What is the best course of action for a 58-year-old female presenting with dizziness, headache, and nausea, with a history of migraines (unilateral headache and nausea/vomiting (N/V) with vision changes), and no prior symptoms of dizziness?

Management of Atypical Dizziness with Headache and Nausea in a 58-Year-Old Female

This patient requires observation with close monitoring and consideration for admission, as her atypical presentation—dizziness without true vertigo, bilateral facial paresthesias, and frontal headache differing from her typical migraine pattern—raises concern for a central process despite negative initial imaging. 1

Critical Assessment of This Atypical Presentation

This is NOT a typical migraine attack based on several red flags:

• No true vertigo (room spinning): The patient describes "dizziness, lightheaded and some imbalance" but explicitly denies room spinning, which is the hallmark of vestibular migraine 1
• Bilateral facial paresthesias: This is a nonlocalizing neurologic symptom that does not fit typical migraine aura patterns 1
• Frontal headache pattern: Her typical migraines are unilateral with vision changes, but this headache is frontal without her usual visual symptoms 1
• New symptom of dizziness: She has never had dizziness with her migraines before, making this a change in her established pattern 1
• Progressive worsening over 2 hours: This evolution pattern warrants heightened vigilance 1

Why Standard Migraine Treatment Should NOT Be the Primary Approach

Despite negative CT, CTA, and MRI, the atypical features make this a "red flag" presentation requiring extended observation rather than routine migraine treatment and discharge. 1

The American Academy of Otolaryngology-Head and Neck Surgery emphasizes that vestibular migraine requires ≥5 episodes of vestibular symptoms lasting 5 minutes to 72 hours with ≥1 migraine symptom during at least 50% of dizzy episodes 1. This patient has never had dizziness with her migraines, making vestibular migraine an unlikely diagnosis on first presentation.

The American Academy of Otolaryngology-Head and Neck Surgery guidelines specifically state that stroke/ischemia can present with vertigo lasting minutes with nausea, vomiting, and severe imbalance, and may be comorbid with other neurologic symptoms 1. While her imaging is negative, the bilateral facial paresthesias and atypical presentation warrant caution.

Recommended Management Algorithm

Immediate Actions (Emergency Department)

• Admit for observation or place in extended ED observation unit for 24-48 hours given atypical features and progressive symptoms 1
• Repeat neurologic examination every 4-6 hours to detect any evolving focal deficits 1
• Symptomatic treatment with antiemetics: Metoclopramide 10 mg IV or prochlorperazine 10 mg IV for nausea 2, 3
• Consider ketorolac 30 mg IV for headache relief if no contraindications (renal impairment, GI bleeding history) 2, 3

Avoid Premature Migraine-Specific Treatment

Do NOT administer triptans at this stage because:

• This does not meet criteria for definite migraine given the atypical features 1
• Triptans are contraindicated if there is any possibility of stroke or vascular pathology 1, 2
• The bilateral facial paresthesias and new dizziness pattern require exclusion of central causes first 1

Extended Evaluation During Observation

• MRI with diffusion-weighted imaging (DWI) if not already performed, as early stroke may not appear on initial CT 1
• Vestibular function testing if symptoms persist, to differentiate peripheral from central causes 1
• Consider MRA or CTA of neck vessels if not already done, given age and vascular risk factors 1
• Cardiology consultation if any suggestion of cardiac source for embolic phenomena 1

If Symptoms Resolve and Central Causes Are Excluded

Only after 24-48 hours of observation with stable/improving symptoms and no new neurologic findings should migraine treatment be considered:

• NSAIDs as first-line: Naproxen 500-825 mg orally for future episodes 2, 3
• Triptans as second-line: Sumatriptan 50-100 mg orally for moderate-to-severe attacks 2, 3
• Antiemetics as adjunct: Metoclopramide 10 mg orally 20-30 minutes before analgesics 2, 3
• Limit acute medication use to no more than 2 days per week to prevent medication-overuse headache 1, 2

Critical Pitfalls to Avoid

The most dangerous error would be to diagnose this as "atypical migraine" and discharge with triptans without adequate observation, given:

• The American Academy of Family Physicians states that headache with atypical features or not meeting strict migraine definition warrants a lower threshold for neuroimaging and extended evaluation 1
• The American Academy of Otolaryngology-Head and Neck Surgery emphasizes that elderly patients with new-onset symptoms require thorough evaluation for stroke, particularly with bilateral symptoms 1
• Posterior circulation strokes can present with isolated dizziness and headache and may have delayed imaging findings 1

Do not be falsely reassured by negative initial imaging—the American Academy of Neurology notes that early MRI may miss small posterior circulation infarcts, and clinical vigilance remains paramount 1.

Disposition Decision

Admit or observe for 24-48 hours if any of the following persist:

• Bilateral facial paresthesias 1
• Progressive symptoms 1
• Inability to ambulate safely 1
• Persistent nausea preventing oral intake 2

Discharge is appropriate only if:

• Complete resolution of dizziness and paresthesias 1
• Normal serial neurologic examinations 1
• Able to tolerate oral intake 2
• Reliable follow-up within 24-48 hours with neurology 1