Differential Diagnosis for Dizzy Spells

The patient presents with dizzy spells lasting hours, occurring spontaneously, sometimes accompanied by nausea, and a negative Dix-Hallpike maneuver. Here's a categorized differential diagnosis:

• Single Most Likely Diagnosis

  • Vestibular Migraine: This condition is characterized by episodic vertigo lasting from minutes to days, often accompanied by headache, nausea, and sensitivity to light and sound. The negative Dix-Hallpike maneuver helps to rule out benign paroxysmal positional vertigo (BPPV), making vestibular migraine a more likely cause of the patient's symptoms.

• Other Likely Diagnoses

  • Meniere's Disease: A disorder of the inner ear that affects balance and hearing, causing episodes of vertigo, tinnitus, hearing loss, and a feeling of fullness in the ear. The duration of vertigo episodes in Meniere's can range from minutes to hours, which aligns with the patient's symptoms.
  • Labyrinthitis: An inner ear disorder characterized by inflammation of the labyrinth, which can cause vertigo, dizziness, and sometimes nausea. The symptoms can last from days to weeks, and the absence of a positive Dix-Hallpike maneuver does not rule out this condition.
  • Viral Vestibular Neuritis: An inflammation of the vestibular nerve, often following a viral infection, leading to sudden onset of vertigo, which can last from days to weeks. Nausea and vomiting may accompany the vertigo.

• Do Not Miss Diagnoses

  • Posterior Circulation Stroke: Although less common, a stroke in the posterior circulation can present with vertigo, nausea, and vomiting. It is crucial to consider this diagnosis due to its severe implications and the need for immediate intervention.
  • Multiple Sclerosis: In rare cases, multiple sclerosis can present with vertigo as an initial symptom due to lesions in the brainstem or cerebellum. Given the potential for significant morbidity, this diagnosis should not be overlooked.
  • Acoustic Neuroma: A benign tumor on the vestibular nerve can cause vertigo, hearing loss, and tinnitus. While rare, its potential impact on the patient's quality of life warrants consideration.

• Rare Diagnoses

  • Mal de Debarquement Syndrome: A rare condition characterized by a persistent feeling of swaying or imbalance after a voyage, which can last from days to years. It's an unlikely cause but should be considered in patients with a history of recent travel by sea or air.
  • Perilymph Fistula: An abnormal connection between the inner and middle ear, leading to vertigo, hearing loss, and tinnitus. The symptoms can be provoked by changes in pressure, such as sneezing or straining.