What's the next step for a patient with persistent dizziness, neck tension, and temple pain for 6 weeks, despite treatment with Medrol (methylprednisolone) dose pack, tizanidine, and meclizine, with normal lab results, normal computed tomography (CT) brain scan, and pending magnetic resonance imaging (MRI) results?

Next Steps for Persistent Dizziness with Neck Tension

Await the pending MRI brain without contrast, as this is the appropriate imaging modality for your presentation, and immediately refer to neurology for comprehensive vestibular examination including HINTS testing and evaluation for cervicogenic dizziness or vestibular migraine. 1, 2

Why Your Current Treatments Haven't Worked

Your symptom pattern—persistent dizziness for 6 weeks with neck tension, skull base pain, and temple tension—does not fit typical benign paroxysmal positional vertigo (BPPV), which explains why the treatments failed:

• Meclizine is ineffective for most causes of persistent dizziness and should not be continued beyond acute vestibular neuritis (typically resolves in days to weeks). 2, 3
• Medrol (methylprednisolone) dose pack is only indicated for acute vestibular neuritis within the first 72 hours of symptom onset, not for 6-week persistent symptoms. 3
• Tizanidine may help neck muscle tension but does not address the underlying vestibular or neurological cause of your dizziness. 4

Critical Next Steps

1. Complete the MRI Brain Without Contrast

• MRI is essential because CT brain (which you already had) has only 20-40% sensitivity for detecting posterior circulation pathology and misses most causes of persistent dizziness. 1, 5
• MRI with diffusion-weighted imaging has a diagnostic yield of 4-12% in persistent dizziness cases and is far superior to CT for detecting posterior circulation infarcts, which account for 70% of stroke-related dizziness. 1, 6
• Your normal CT does not exclude serious neurological causes. 2, 5

2. Urgent Neurology Referral for Specialized Examination

You need a trained specialist to perform:

• HINTS examination (Head Impulse, Nystagmus, Test of Skew), which has 100% sensitivity for detecting posterior circulation stroke when performed by trained practitioners—more sensitive than early MRI. 1, 2
• Dix-Hallpike maneuver and supine roll test to definitively rule out BPPV, as lack of response to treatment suggests either incorrect diagnosis or atypical presentation. 1, 5
• Assessment for central nystagmus patterns (downbeating, direction-changing without head position changes) that indicate central nervous system pathology. 2, 5

3. Consider Alternative Diagnoses Based on Your Symptom Pattern

Your constellation of symptoms—neck tension, skull base pain, temple tension, and persistent dizziness—suggests several possibilities:

Vestibular Migraine

• Characterized by dizziness with headache, photophobia, phonophobia, and temple/neck tension. 1, 2
• Requires migraine prophylaxis and lifestyle modifications, not vestibular suppressants. 2, 5

Cervicogenic Dizziness

• Associated with neck pain, decreased cervical range of motion, and gradual onset of symptoms. 7
• Patients with concurrent neck pain and dizziness have more severe symptoms, visual disturbances, and decreased neck flexibility compared to those with dizziness alone. 7
• May benefit from physical therapy targeting cervical dysfunction rather than medications. 7

Spontaneous Intracranial Hypotension (SIH)

• Can present with non-orthostatic headaches, dizziness, neck pain, and skull base symptoms. 1
• MRI findings include diffuse dural and leptomeningeal enhancement. 1
• This is a critical diagnosis not to miss, as it can lead to serious complications including cerebral venous thrombosis. 1

Posterior Circulation Insufficiency

• Can cause persistent dizziness with neck pain and temple tension, especially if vascular risk factors are present. 1, 2
• Requires MRA or CTA of head and neck if MRI brain shows concerning findings. 1

What to Stop Doing

• Discontinue meclizine immediately unless you have acute vestibular neuritis (which would have resolved by now). Vestibular suppressants impede natural compensation and prolong recovery. 2, 5, 3
• Do not pursue additional CT imaging, as it has less than 1% diagnostic yield for isolated dizziness. 1, 5, 8
• Avoid benzodiazepines if offered, as they impede vestibular compensation. 5

Red Flags Requiring Immediate Emergency Evaluation

If you develop any of the following before your MRI, go to the emergency department immediately:

• New severe headache different from your current symptoms. 1, 2
• Focal neurological deficits (weakness, numbness, vision changes, speech difficulties). 1, 2
• Sudden hearing loss. 1, 2
• Inability to stand or walk. 2, 5
• New or worsening right-sided weakness or other asymmetric neurological symptoms. 1

Common Pitfalls to Avoid

• Do not assume your normal neurologic exam rules out stroke—75-80% of patients with posterior circulation infarcts have no focal neurologic deficits. 1, 2
• Do not rely on describing your dizziness as "spinning" versus "off-balance"—timing, triggers, and associated symptoms are more diagnostically valuable. 1, 2
• Do not accept reassurance based solely on normal CT and labs—your symptom duration (6 weeks) and treatment failure mandate further investigation. 1, 5

Specific Management Algorithm

1. Complete pending MRI brain without contrast within the next few days. 1, 6
2. See neurology urgently (within 1 week) for HINTS examination and vestibular assessment. 1, 2
3. If MRI shows dural enhancement, consider spontaneous intracranial hypotension and may need epidural blood patch. 1
4. If HINTS suggests central cause, may need MRA/CTA of head and neck. 1
5. If vestibular migraine is diagnosed, start migraine prophylaxis (not vestibular suppressants). 2, 5
6. If cervicogenic dizziness is confirmed, refer to physical therapy specializing in vestibular rehabilitation. 7