What is the best course of action for a patient with new-onset dizziness, fatigue, migraines, and chest pain?

Management of New-Onset Dizziness, Fatigue, Migraines, and Chest Pain

Immediate Priority: Rule Out Acute Coronary Syndrome

This patient requires urgent cardiac evaluation with ECG and troponin measurement given the combination of chest pain, cardiovascular risk factors (age 54, elevated LDL 3.8), and concerning systemic symptoms. 1, 2

The chest pain characteristics—central sternal location, nocturnal occurrence, positional relief, and tenderness—do not exclude cardiac etiology, as atypical presentations are common, particularly in women and middle-aged patients. 2

Critical First Steps

• Obtain 12-lead ECG immediately to evaluate for ischemic changes, as this is the cornerstone of acute chest pain evaluation and should be completed within 10 minutes of presentation. 1, 2

• Measure cardiac troponin (preferably troponin T or I) at presentation and repeat at 6-12 hours to detect myocardial injury, as this is essential for risk stratification in suspected acute coronary syndrome. 1

• Check complete blood count, glucose, and thyroid function as planned, since anemia, hypoglycemia, and thyroid dysfunction can all cause dizziness and fatigue. 1

• Assess orthostatic vital signs formally (already done—no postural drop noted, which helps exclude volume depletion or autonomic dysfunction).

Risk Stratification for Chest Pain

This patient falls into the intermediate-risk category for acute coronary syndrome based on: 1

• Atypical but concerning chest pain pattern
• Multiple cardiovascular risk factors (age, dyslipidemia with LDL 3.8)
• No known coronary artery disease
• Normal initial vital signs and examination

Recommended Cardiac Workup Algorithm

If initial ECG and troponin are negative: 1

• Coronary CT angiography (CCTA) is the preferred test for intermediate-risk patients with no known CAD to exclude atherosclerotic plaque and obstructive coronary disease (Class 1, Level A recommendation). 1

• Alternative: Stress testing (exercise ECG, stress echocardiography, or stress nuclear imaging) is reasonable if CCTA is unavailable or contraindicated. 1

• If CCTA shows 40-90% stenosis, fractional flow reserve CT (FFR-CT) can determine vessel-specific ischemia and guide revascularization decisions. 1

If troponin is elevated or ECG shows ischemic changes: 1

• Immediate cardiology consultation and admission for management as acute coronary syndrome with consideration for invasive coronary angiography. 1

• Initiate guideline-directed medical therapy including aspirin 162-325 mg (chewed), antiplatelet therapy, anticoagulation, beta-blocker, and nitrates if not contraindicated. 1

Migraine Management

The new-onset migraines with associated dizziness and fatigue represent a distinct but potentially related problem that requires attention after cardiac clearance.

Diagnostic Considerations

• Vestibular migraine is the most common cause of spontaneous episodic vertigo and frequently presents with dizziness, fatigue, and headache in combination. 3, 4

• The constellation of "giddy, heavy, tired" feelings with migraines suggests possible vestibular migraine, which affects up to 1% of the general population and is often underdiagnosed. 4

• Chest pain can be a manifestation of migraine exacerbation, particularly chest wall pain that resolves with antimigraine treatment, though this must be diagnosed only after excluding cardiac causes. 5

Acute Migraine Treatment

Once cardiac etiology is excluded, initiate triptan therapy for acute migraine attacks: 6

• Sumatriptan 50-100 mg orally is recommended as first-line therapy for moderate-to-severe migraine attacks, with 61-62% achieving headache response at 2 hours and 78-79% at 4 hours. 6

• Cardiovascular evaluation is required before first triptan dose in patients with multiple cardiovascular risk factors (this patient has age >50, dyslipidemia). 6

• Consider administering first dose in medically supervised setting with post-dose ECG given her cardiovascular risk factors and chest pain history. 6

• Alternative: Sumatriptan 25 mg if concerned about tolerability, though 50-100 mg doses show superior efficacy. 6

• Avoid triptans if cardiac evaluation reveals CAD, coronary vasospasm, uncontrolled hypertension, or recent cardiovascular events, as these are absolute contraindications. 6

Preventive Considerations

• Dizziness handicap in migraine patients is associated with headache impact, anxiety, and depression, requiring comprehensive assessment beyond just headache frequency. 7

• Consider migraine prophylaxis if attacks become frequent (≥4 per month), as this patient has had 4 migraines in one week.

Additional Diagnostic Workup

Evaluate for Secondary Causes

• Hemoglobin measurement is critical given fatigue and to exclude anemia as a contributor to both dizziness and potential cardiac symptoms. 1

• Thyroid function testing (TSH, free T4) should be completed as planned, since thyroid dysfunction commonly causes fatigue, dizziness, and can trigger migraines.

• Fasting glucose and HbA1c to exclude diabetes or prediabetes, particularly given family history considerations and weight changes.

• Consider vitamin B12 and vitamin D levels if initial workup is unrevealing, as deficiencies can cause fatigue, dizziness, and numbness/tingling.

Neurological Evaluation

• The numbness/tingling in legs warrants attention, particularly if it persists after other causes are addressed, as it could represent peripheral neuropathy or other neurological conditions.

• Brain MRI should be considered if migraines have atypical features, neurological deficits develop, or symptoms don't respond to treatment, to exclude structural lesions or stroke. 4

Critical Pitfalls to Avoid

• Do not dismiss chest pain based on positional relief or chest wall tenderness alone, as these features do not reliably exclude acute coronary syndrome. 2

• Do not prescribe triptans without cardiac evaluation in patients with multiple cardiovascular risk factors, as serious cardiac events including MI, arrhythmias, and coronary vasospasm have been reported. 6

• Do not attribute all symptoms to migraine until cardiac and other serious causes are excluded—migraine is a diagnosis of exclusion in this context. 2, 4

• Do not delay emergency evaluation if chest pain worsens or recurs, as the patient should be instructed to call emergency services immediately for unimproved or worsening chest pain. 2, 8

Immediate Action Plan

1. Complete ECG and troponin measurement today 1, 2
2. If negative: Arrange CCTA or stress testing within 72 hours 1
3. If positive: Immediate cardiology consultation and admission 1
4. Complete planned blood work (FBC, glucose, thyroid) 1
5. Provide medical certificate for time off work given safety concerns with driving and dizziness
6. After cardiac clearance: Initiate supervised trial of sumatriptan with ECG monitoring 6
7. Schedule follow-up within 1 week to review test results and adjust management

Patient Safety Instructions

• Call emergency services (111 in New Zealand) immediately if chest pain recurs and is unimproved or worsening after 5 minutes. 2, 8

• Do not drive until dizziness resolves and cardiac evaluation is complete, given safety concerns the patient has already identified. 2

• Avoid operating heavy machinery or working at heights until symptoms are controlled.