What is the treatment for a patient presenting with headache and vertigo?

Treatment of Headache Plus Vertigo

The treatment approach depends critically on distinguishing between benign paroxysmal positional vertigo (BPPV), vestibular migraine, and central causes—with physical repositioning maneuvers for BPPV, migraine-specific therapy for vestibular migraine, and urgent neuroimaging with stroke protocols for suspected central pathology. 1, 2

Initial Clinical Assessment and Risk Stratification

The first priority is determining whether this represents a peripheral vestibular disorder, vestibular migraine, or a dangerous central cause requiring immediate intervention:

• Perform the Dix-Hallpike maneuver to identify BPPV, looking for characteristic torsional upbeating nystagmus triggered by specific head positions 1, 2
• Apply the HINTS examination (Head Impulse, Nystagmus, Test of Skew) if acute vestibular syndrome is present—a normal head impulse test, direction-changing nystagmus, or skew deviation suggests central pathology and requires urgent imaging 3, 2
• Assess for red flags including focal neurological deficits, atypical nystagmus patterns, severe headache of sudden onset, or failure to improve with initial treatment—any of these mandate brain imaging 1, 3, 2

Treatment for BPPV (Triggered Episodic Vertigo)

When the Dix-Hallpike test is positive with typical nystagmus:

• Perform the Epley maneuver as first-line treatment, which has a 90-98% success rate when performed correctly 2
• Avoid vestibular suppressants (antihistamines like meclizine or benzodiazepines) as primary treatment—these medications are not effective for BPPV and may interfere with central compensation 1
• Reserve meclizine only for short-term management of severe nausea or vomiting in highly symptomatic patients who cannot tolerate repositioning maneuvers 1, 4
• Reassess within 1 month to confirm symptom resolution, as failure to respond suggests either incorrect diagnosis (including central causes mimicking BPPV in 1-3% of cases) or need for repeat maneuvers 1

Treatment for Vestibular Migraine

When headache accompanies vertigo with migrainous features (photophobia, phonophobia, visual aura, or triggers like stress, sleep deprivation, hormonal changes):

• For acute attacks: Use NSAIDs as first-line therapy (aspirin, ibuprofen, naproxen sodium, or acetaminophen-aspirin-caffeine combination) 1
• For migraine-specific therapy: Consider triptans (sumatriptan, rizatriptan, zolmitriptan, naratriptan) when NSAIDs fail, but avoid in patients with uncontrolled hypertension, basilar migraine, or cardiovascular risk 1
• Treat associated nausea with antiemetics via nonoral routes when nausea presents early 1
• Consider preventive therapy if attacks occur ≥2 times per month with ≥3 days of disability, or if rescue medication is needed more than twice weekly 1
• Limit acute treatment to no more than twice weekly to prevent medication-overuse headaches 1

Neuroimaging Indications

Brain imaging is critical when central pathology is suspected:

• Order MRI with diffusion-weighted imaging (DWI) as the preferred modality for detecting posterior circulation strokes, masses, inflammatory processes, and demyelinating disease—superior to CT for soft tissue resolution 3, 2
• Use CT as rapid screening only when MRI is unavailable, recognizing it detects acute lesions in only 6% of central positional vertigo cases 3
• Image immediately for focal neurological deficits (up to 11% have acute brain infarcts), atypical Dix-Hallpike findings, failure to respond to repositioning maneuvers, elderly patients, post-traumatic onset in young patients, or short-term symptom recurrence 1, 3, 2

Special Considerations

Vertebral artery dissection may present with headache, neck pain, and vertigo—particularly after sudden neck movements—and requires vascular imaging (CTA or MRA) followed by anticoagulation as conservative management 1

Avoid imaging in typical BPPV with positive Dix-Hallpike test and characteristic nystagmus, as imaging adds no value 1, 2

Do not discharge patients with persistent symptoms after initial treatment without reassessment, as 1-3% of presumed BPPV cases are actually central nervous system lesions 1