What is the management approach for a patient presenting with acute onset headache and dizziness?

Management of Acute Onset Headache with Dizziness

Acute onset headache with dizziness requires immediate evaluation to exclude life-threatening conditions, particularly subarachnoid hemorrhage (SAH) and posterior circulation stroke, before considering benign causes like migraine with brainstem aura or vestibular disorders. 1

Immediate Risk Stratification

Red Flags Requiring Urgent Workup

The presence of any of the following mandates immediate neuroimaging and potential neurosurgical consultation:

• Thunderclap headache (pain reaching maximal intensity within seconds to 1 minute) 1
• Age ≥40 years at onset 2
• Witnessed loss of consciousness 2
• Onset during exertion 2
• Neck pain or stiffness 2
• Limited neck flexion on examination 2
• New neurological deficit (focal weakness, ataxia, dysarthria, altered consciousness) 1

Critical Diagnostic Algorithm

For patients presenting >6 hours from symptom onset OR with any neurological deficit:

• Obtain noncontrast head CT immediately 1
• If CT is negative but clinical suspicion remains high, perform lumbar puncture with CSF analysis for xanthochromia (ideally >12 hours from onset) 1
• If SAH is confirmed, obtain urgent neurosurgical consultation and consider digital subtraction angiography (DSA) to identify aneurysm 1

For patients presenting <6 hours from symptom onset WITHOUT neurological deficit:

• High-quality noncontrast CT interpreted by experienced neuroradiologist may be sufficient to exclude SAH 1
• If CT unavailable or read by non-neuroradiologist, proceed with lumbar puncture if clinical suspicion persists 1

Distinguishing Stroke from Benign Vestibular Causes

When dizziness accompanies acute headache, the timing pattern guides diagnosis 3:

Acute Vestibular Syndrome (continuous symptoms >24 hours)

Bedside examination differentiates posterior circulation stroke from vestibular neuritis:

• Perform HINTS examination (Head Impulse, Nystagmus, Test of Skew) 3
• Stroke indicators: normal head impulse test, direction-changing nystagmus, or skew deviation 3
• Vestibular neuritis indicators: abnormal head impulse test, unidirectional horizontal nystagmus, no skew deviation 3
• Posterior circulation stroke carries high mortality risk and requires immediate neurology consultation 4

Episodic Vestibular Syndrome (recurrent brief episodes)

For spontaneous episodes:

• Consider vestibular migraine if accompanied by photophobia, phonophobia, or visual aura 3
• Consider transient ischemic attack if vascular risk factors present or episodes last <1 hour 3

For triggered episodes (positional):

• Perform Dix-Hallpike maneuver to diagnose benign paroxysmal positional vertigo 3
• If negative but suspicion high, consider posterior fossa structural lesion 3

Management Based on Etiology

If SAH Confirmed

• Transfer immediately to tertiary center with neurosurgical expertise 1
• Start nimodipine (60 mg every 4 hours orally) within 96 hours if adequate blood pressure 1
• Secure aneurysm urgently (within 24-72 hours) via endovascular coiling or surgical clipping 1
• Mortality exceeds 40% at 30 days without prompt intervention 1

If Migraine with Brainstem Aura Suspected

Diagnosis requires 1:

• At least two attacks with fully reversible brainstem symptoms (vertigo, dysarthria, tinnitus, diplopia)
• Visual, sensory, or speech aura symptoms
• Each aura symptom lasting 5-60 minutes
• Headache accompanying or following aura within 60 minutes

Acute treatment:

• NSAIDs (naproxen 500-825 mg, ibuprofen 400-800 mg) as first-line for mild-moderate attacks 5, 6
• Triptans are contraindicated in basilar-type migraine due to vasoconstriction risk in posterior circulation 1
• Antiemetics (metoclopramide 10 mg IV or prochlorperazine 10 mg IV) for nausea and synergistic analgesia 5
• Ketorolac 30 mg IV for severe attacks requiring parenteral therapy 5

If Posterior Circulation Stroke Confirmed

• Immediate neurology consultation 4
• Lesion enlargement occurs in 54% of cases and significantly increases mortality 4
• Monitor for acute brain failure, which occurs in 96% of stroke patients with initial dizziness 4
• 30-day mortality approaches 64% in patients with acute dizziness from stroke 4

Critical Pitfalls to Avoid

Do not rely on symptom quality alone (vertigo vs. lightheadedness) to differentiate benign from dangerous causes—this traditional approach is inconsistent with current evidence and leads to frequent misdiagnosis 3

Do not assume young age excludes SAH—while age ≥40 increases risk, SAH occurs across all adult age groups 2

Do not discharge patients with persistent neurological findings even if initial CT is negative—posterior circulation strokes may not appear on early CT and require MRI with diffusion-weighted imaging 3

Do not use opioids for headache management—they increase risk of medication-overuse headache, dependency, and do not address underlying pathology 5, 6

Limit acute headache medications to ≤2 days per week to prevent medication-overuse headache, which can transform episodic migraine into chronic daily headache 5, 6