What could be causing my mid-front forehead pain, intermittent dizziness, feeling uncoordinated, sluggishness, occasional nausea, and slowed reaction time, especially when symptoms worsen in the morning?

Differential Diagnosis and Evaluation

Your symptom constellation—mid-frontal headache worse in the morning, intermittent dizziness, incoordination, sluggishness, occasional nausea, and slowed reaction time—most strongly suggests vestibular migraine or chronic migraine, though several other conditions must be systematically excluded.

Primary Diagnostic Considerations

Vestibular Migraine (Most Likely)

Vestibular migraine should be your primary diagnostic consideration given the combination of headache with dizziness, nausea, and cognitive symptoms. 1

• The frontal headache location, morning worsening, and associated dizziness with nausea are characteristic features 1, 2
• Vestibular migraine causes episodic vertigo/dizziness lasting minutes to hours, often accompanied by headache, photophobia, or phonophobia 1
• The "sluggishness" and slowed reaction time you describe align with the cognitive dysfunction commonly reported in migraine 3
• Morning worsening is typical of migraine, particularly when sleep disturbances or medication overuse are present 1

Medication Overuse Headache

• If you are using pain relievers (over-the-counter or prescription) more than twice weekly, medication overuse headache becomes a critical consideration 1
• This condition causes increasing headache frequency, often progressing to daily headaches with associated symptoms like dizziness and cognitive slowing 1
• Analgesics containing butalbital, caffeine, opiates, or even NSAIDs and triptans can cause this pattern 1

Tension-Type Headache with Comorbid Vestibular Dysfunction

• Tension-type headache typically presents as bilateral, band-like frontal-to-occipital pain described as pressure or tightness 4
• However, pure tension-type headache should NOT cause dizziness, nausea, or significant cognitive symptoms 4
• The presence of dizziness and nausea makes this diagnosis less likely as the sole explanation 5

Critical Red Flags to Exclude Immediately

You must urgently evaluate for these dangerous conditions: 5, 6

• Focal neurological deficits (weakness, numbness, vision changes, speech difficulties)
• Sudden severe headache (thunderclap onset suggesting subarachnoid hemorrhage)
• Progressive worsening over days to weeks (suggesting mass lesion or increased intracranial pressure)
• New headache after age 50 (increased risk of temporal arteritis or secondary causes)
• Inability to stand or walk (suggesting cerebellar or brainstem pathology)
• Fever with headache (meningitis or encephalitis)

Specific Evaluation Steps

History Details You Must Clarify

Duration and timing: 5, 6

• Are dizzy episodes brief (seconds = BPPV) or prolonged (minutes to hours = vestibular migraine or Ménière's)? 5
• Is dizziness constant or episodic? 5
• Does head position trigger dizziness? 5

Associated symptoms: 1, 5

• Hearing loss, tinnitus, or ear fullness? (suggests Ménière's disease) 1, 5
• Photophobia or phonophobia? (supports vestibular migraine) 1
• True spinning vertigo versus lightheadedness? 5

Medication use: 1, 6

• Frequency of pain reliever use (critical for identifying medication overuse) 1
• Antihypertensives, sedatives, or anticonvulsants (common causes of chronic dizziness) 6

Physical Examination

Perform these specific maneuvers: 5, 6

• Dix-Hallpike maneuver to assess for BPPV (brief positional vertigo) 5
• Complete neurological examination including cranial nerves, coordination, gait, and Romberg test 5
• Otoscopic examination to exclude middle ear pathology 5

Diagnostic Testing

Imaging is NOT routinely indicated unless red flags are present 6

• No imaging needed if examination is normal and symptoms fit vestibular migraine pattern 6
• MRI brain without contrast is preferred over CT if imaging becomes necessary (CT has <1% diagnostic yield for isolated dizziness) 6
• Consider MRI only if: progressive symptoms, abnormal neurological exam, age >50 with new headache, or failure to respond to appropriate treatment 6

Laboratory testing: 5

• Only order if specific concerns exist (thyroid dysfunction, infection, electrolyte abnormalities) 5
• Not routinely needed for typical vestibular migraine presentation 5

Treatment Approach

Acute Management

For acute headache attacks: 1, 3

• First-line: NSAIDs (ibuprofen, naproxen sodium, or aspirin) 1
• Second-line: Triptans if NSAIDs fail (oral sumatriptan, rizatriptan, or zolmitriptan eliminate pain in 20-30% by 2 hours) 1, 3
• Contraindications to triptans: cardiovascular disease, uncontrolled hypertension, basilar or hemiplegic migraine 1, 7
• Treat nausea directly with antiemetics like metoclopramide, not just when vomiting occurs 1

Critical limitation: Use acute medications no more than twice weekly to prevent medication overuse headache 1

Preventive Therapy Indications

You should initiate preventive therapy if: 1

• Two or more attacks per month causing disability lasting ≥3 days 1
• Using acute medications more than twice weekly 1
• Contraindication to or failure of acute treatments 1

First-line preventive agents: 1

• Propranolol 80-240 mg/day 1
• Amitriptyline 30-150 mg/day (particularly effective if concurrent tension-type features) 1
• Divalproex sodium 500-1500 mg/day 1
• Topiramate (FDA-approved for migraine prevention) 1

Allow 2-3 months for preventive medications to demonstrate full benefit 1

Common Pitfalls to Avoid

Do not: 1, 5, 6

• Rely solely on patient's description of "dizziness" without clarifying exact timing, triggers, and associated symptoms 5, 6
• Assume normal neurological exam excludes stroke (75-80% of posterior circulation strokes have no focal deficits) 6
• Order routine imaging for typical vestibular migraine presentation 6
• Allow frequent use of acute medications (>2 days/week) without initiating preventive therapy 1
• Dismiss cognitive symptoms as unrelated—they are part of the migraine syndrome 3

Do: 1, 5

• Perform Dix-Hallpike maneuver in all patients with positional dizziness 5
• Directly ask about medication frequency to identify overuse 1
• Educate about realistic treatment expectations and the 2-3 month timeline for preventive therapy 1
• Consider psychiatric comorbidities (anxiety, depression) which commonly accompany chronic dizziness 6