What is the recommended workup for a 40-year-old male presenting with acute dizziness, headache, and 'spacey' complaints?

Diagnostic Workup for Acute Dizziness, "Spacey" Complaints, and Headache in a 40-Year-Old Male

The initial evaluation of a 40-year-old male with acute dizziness, "spacey" complaints, and headache should focus on timing and triggers rather than symptom quality, including targeted history, physical examination with orthostatic blood pressure measurements, neurological assessment, and a 12-lead ECG. 1

Initial Assessment

History

• Obtain detailed information about:
  • Timing: Onset, duration, frequency of symptoms
  • Triggers: Positional changes, specific movements, stress
  • Associated symptoms: Visual disturbances, hearing changes, nausea/vomiting
  • Headache characteristics: Location, quality, severity, radiation
  • Previous episodes: Similar symptoms in the past
  • Risk factors: Hypertension, smoking, alcohol use, family history

Physical Examination

• Vital signs with orthostatic blood pressure measurements
• Complete neurological examination including:
  • HINTS examination (Head-Impulse, Nystagmus, Test of Skew) to differentiate central from peripheral causes
  • Dix-Hallpike maneuver to assess for BPPV
  • Cerebellar testing (finger-to-nose, heel-to-shin)
  • Cranial nerve assessment
  • Motor and sensory examination

Diagnostic Testing Algorithm

First-Line Testing

1. Non-contrast head CT

   • If negative and suspicion for subarachnoid hemorrhage remains high, proceed to lumbar puncture 2

2. Basic laboratory tests:

   • Complete blood count
   • Basic metabolic panel
   • Blood glucose
   • Thyroid function tests

3. 12-lead ECG to rule out cardiac causes

Second-Line Testing (Based on Initial Findings)

• If abnormal HINTS examination or neurological deficits present:

  • MRI brain (without contrast) 1

• If symptoms suggest vestibular disorder:

  • Consider vestibular function testing (VNG) if diagnosis remains unclear after bedside tests 1

• If orthostatic hypotension is suspected:

  • Review medications
  • Consider autonomic testing

Differential Diagnosis to Consider

Urgent/Emergent Conditions

• Cerebral venous thrombosis (CVT)

  • May present with headache, dizziness, and altered mental status 2
  • Risk increases with spontaneous intracranial hypotension

• Vertebrobasilar insufficiency/TIA/Stroke

  • Can present with isolated episodes of vertigo lasting less than 30 minutes 1
  • May precede a stroke by weeks or months

• Subarachnoid hemorrhage

  • Presents with sudden severe headache ("thunderclap")
  • Requires immediate CT scan and possible lumbar puncture 2

Non-Emergent Conditions

• Vestibular migraine

  • Variable duration episodes
  • Often with history of migraine and light sensitivity 1
  • Diagnosis of exclusion requiring episodic vestibular symptoms and migraine criteria

• Benign paroxysmal positional vertigo (BPPV)

  • Positional vertigo lasting seconds
  • Positive Dix-Hallpike test

• Medication-related dizziness

  • Review current medications, especially those affecting blood pressure

Red Flags Requiring Immediate Attention

• Sudden severe headache with dizziness
• New neurological symptoms
• Inability to walk or stand
• Persistent vomiting with dizziness 1
• Somnolence or altered mental status

Management Considerations

For Suspected Cerebral Venous Thrombosis

• If CVT is suspected, urgent neuroimaging with CT venography or MR venography is indicated
• Early anticoagulation may be necessary 2

For Suspected Vestibular Migraine

• Consider symptomatic treatment with migraine-specific medications
• For moderate to severe migraine, consider triptans or combination therapy 2

For Suspected BPPV

• Canalith repositioning procedures (e.g., Epley maneuver) 1

Follow-up Recommendations

• Close follow-up for patients with undiagnosed dizziness not responding to initial treatment
• Consider referral to neurology or ENT if symptoms persist
• Document triggers, timing, and associated symptoms to aid in diagnosis

Pitfalls and Caveats

• Dizziness is often misdiagnosed, especially when associated with serious conditions like CVT or stroke
• Don't rely solely on symptom quality (vertigo vs. lightheadedness) for diagnosis
• Avoid prolonged use of vestibular suppressant medications as they can interfere with central compensation 1
• Consider multifactorial causes, including medication side effects and vascular disease

Remember that acute onset of severe headache with dizziness warrants a high level of suspicion for serious neurological conditions that require immediate evaluation and treatment.