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, with no photophobia or headache. Based on these symptoms, the differential diagnosis can be categorized as follows:

• Single Most Likely Diagnosis

  • Vestibular Migraine: This condition is characterized by episodic vertigo that can last from minutes to days, often accompanied by nausea but not necessarily headache or photophobia. The absence of headache and photophobia does not rule out vestibular migraine, as these symptoms can be variable.

• Other Likely Diagnoses

  • Benign Paroxysmal Positional Vertigo (BPPV): Although the Dix-Hallpike maneuver is negative, BPPV cannot be entirely ruled out without further testing, such as a roll test or a supine roll test, as the condition can be intermittent.
  • Meniere's Disease: Characterized by episodes of vertigo lasting from minutes to hours, often accompanied by nausea and sometimes hearing loss or tinnitus. The absence of auditory symptoms does not exclude Meniere's, as these can develop over time.
  • Viral Vestibular Neuritis: An inner ear disorder that causes vertigo, often following a viral infection. Symptoms can include severe vertigo lasting days to weeks, usually without hearing loss.

• Do Not Miss Diagnoses

  • Posterior Circulation Stroke: Although less common, a stroke in the posterior circulation can present with vertigo, nausea, and vomiting without headache. This diagnosis is critical to rule out due to its potential for severe consequences if missed.
  • Multiple Sclerosis: Can present with vertigo among other neurological symptoms. While less likely, the potential for significant impact on the patient's life warrants consideration.
  • Acoustic Neuroma: A benign tumor on the vestibular nerve that can cause vertigo, hearing loss, and tinnitus. Early detection is crucial for effective management.

• Rare Diagnoses

  • Mal de Debarquement Syndrome: A rare condition where vertigo is triggered by a history of motion exposure (like boat travel) and can persist for a long time after the exposure has ceased.
  • Perilymph Fistula: An abnormal connection between the inner and middle ear, causing vertigo, hearing loss, and sometimes a sensation of fullness in the ear. Symptoms can be variable and may mimic other inner ear disorders.

Each of these diagnoses should be considered in the context of the patient's full medical history, physical examination, and potentially further diagnostic testing to determine the underlying cause of the dizzy spells.