What is the appropriate evaluation and management for a young healthy female presenting with headaches, dizziness, fatigue, and palpitations?

Evaluation and Management of Young Healthy Female with Headaches, Dizziness, Fatigue, and Palpitations

This symptom constellation requires systematic evaluation to distinguish between benign primary disorders (most likely vasovagal syncope or migraine) and potentially serious secondary causes, with initial focus on cardiac arrhythmias, orthostatic hypotension, and in women of childbearing age, pregnancy-related complications.

Initial Clinical Assessment

Critical History Elements

Obtain specific details about the palpitations to guide diagnosis:

• Regularity of palpitations: Regular with sudden onset/termination suggests supraventricular tachycardia (AVRT or AVNRT), while irregular palpitations suggest premature depolarizations, atrial fibrillation, or multifocal atrial tachycardia 1
• Termination by vagal maneuvers: Suggests re-entrant tachycardia involving AV nodal tissue 1
• Position when symptoms occur: Symptoms occurring upon standing suggest orthostatic hypotension or orthostatic intolerance syndromes 1, 2
• Prodromal symptoms: Presence of typical prodromal symptoms (nausea, warmth, diaphoresis) before dizziness suggests vasovagal etiology and indicates low-risk features 2
• Exercise relationship: Presyncope or palpitations during exercise is a high-risk feature requiring cardiac evaluation 2

Headache-Specific Questions

Ask about headache characteristics to differentiate primary from secondary causes:

• Character of pain: Throbbing pain suggests migraine, while new severe headache requires exclusion of secondary causes 1, 3
• Associated symptoms: Nausea, vomiting, photophobia, and phonophobia support migraine diagnosis 1
• Time of day and menstrual relationship: In women, headaches occurring during menstrual cycle suggest menstrual migraine 1
• Duration: Migraine typically lasts 4-72 hours if untreated 3

Red Flags Requiring Urgent Evaluation

Immediately assess for these concerning features:

• Sudden onset "thunderclap" headache: Requires urgent CT and lumbar puncture to exclude subarachnoid hemorrhage 4, 5
• New headache after age 50: Up to 15% may have serious pathology including stroke, temporal arteritis, or subdural hematoma 4, 5
• Neurologic signs or symptoms: Abnormal neurologic examination warrants neuroimaging 1, 5
• Pregnancy with hypertension: New headache in pregnant woman with hypertension should be considered preeclampsia until proven otherwise and requires urgent blood pressure assessment 1, 6
• Nystagmus with headache in pregnancy: May indicate structural neurologic pathology, increased intracranial pressure, or eclampsia 6
• Syncope during exercise or without prodrome: High-risk cardiac features requiring cardiology referral 2

Physical Examination

Cardiovascular Examination

• Orthostatic vital signs: Measure blood pressure and heart rate supine and after standing for 3 minutes to assess for orthostatic hypotension (systolic BP drop ≥20 mmHg or diastolic drop ≥10 mmHg) or postural orthostatic tachycardia syndrome (heart rate increase ≥30 bpm) 1, 2
• Complete cardiovascular examination: Assess heart rate, rhythm, heart sounds, and peripheral pulses to identify cardiac abnormalities 2

Neurologic Examination

• Thorough neurologic examination: If normal, neuroimaging is usually not warranted for primary headache disorders 1, 5
• Papilledema: Suggests increased intracranial pressure requiring urgent evaluation 1, 6

Initial Diagnostic Testing

Mandatory Tests

• 12-lead ECG: Fundamental test for all patients with palpitations or presyncope to detect conduction abnormalities, channelopathies, and structural heart disease 2
• Pregnancy test: Essential in all women of childbearing age given the symptom constellation and risk of preeclampsia 1

Conditionally Indicated Tests

• Complete blood count and basic metabolic panel: Order if clinically indicated (e.g., fatigue suggesting anemia, symptoms suggesting electrolyte abnormalities) but not routinely necessary 2
• Thyroid function tests: Consider if symptoms suggest thyroid dysfunction (weight changes, heat/cold intolerance)

Risk Stratification for Cardiac Causes

High-Risk Features Requiring Cardiology Referral

• Palpitations or presyncope during exercise 2
• Abnormal ECG findings 2
• Family history of sudden cardiac death, arrhythmias, or structural heart disease 2
• Absence of prodromal symptoms before dizziness 2
• Associated chest pain 2

Low-Risk Features (Likely Benign)

• Clear vasovagal trigger (prolonged standing, emotional stress, pain) 2
• Presence of typical prodromal symptoms (nausea, warmth, visual changes) 2
• Post-exercise occurrence rather than during exercise 2

Neuroimaging Indications for Headache

Neuroimaging is NOT routinely indicated for primary headache disorders with normal neurologic examination 1, 5. The yield of neuroimaging in patients with headache and normal neurologic examination is quite low: brain tumors 0.8%, arteriovenous malformations 0.2%, aneurysm 0.1% 4.

Specific Indications for Neuroimaging

• Abnormal neurologic examination 1, 5
• Headache worsened with Valsalva maneuver 1
• Headache awakening patient from sleep 1
• New onset headache in patient over 50 years 1, 4
• Progressively worsening headache 1
• Headache with atypical features not meeting strict migraine criteria 1

Imaging Modality Selection

• Noncontrast CT scan: Preferred initial test to rule out hemorrhage, followed by lumbar puncture if CT is normal and subarachnoid hemorrhage suspected 5
• MRI: More detailed than CT and necessary for imaging posterior fossa, but more expensive and less widely available 5

Management Based on Most Likely Diagnoses

If Vasovagal Syncope/Presyncope (Most Common in Young Healthy Females)

• Immediate management: Maintain safe position (sitting or lying down), perform physical counterpressure maneuvers (leg crossing, arm tensing) to increase blood pressure 2
• Long-term management: Ensure adequate hydration, avoid triggers, educate on recognizing prodromal symptoms 2

If Migraine (Second Most Common Primary Headache)

Acute treatment options:

• Acetaminophen, NSAIDs, or combination products with caffeine for mild-to-moderate migraine 3
• Triptans (5-HT1B/D agonists) eliminate pain in 20-30% by 2 hours but avoid in cardiovascular disease due to vasoconstrictive properties 3
• Gepants (rimegepant, ubrogepant) eliminate headache in 20% at 2 hours with adverse effects of nausea and dry mouth in 1-4% 3

Preventive therapy indications:

• Consider if patient has more than 2 headaches per week to avoid medication-overuse headaches 1
• First-line options: propranolol, topiramate, amitriptyline 1

If Menstrual Migraine

• Perimenstrual preventive treatment: Daily long-acting NSAID (naproxen) or triptan (frovatriptan, naratriptan) for 5 days beginning 2 days before expected menstruation 1
• Contraception considerations: Combined hormonal contraceptives are absolutely contraindicated in women with migraine with aura due to increased stroke risk 1

If Orthostatic Hypotension

• Increase fluid and salt intake 1
• Review and discontinue or adjust any vasoactive medications or diuretics 1
• Consider compression stockings and physical counterpressure maneuvers 1

Follow-Up and Monitoring

• Headache calendar: Extremely useful for capturing attack frequency, severity, and acute medication use with minimal time commitment 1
• Re-evaluation timeline: Assess treatment response within 2-3 months after initiation or change in treatment 1
• Ambulatory cardiac monitoring: Consider if high-risk cardiac features present or palpitations remain unexplained after initial evaluation 2

Common Pitfalls to Avoid

• Medication-overuse headache: Frequent use of ergotamine, opiates, analgesics, and triptans may cause rebound headaches; preventive therapy should be considered if using acute medications more than 2 days per week 1
• Underdiagnosis in women: Women with chest pain and palpitations are at risk for underdiagnosis of cardiac causes; maintain high index of suspicion 1
• Missing pregnancy-related complications: Always obtain pregnancy test in women of childbearing age, as preeclampsia can present with this symptom constellation 1
• Dismissing exercise-related symptoms: Palpitations or presyncope during (not after) exercise is a high-risk feature requiring cardiac evaluation 2