What could be causing my episodic vertigo, nausea, and tinnitus with negative physical exam findings?

Likely Diagnosis: Ménière's Disease or Vestibular Migraine

Based on your episodic vertigo (room spinning lasting hours), bilateral tinnitus, nausea, and negative physical exam, you most likely have either Ménière's disease or vestibular migraine—both require urgent ENT/neurology evaluation to confirm diagnosis and initiate treatment. 1, 2

Why This Is NOT Benign Paroxysmal Positional Vertigo (BPPV)

Your presentation is inconsistent with BPPV for several critical reasons:

• Duration mismatch: BPPV causes vertigo lasting less than 1 minute, not the hours-long episodes you describe at 9 am and 4 am 3
• Trigger pattern: BPPV is provoked by specific head position changes (rolling over in bed, looking up, bending forward), not spontaneous onset while presumably stationary 3
• Tinnitus presence: Bilateral tinnitus is not a feature of BPPV, which is purely a mechanical inner ear crystal problem without auditory symptoms 3
• Negative exam: While one-third of atypical BPPV cases may still show positive Dix-Hallpike testing, your completely negative exam combined with tinnitus makes BPPV extremely unlikely 3

Most Likely Diagnoses

Ménière's Disease (Primary Consideration)

This is the most probable diagnosis given your symptom constellation:

• Classic triad present: Episodic vertigo (lasting hours), tinnitus, and presumed fluctuating hearing (though you didn't mention hearing loss, it may be subclinical early on) 1
• Episode duration: Ménière's attacks typically last 20 minutes to several hours, matching your 9 am and 4 am episodes 1
• Bilateral tinnitus: While Ménière's classically affects one ear initially, bilateral involvement occurs in up to 30-40% of cases over time 3
• Spontaneous onset: Episodes occur without positional triggers, consistent with your presentation 1

Vestibular Migraine (Strong Alternative)

This remains a significant possibility:

• Diagnostic criteria: Requires ≥5 episodes of vestibular symptoms lasting 5 minutes to 72 hours, with migraine features during ≥50% of episodes 3
• Prevalence: Accounts for up to 14% of vertigo cases and may present without headache in some instances 3
• Associated features to assess: Ask yourself about photophobia, phonophobia, visual aura, or headache during or after these episodes 3, 4
• Lifetime prevalence: 3.2% in general population, making it very common 3

Red Flags You Must Rule Out Immediately

You need urgent evaluation if ANY of these develop 2:

• Speech difficulties (dysarthria/dysphasia) suggesting stroke 2
• Difficulty swallowing (dysphagia) indicating brainstem involvement 2
• Visual disturbances beyond typical migraine aura 2
• Weakness or numbness in limbs (motor/sensory deficits) 2
• Severe imbalance disproportionate to vertigo (inability to stand/walk) 2
• New-onset severe occipital headache 2
• Symptoms persisting >24 hours without any improvement 1, 2

Why Imaging Is NOT Indicated Yet

• ACR guidelines: Imaging is not recommended for typical episodic vertigo with normal neurologic exam and no red flags 3
• BPPV context: Even if this were BPPV with typical Dix-Hallpike findings, imaging would be unnecessary 3
• Cost-effectiveness: CT detection rate for CNS pathology in vertigo with normal exam is <1% 3
• Exception: MRI would be indicated if you develop focal neurologic deficits or if symptoms suggest central vertigo 3, 5

Immediate Next Steps

Required Evaluations

1. Comprehensive audiometry: Essential to document hearing loss pattern and confirm Ménière's vs. other diagnoses 3
2. Detailed migraine history: Document presence of photophobia, phonophobia, visual aura, or headache patterns 3, 4
3. Medication review: Many medications cause or worsen tinnitus and dizziness 3
4. Vascular risk assessment: Hypertension, diabetes, and atherosclerosis increase risk of central causes 2

Specialist Referral

• ENT consultation: Required for definitive diagnosis, especially if audiometry shows sensorineural hearing loss suggesting Ménière's 3
• Neurology consultation: Indicated if vestibular migraine is suspected or if any atypical features emerge 3, 2

Common Pitfalls to Avoid

• Assuming BPPV: The most common error is misdiagnosing all vertigo as BPPV without considering episode duration and associated symptoms 3, 2
• Ignoring tinnitus: Tinnitus with vertigo narrows the differential significantly and excludes pure vestibular disorders like BPPV or vestibular neuritis 3, 1
• Delaying audiometry: Hearing assessment is critical and often reveals subclinical hearing loss that confirms inner ear pathology 3
• Missing vestibular migraine: This diagnosis requires specific questioning about migraine features that may not be volunteered 3, 4

Treatment Considerations (Pending Diagnosis)

If Ménière's Disease Confirmed

• High-dose betahistine for long-term management 6
• Dietary sodium restriction and diuretics 6
• Vestibular rehabilitation therapy 7

If Vestibular Migraine Confirmed

• Migraine-specific preventive medications (beta-blockers, calcium channel blockers, topiramate) 4
• Lifestyle modifications including sleep hygiene and trigger avoidance 4
• Abortive therapy for acute episodes 4

Symptomatic Relief

• Meclizine may provide temporary symptom relief during acute episodes 8
• Vestibular suppressants should be used sparingly and only during acute attacks, not chronically 7