What is the best course of treatment for a 23-year-old female experiencing dizziness, vertigo, and loss of balance, with symptoms starting after a severe headache, and no relief from Halpike-Dix (Dix-Hallpike) maneuvers?

Evaluation for Central Nervous System Pathology

This patient requires urgent neurological evaluation for a central cause of vertigo, specifically posterior circulation stroke or other CNS pathology, given the severe headache preceding symptom onset and failure of Dix-Hallpike maneuvers to provide relief. 1

Critical Red Flags Present

This clinical presentation contains several concerning features that distinguish it from benign paroxysmal positional vertigo (BPPV):

• Massive headache preceding vertigo onset - This temporal relationship strongly suggests vestibular migraine or, more concerning, a posterior circulation vascular event 1, 2
• Failure of Dix-Hallpike maneuvers - When positional testing fails to reproduce or relieve symptoms, this raises concern that the underlying diagnosis may not be BPPV 1
• Persistent symptoms for one week - The combination of ongoing symptoms with negative provocative maneuvers warrants reevaluation 1, 3

Differential Diagnosis Priority

Most Urgent: Central Nervous System Causes

Cerebellar or brainstem stroke must be ruled out first, as 10% of cerebellar strokes present similarly to peripheral vestibular processes 1. Key distinguishing features to assess include:

• Dysarthria, dysmetria, or dysphagia 1
• Sensory or motor deficits 1
• Horner's syndrome 1
• Direction-changing nystagmus without head position changes 1
• Downbeating nystagmus on Dix-Hallpike (particularly without torsional component) 1
• Gaze-holding nystagmus 1

Likely: Vestibular Migraine

Given the severe headache preceding vertigo, vestibular migraine is the most probable diagnosis if CNS pathology is excluded 2, 4. Diagnostic criteria include:

• ≥5 episodes of vestibular symptoms lasting 5 minutes to 72 hours 1, 2
• Current or history of migraine 2
• ≥1 migraine symptom during at least 50% of dizzy episodes (photophobia, phonophobia, visual aura) 1, 2
• Vestibular migraine has a 3.2% lifetime prevalence and accounts for up to 14% of vertigo cases 2

Consider: Other Peripheral Causes

• Vestibular neuritis - typically presents with acute onset, but would show baseline nystagmus without provocative maneuvers 1
• Meniere's disease - would typically include hearing loss, which this patient denies 3

Immediate Management Steps

1. Neurological Examination and Imaging

Do not obtain routine imaging for typical BPPV, but this case warrants neuroimaging given atypical features 1. The American Academy of Otolaryngology-Head and Neck Surgery states that imaging should be obtained when there are "additional signs and/or symptoms inconsistent with BPPV" 1.

Perform or refer for:

• Complete neurological examination focusing on posterior circulation findings 1
• HINTS examination (head-impulse, nystagmus, test of skew) to distinguish peripheral from central causes 5
• MRI brain with attention to posterior fossa if any concerning neurological findings 1, 6

2. Repeat Diagnostic Testing

Reassess with proper vestibular testing 1, 3:

• Repeat Dix-Hallpike maneuver bilaterally to confirm absence of posterior canal BPPV 1, 3
• Perform supine roll test to evaluate for lateral canal BPPV 1, 3
• Document any nystagmus characteristics (direction, duration, presence without provocation) 1

3. Treatment Based on Final Diagnosis

If Vestibular Migraine Confirmed:

First-line treatment includes lifestyle modifications followed by preventive medications 2:

• Dietary modifications: limit salt/sodium, avoid excessive caffeine, alcohol, nicotine 2
• Maintain regular sleep schedule and adequate hydration 2
• Stress management and regular exercise 2

Pharmacological prevention (if symptoms occur ≥2 days per month) 2:

• Beta-blockers (propranolol, atenolol) as first-line 2
• Topiramate or candesartan as alternatives 2
• Avoid long-term vestibular suppressants (meclizine, benzodiazepines) as they interfere with central compensation 3, 7

Acute attack management 2:

• Triptans for concurrent headache 2
• Short-term antiemetics (prochlorperazine) for severe nausea 7, 2
• Vestibular suppressants only for severe acute symptoms, not chronic use 2

If Persistent BPPV Identified:

• Repeat canalith repositioning procedures achieve 90-98% success rates 1, 3
• Consider vestibular rehabilitation if multiple repositioning attempts fail 1

Critical Pitfalls to Avoid

• Do not prescribe vestibular suppressants as primary treatment - The American Academy of Otolaryngology-Head and Neck Surgery explicitly recommends against routine use of antihistamines or benzodiazepines for BPPV, as they do not address the underlying cause and may delay recovery 1, 3, 7
• Do not assume BPPV when Dix-Hallpike is negative or unhelpful - This warrants further evaluation for alternative diagnoses 1
• Do not delay neurological evaluation when red flags are present, particularly the severe headache preceding vertigo onset 1

Follow-Up Requirements

Reassess within 1 month to document resolution or persistence of symptoms 1, 3. Earlier follow-up is warranted if:

• Any new neurological symptoms develop 1
• Symptoms worsen despite treatment 1
• Patient develops hearing loss, severe headache, or focal neurological deficits 1, 2