What is the management approach for a 70-year-old male with a 1-day history of headache, dizziness, and horizontal nystagmus, presenting with a blood pressure of 150/80 mmHg and pulsating headache?

Management of 70-Year-Old Male with Headache, Dizziness, and Horizontal Nystagmus

This patient requires urgent neuroimaging to rule out posterior circulation stroke before considering benign peripheral vestibular causes, given the combination of headache, horizontal nystagmus, and vascular risk factors in an elderly patient.

Immediate Priority: Exclude Central Causes

Critical Red Flags Present

• Age 70 with new-onset dizziness and headache suggests higher stroke risk 1
• Horizontal nystagmus can indicate either peripheral or central pathology 2
• Pulsating headache is atypical for benign paroxysmal positional vertigo (BPPV) 2
• Blood pressure 150/80 is elevated but does not meet hypertensive emergency criteria (≥180/110 with acute organ damage) 2

Perform HINTS Examination Immediately

The three-step bedside oculomotor examination is more sensitive than early MRI for stroke detection 3:

• Head Impulse Test: Assess vestibulo-ocular reflex function. A normal head impulse test suggests central pathology (stroke), while an abnormal test suggests peripheral vestibular dysfunction 3
• Nystagmus characteristics: Direction-changing nystagmus in eccentric gaze indicates stroke 3
• Test of Skew: Vertical ocular misalignment (skew deviation) predicts brainstem involvement and stroke 3

The presence of normal head impulse test, direction-changing nystagmus, or skew deviation is 100% sensitive and 96% specific for stroke 3

Obtain Urgent Neuroimaging

• MRI brain with and without contrast is mandatory given the clinical presentation 4
• Focus on posterior circulation (vertebrobasilar territory, cerebellum, brainstem) 1
• Early MRI can be falsely negative in 12% of cases within 48 hours of symptom onset 3
• If MRI unavailable, CT may miss posterior fossa lesions but should still be obtained 4

Differential Diagnosis to Consider

Central Causes (Must Rule Out First)

• Posterior circulation TIA/stroke: Most critical diagnosis given age, headache, and dizziness 1
• Vertebrobasilar insufficiency: Common in elderly with vascular risk factors 2
• Cerebellar stroke or hemorrhage: Can present with isolated dizziness and nystagmus 4, 3
• Demyelinating diseases: Less likely at age 70 but possible 2

Peripheral Vestibular Causes (Consider After Excluding Central)

• Vestibular neuritis: Typically presents with unidirectional horizontal nystagmus 5
• Lateral canal BPPV: Would show direction-changing horizontal nystagmus on supine roll test 2
• Ménière's disease: Usually includes hearing loss and tinnitus 2

Other Considerations

• Vestibular migraine: Can present with headache and dizziness, but less likely as first presentation at age 70 6
• Giant cell arteritis: Check ESR and CRP if patient has scalp tenderness or jaw claudication 2

Diagnostic Algorithm

Step 1: Perform HINTS Examination

Document head impulse test, nystagmus pattern, and test of skew 3

Step 2: If Any HINTS Finding Suggests Central Cause

• Obtain urgent MRI brain with focus on posterior fossa 4, 1
• Admit for observation and stroke workup 1
• Consult neurology immediately 1

Step 3: If HINTS Suggests Peripheral Cause

• Perform Dix-Hallpike maneuver to assess for posterior canal BPPV 2
• Perform supine roll test if Dix-Hallpike shows horizontal or no nystagmus 2
• Still obtain neuroimaging given age and headache, even if peripheral findings present 2

Step 4: Additional Workup

• Check blood pressure, glucose, hemoglobin A1c for vascular risk factors 2
• If temporal tenderness present: ESR, CRP, consider temporal artery biopsy 2
• Vertebral and basilar artery imaging if TIA suspected 1

Management Approach

If Central Cause Confirmed

• Admit for stroke protocol 1
• Antiplatelet therapy, statin, aggressive risk factor modification 1
• Neurology consultation for ongoing management 1

If Peripheral Cause Confirmed (After Excluding Central)

• Canalith repositioning procedure for posterior canal BPPV 2
• Supine roll test and appropriate repositioning for lateral canal BPPV 2
• Do NOT use vestibular suppressants (antihistamines, benzodiazepines) routinely as they delay central compensation 2, 7
• Reassess within 1 month to document improvement 2, 7

Critical Pitfalls to Avoid

• Do not assume BPPV based solely on horizontal nystagmus without proper diagnostic maneuvers 4
• Do not delay neuroimaging in elderly patients with new-onset symptoms and vascular risk factors 2
• Downbeat nystagmus without torsional component strongly suggests central pathology, not BPPV 4
• Do not obtain routine radiographic imaging only if BPPV is definitively diagnosed AND no concerning features present 2
• Avoid prolonged vestibular suppressants which increase fall risk and delay recovery 7