What is the appropriate evaluation and management for a 36-year-old male presenting with dizziness, decreased sleep, and headache?

Evaluation and Management of a 36-Year-Old Male with Dizziness, Decreased Sleep, and Headache

This patient requires immediate systematic evaluation focusing on timing and triggers of dizziness, headache red flags, and sleep pattern assessment to differentiate between benign peripheral vestibular disorders, vestibular migraine, and potentially life-threatening central pathology.

Initial Diagnostic Approach

Characterize the Dizziness by Timing and Triggers

• Focus on duration and triggers rather than vague descriptions like "spinning" or "lightheadedness," as patients cannot reliably describe quality but can identify timing 1, 2
• Brief episodic vertigo (seconds to minutes) triggered by head position changes suggests benign paroxysmal positional vertigo (BPPV) 1, 3
• Spontaneous episodic vertigo (minutes to hours) with headache, photophobia, and phonophobia strongly suggests vestibular migraine 1, 3
• Acute persistent vertigo (days to weeks) requires urgent differentiation between vestibular neuritis and posterior circulation stroke, as 75-80% of posterior circulation strokes present without focal neurologic deficits 1, 2

Assess for Headache Red Flags

New severe headache accompanying dizziness mandates immediate imaging and neurologic consultation to exclude hemorrhage, dissection, or posterior fossa pathology 1, 2. Additional concerning features include:

• Headache worsened by Valsalva maneuver, awakening from sleep, or progressively worsening warrants neuroimaging 4
• Headache with focal neurological deficits, diplopia, dysarthria, facial numbness, or limb weakness indicates central pathology requiring urgent MRI 2
• Unilateral or pulsatile tinnitus requires neuroimaging to exclude cerebellopontine angle tumors or vascular malformations 1, 2

Evaluate Sleep Disturbance

• Assess for medication-induced sleep disruption, particularly if the patient takes diuretics, sympathomimetics, bronchodilators, stimulating antidepressants, anti-Parkinsonian agents, antihypertensives, or cholinesterase inhibitors 4
• Screen for psychiatric comorbidities including anxiety, panic disorder, and depression, which commonly cause both chronic dizziness and sleep disturbance 4, 5
• Inquire about sleep hygiene, caffeine intake, regular meals, hydration, and stress management 4

Physical Examination

Mandatory Bedside Testing

• Perform the Dix-Hallpike maneuver immediately if brief episodic vertigo is present, looking for latency of 5-20 seconds, torsional upbeating nystagmus toward the affected ear, and symptoms resolving within 60 seconds 1, 3
• Conduct full neurologic examination specifically assessing for focal deficits, as their absence does not exclude posterior circulation stroke 2
• Assess nystagmus patterns: downbeating nystagmus or direction-changing nystagmus without head position change indicates central pathology 3, 2
• Test gait and balance: inability to stand or walk independently requires urgent evaluation 1, 2
• Measure orthostatic blood pressures to evaluate for presyncope 5, 6

HINTS Examination (If Acute Persistent Vertigo Present)

The HINTS examination (Head Impulse, Nystagmus, Test of Skew) has 100% sensitivity for detecting posterior circulation stroke when performed by trained practitioners, superior to early MRI (46% sensitivity) 1, 2. However, results are less reliable when performed by non-experts 1.

Imaging Decisions

When Imaging Is NOT Indicated

• Brief episodic vertigo with typical BPPV features and positive Dix-Hallpike test requires no imaging 1, 3
• Spontaneous episodic vertigo consistent with vestibular migraine (headache, photophobia, phonophobia, family history) requires no imaging 1, 3
• Acute persistent vertigo with normal neurologic exam and peripheral HINTS findings by trained examiner requires no imaging 1

When MRI Brain Without Contrast Is Required

• High vascular risk patients with acute vestibular syndrome even with reassuring bedside examination 1, 2
• Abnormal neurologic examination or HINTS suggesting central cause 1
• New severe headache accompanying dizziness 1, 2
• Unilateral or pulsatile tinnitus 1, 2
• Sudden unilateral hearing loss 2
• Failure to respond to appropriate vestibular treatments 1, 2

Critical pitfall: CT head has only 20-40% sensitivity for causative pathology in dizziness and misses many posterior circulation infarcts 2. CT should not be used instead of MRI when stroke is suspected 1, 2.

Management Based on Diagnosis

If BPPV Confirmed

• Perform canalith repositioning procedures (Epley maneuver) as first-line treatment with 90-98% success rates 1, 3
• No medications or imaging needed for typical BPPV 1
• Reassess within one month to document resolution or persistence 1

If Vestibular Migraine Suspected

• Initiate migraine preventative medications early, as they take 3-4 months to reach maximal efficacy 4
• Tailor acute therapy to headache phenotype: triptans combined with NSAIDs or acetaminophen plus antiemetic for migrainous attacks, limited to 2 days per week to avoid medication overuse headache 4
• Implement lifestyle modifications: limit caffeine, ensure regular meals and hydration, establish sleep hygiene, and consider behavioral techniques like cognitive-behavioral therapy 4
• Avoid opioids, which should not be prescribed for headaches 4

Sleep Management

• Address medication-induced sleep disruption by reviewing and adjusting timing or choice of medications 4
• Treat underlying psychiatric conditions if anxiety or depression identified 4
• Implement sleep hygiene measures including regular sleep-wake schedule, limiting caffeine, and stress management 4

Critical Pitfalls to Avoid

• Do not rely on patient's description of "spinning" versus "lightheadedness"—focus on timing and triggers instead 1, 2
• Do not assume normal neurologic exam excludes stroke—75-80% of posterior circulation strokes have no focal deficits 1, 2
• Do not order routine imaging for isolated dizziness with typical peripheral features—diagnostic yield is extremely low (<1% for CT) 1, 2
• Do not use CT instead of MRI when stroke is suspected—CT misses most posterior circulation infarcts 1, 2
• Do not prescribe opioids for headache management—they lead to dependency and medication overuse headache 4
• Warn patients about medication overuse headache risk (simple analgesics >15 days/month or triptans >10 days/month for >3 months) 4