What is the best management approach for a patient with vertiginous mild dizziness and brain fog, with a negative Dix-Hallpike test, no orthostatic hypotension, and no hearing or ear changes?

Management of Vertiginous Mild Dizziness with Brain Fog and Negative Dix-Hallpike

This patient most likely has vestibular migraine and should be started on lifestyle modifications immediately, with beta blockers (propranolol, metoprolol, or atenolol) or topiramate as first-line preventive therapy if symptoms occur ≥2 days per month. 1

Diagnostic Approach

The negative Dix-Hallpike test effectively rules out posterior canal BPPV, though it has a negative predictive value of only 52% in primary care settings, meaning the test may need repeating at a separate visit if suspicion remains high. 2 However, given the presence of brain fog (a non-specific cognitive symptom) alongside vertiginous dizziness without positional triggers, BPPV is unlikely. 2

Vestibular migraine is the most probable diagnosis based on:

• Vertiginous symptoms without clear positional triggers 1
• Brain fog (consistent with migraine-associated cognitive dysfunction) 1
• Absence of hearing changes (excludes Ménière's disease) 2
• No orthostatic hypotension (excludes presyncope) 3
• Otherwise well (no red flags for central pathology) 1

Vestibular migraine has a lifetime prevalence of 3.2% and accounts for up to 14% of vertigo cases. 1 The diagnostic criteria require ≥5 episodes of vestibular symptoms lasting 5 minutes to 72 hours. 1

Immediate Management Strategy

First-Line: Lifestyle Modifications

Implement these dietary and lifestyle changes immediately: 1, 4

• Limit salt/sodium intake
• Avoid excessive caffeine, alcohol, and nicotine
• Eat well-balanced meals with adequate hydration
• Establish regular sleep patterns (critical for migraine control)
• Implement stress management techniques
• Begin regular exercise program
• Identify and manage potential triggers

Pharmacological Treatment Decision Algorithm

If symptoms occur ≥2 days per month despite lifestyle modifications, initiate preventive medication: 1

First-line preventive options (choose one): 1

• Beta blockers: Propranolol, metoprolol, atenolol, or bisoprolol (particularly beneficial if comorbid hypertension exists)
• Topiramate: 50-100 mg oral daily (especially beneficial if patient is obese)
• Candesartan: Angiotensin receptor blocker option

Assess efficacy after 2-3 months at therapeutic dose. 1, 4 Do not abandon treatment prematurely—efficacy takes weeks to months to establish. 1, 4

If first-line agents fail, escalate to second-line: 1

• Flunarizine: 5-10 mg oral once daily (avoid in Parkinsonism or depression)
• Amitriptyline: 10-100 mg oral at night OR nortriptyline (particularly useful if coexisting anxiety or depression)

For refractory cases after first- and second-line failure, consider third-line: 1

• CGRP monoclonal antibodies: Erenumab 70-140 mg subcutaneous monthly, fremanezab 225 mg monthly or 675 mg quarterly, or eptinezumab 100-300 mg IV quarterly (assess efficacy after 3-6 months)
• OnabotulinumtoxinA: 155-195 units every 12 weeks for chronic migraine with vestibular symptoms (assess efficacy after 6-9 months)

Acute Symptom Management

For acute attacks: 1, 4, 5

• Vestibular suppressants (meclizine, diphenhydramine) for acute attacks only—not for long-term management 4, 5
• Antiemetics to ameliorate nausea during attacks 1
• Triptans if concurrent headache present 1

Avoid centrally acting anticholinergics like scopolamine due to significant side effects, and limit benzodiazepines due to drug dependence risk. 4

Vestibular Rehabilitation Therapy

Implement VRT regardless of etiology, as it promotes central compensation: 4, 6

• Progressive exercises focusing on habituation, adaptation, and compensation for vestibular deficits 4
• Cawthorne-Cooksey exercises performed until symptoms fatigue 4
• Home-based therapy is equally effective as clinician-supervised therapy 4
• Combining VRT with cognitive behavioral therapy (CBT) improves outcomes, particularly for anxiety reduction and avoidance behaviors 6, 7, 8

Reassessment Timeline

Reassess within 1 month to confirm symptom resolution or identify treatment failure. 2 At reassessment: 2, 4

• Determine if vertigo is provoked by positional changes (suggests persistent BPPV requiring repeat Dix-Hallpike)
• Screen for coexisting vestibular conditions
• Rule out central causes if symptoms persist or worsen (stroke, multiple sclerosis) 1, 4

Critical Pitfalls to Avoid

• Do not use oral ergot alkaloids, opioids, or barbiturates—questionable efficacy with considerable adverse effects and dependency risk 1, 4
• Avoid prolonged vestibular suppressant use—impairs central compensation and not recommended for long-term management 4
• Do not overuse acute medications—risks medication overuse headache 1, 4
• Do not assume treatment failure with one agent predicts failure of other drug classes—failure of one preventive treatment does not predict failure of others 1, 4
• Screen for and treat comorbid anxiety, depression, and sleep disturbances—these worsen vertigo and require concurrent treatment 4, 7
• Avoid imaging in typical presentations—radiographic imaging not indicated unless diagnosis uncertain or additional symptoms suggest central pathology 4

If Symptoms Persist After Initial Management

If symptoms fail to resolve after 1 month of appropriate treatment: 2, 4

• Repeat Dix-Hallpike to exclude persistent or converted BPPV
• Escalate preventive medication to next tier
• Intensify VRT with formal vestibular rehabilitation program
• Consider referral to neurology or otolaryngology for refractory cases
• Reevaluate for alternative diagnoses including Ménière's disease (though hearing changes would be expected) or central pathology 2, 4

Consider pausing preventive treatment after 6-12 months of successful control to determine if therapy can be stopped. 1, 4