What are the recommended evaluations and treatments for persistent headache, vertigo, and fluctuating blood pressure over 2 weeks?

Evaluation and Management of Persistent Headache, Vertigo, and Blood Pressure Changes

For a patient presenting with 2 weeks of headache, vertigo, and blood pressure fluctuations, you must urgently evaluate for posterior circulation stroke or TIA, as dizziness is the most common symptom of posterior circulation TIA and carries high risk of recurrent events. 1

Immediate Risk Stratification

Critical red flags requiring urgent neuroimaging:

• Vertigo lasting more than 24 hours with severe imbalance, nausea, vomiting, visual blurring, or drop attacks 2
• Any neurologic symptoms including dysphagia, dysphonia, or other focal deficits 2
• Nystagmus that changes direction without head position changes, downward nystagmus, or spontaneous nystagmus without provocation 3
• Severe hypertension (SBP ≥180 mm Hg or DBP ≥110 mm Hg) requires prompt evaluation and treatment 2

Blood Pressure Assessment

Measure blood pressure properly and evaluate for orthostatic hypotension:

• Perform Schellong test (blood pressure in supine and standing positions) as orthostatic hypotension is statistically higher in hypertensive patients and commonly causes vertigo 4
• Vertigo in hypertensive patients is typically unrelated to elevated pressure itself but rather to hypotension after antihypertensive medications or concomitant vestibular disease 5
• For stage 2 hypertension (≥140/90 mm Hg), initiate combination antihypertensive therapy with two agents of different classes and reassess in 1 month 2
• For very high BP (≥180/110 mm Hg), prompt antihypertensive treatment is required 2

Vertigo Characterization

Distinguish true vertigo from other dizziness:

• True vertigo is a false sensation of self-motion or spinning of visual surroundings, indicating inner ear dysfunction 2
• Duration matters critically: seconds suggests BPPV, minutes to hours suggests vestibular migraine or TIA, 12-36 hours suggests vestibular neuritis, persistent >24 hours with hearing loss suggests labyrinthitis 2
• Ask specifically about hearing loss, tinnitus, or aural fullness occurring before, during, or after vertigo attacks (suggests Ménière's disease) 2
• Positional triggers (head movement) suggest BPPV rather than central causes 2

Neuroimaging Decision

MRI with diffusion-weighted imaging is the test of choice when central causes are suspected:

• MRI has 79.8% sensitivity and 98.8% specificity for detecting stroke in acute vertigo patients 6
• CT scan has only 28.5% sensitivity (misses most strokes) but 98.9% specificity 6
• Obtain MRI of brain and posterior fossa with vertebrobasilar imaging for: persistent symptoms >24 hours, associated neurologic symptoms, atypical nystagmus patterns, or vascular risk factors 3, 1
• Approximately 3% of treatment-refractory vertigo cases have underlying CNS disorders, and 10% of cerebellar strokes mimic peripheral vestibular disease 3

Headache Evaluation

Screen for secondary headache etiologies given the combination with vertigo and BP changes:

• The combination of headache with vertigo and BP fluctuations raises concern for posterior circulation pathology 7
• Red flags include sudden onset, worst headache of life, focal neurologic deficits, altered mental status, or progressive worsening 7
• Consider vestibular migraine if attacks last hours with photophobia and migraine history, though hearing loss is less common than in Ménière's disease 2

Treatment Algorithm

For peripheral vestibular causes:

• If BPPV is confirmed by Dix-Hallpike testing, perform canalith repositioning procedure (Epley maneuver) with 90-98% success rate 2, 3
• Avoid benzodiazepines as they impede vestibular compensation 8
• Reassess within 1 month to document resolution or persistence 8

For blood pressure management:

• Initiate ACE inhibitor or ARB plus thiazide diuretic (chlorthalidone preferred) for stage 2 hypertension 2
• Check electrolytes and renal function 2-4 weeks after starting therapy 2
• Evaluate for medication-induced hypotension if vertigo worsens after antihypertensive initiation 5

For Ménière's disease (if fluctuating hearing loss, tinnitus, aural fullness present):

• Consider betahistine or diuretics, though evidence is limited to 2-12 week studies 2
• Intratympanic steroids may be offered for refractory cases 2

Common Pitfalls

• Do not assume vertigo is caused by elevated blood pressure alone—it is usually due to concomitant vestibular disease or medication-induced hypotension 5, 4
• Do not rely on CT scan to rule out stroke—it misses approximately 70% of posterior circulation strokes in acute vertigo 6
• Do not miss the 1-month reassessment window—persistent symptoms require escalation of workup 8
• Do not overlook posterior circulation TIA—dizziness is its most common presentation and carries high stroke risk requiring aggressive medical management with antiplatelet therapy and statins 1