhage (aSAH) 1. The patient's symptoms of nausea, headaches, and dizziness can be indicative of various conditions, ranging from benign to life-threatening.

• A thorough history should be obtained to identify any potential triggers or underlying conditions that may be contributing to the patient's symptoms.
• The physical examination should include:
  • Vital signs: blood pressure in both sitting and standing positions to assess for orthostatic hypotension.
  • Neurological examination: focusing on cranial nerves, cerebellar function, and vestibular testing such as the Dix-Hallpike maneuver.
• Laboratory tests should include:
  • Complete blood count.
  • Comprehensive metabolic panel.
  • Thyroid function tests.
  • Blood glucose measurement.
  • Pregnancy testing in women of childbearing age.
• If symptoms suggest a central nervous system cause, neuroimaging with CT or MRI of the brain may be warranted, particularly if there are focal neurological findings, sudden onset of severe headache, or signs of increased intracranial pressure 1.
• An electrocardiogram should be performed if cardiac symptoms are present.
• For persistent dizziness, vestibular function tests may be appropriate. It is essential to consider the possibility of aSAH, which can present with sudden onset of severe headache, nausea, and vomiting, and requires prompt diagnosis and treatment 1. The diagnostic yield of CT remains very low (<1%) in patients with isolated dizziness, whereas the yield of MRI DWI was slightly greater but still low (4%) 1. Therefore, a high index of suspicion is warranted, and a comprehensive approach should be taken to differentiate between common causes such as vestibular disorders, migraine, medication side effects, metabolic disturbances, or more serious conditions like intracranial pathology, allowing for appropriate treatment planning based on the underlying etiology.

From the FDA Drug Label

The efficacy of sumatriptan tablets in the acute treatment of migraine headaches was demonstrated in 3, randomized, double-blind, placebo-controlled trials. Patients enrolled in these 3 trials were predominately female (87%) and Caucasian (97%), with a mean age of 40 years (range of 18 to 65 years). Patients were instructed to treat a moderate to severe headache Headache response, defined as a reduction in headache severity from moderate or severe pain to mild or no pain, was assessed up to 4 hours after dosing. Associated symptoms such as nausea, photophobia, and phonophobia were also assessed.

The initial workup for a patient presenting with nausea, headaches, and dizziness is not explicitly stated in the provided drug label. The label discusses the treatment of migraine headaches with sumatriptan, but it does not provide a workup or diagnostic approach for these symptoms. 2

From the Research

Initial Workup for Nausea, Headaches, and Dizziness

The initial workup for a patient presenting with nausea, headaches, and dizziness involves a thorough history and physical examination to differentiate between primary and secondary headache disorders 3, 4.

• History: The patient's history should include the quality of pain, intensity, location, rate, duration, modality of onset, relieving or worsening conditions, response to drugs, and associated symptoms or signs 3.
• Physical Examination: A careful neurological examination, including vision and evaluation of rigor nuchalis, can provide important diagnostic information 3.
• Laboratory Exams: Laboratory exams are not usually necessary for most patients with headaches, but may be useful when an infective or inflammatory disease is suspected 3.
• Imaging: Neuroimaging, such as CT scans, may be necessary to rule out organic intracranial causes, such as subarachnoid hemorrhage or intracranial hypertension 3, 5.

Differential Diagnosis

The differential diagnosis for nausea, headaches, and dizziness includes primary headache disorders, such as migraine and cluster headaches, as well as secondary causes, such as meningitis, subarachnoid hemorrhage, and intracranial hypertension 3, 6.

• Primary Headache Disorders: Migraine, cluster headache, and tension-type headache are common primary headache disorders that can present with nausea, headaches, and dizziness 7, 6.
• Secondary Causes: Secondary causes, such as meningitis, subarachnoid hemorrhage, and intracranial hypertension, require prompt diagnosis and treatment to prevent serious complications 3, 6.

Treatment

Treatment for nausea, headaches, and dizziness depends on the underlying cause and may include medications, such as sumatriptan for migraine, as well as other therapies, such as nerve blocks and preventive strategies 7, 6.

• Medications: Sumatriptan is effective in relieving migraine headaches and associated symptoms, such as nausea and vomiting 7.
• Other Therapies: Nerve blocks and preventive strategies, such as avoiding triggers and maintaining a headache diary, can also be effective in managing primary headache disorders 6.