What is the recommended evaluation and management for a patient with a 1-month history of dizziness and a 2-month history of headache?

Evaluation and Management of Dizziness and Headache

This patient requires systematic evaluation to distinguish between migraine with vestibular features, vestibular migraine, or coexisting primary headache and peripheral vestibular disorders, with the primary goal of ruling out dangerous central causes before settling on a benign diagnosis. 1, 2

Initial Clinical Assessment

Red Flag Screening (Must Be Performed First)

Immediately assess for features requiring urgent neuroimaging or emergency referral 1:

• Thunderclap headache ("worst headache of life") suggesting subarachnoid hemorrhage 1
• Altered consciousness, memory, or personality changes 1
• Focal neurological deficits that persist beyond typical aura duration 1, 2
• Neck stiffness or limited neck flexion with unexplained fever (meningitis) 1
• New-onset headache after age 50 with scalp tenderness or jaw claudication (giant cell arteritis) 1
• Progressive worsening headache that awakens from sleep or worsens with Valsalva maneuver 1
• Loss of consciousness (never a migraine symptom) 3, 2
• Recent head or neck trauma 1

If any red flags are present, arrange emergency admission and neuroimaging before further evaluation. 1

Detailed History Taking

Headache Characterization

Document specific features to apply ICHD-3 diagnostic criteria 1, 2:

• Duration of individual episodes: Migraine lasts 4-72 hours; shorter or longer durations suggest alternative diagnoses 1
• Pain location: Unilateral location supports migraine; bilateral suggests tension-type headache 1
• Pain quality: Pulsating/throbbing character is typical of migraine 1
• Pain severity: Moderate-to-severe intensity that interferes with routine activities 1
• Aggravating factors: Routine physical activity worsens migraine but not tension-type headache 1
• Associated symptoms: Nausea/vomiting, photophobia, and phonophobia strongly support migraine 1, 2
• Aura symptoms: Visual phenomena (bright scintillating lights, zigzag lines, scotomas) developing gradually over ≥5 minutes and lasting 5-60 minutes 2, 4

Dizziness Characterization

Distinguish true vertigo from other dizziness types 3, 5:

• Confirm true vertigo: Ask specifically about spinning sensation or false sense of motion (not vague "dizziness" or lightheadedness) 3
• Episode duration: Vestibular migraine episodes last 5 minutes to 72 hours; Ménière's disease typically 20 minutes to 12 hours; BPPV lasts seconds to minutes 3, 2
• Triggers: Head position changes suggest BPPV; spontaneous episodes without triggers may indicate vestibular migraine or Ménière's disease 3, 5
• Hearing symptoms: Unilateral fluctuating hearing loss with tinnitus and aural fullness suggests Ménière's disease; bilateral auditory complaints or difficulty processing sound (not true hearing loss) suggest vestibular migraine 3, 2
• Timing relationship: Does dizziness occur before, during, or after headache? 2

Medication History

Critical for identifying medication-overuse headache 1:

• Acute medication frequency: Non-opioid analgesics ≥15 days/month or triptans/combination medications ≥10 days/month for ≥3 months indicates medication-overuse headache 1, 2
• Over-the-counter medications: Many patients underreport these 3

Additional History Elements

• Family history of migraine: Strong genetic component increases likelihood 1, 2
• Migraine history: Prior diagnosed migraine or migraine features support vestibular migraine 3, 2
• Triggers: Light sensitivity, motion intolerance, specific foods, stress, sleep changes 3, 2
• Frequency pattern: ≥15 headache days/month for >3 months with ≥8 days meeting migraine criteria indicates chronic migraine 1, 2

Physical Examination

Neurological Examination

Perform comprehensive assessment to exclude secondary causes 1:

• Mental status and cranial nerve examination 1
• Motor and sensory examination for focal deficits 1
• Cerebellar testing (finger-to-nose, heel-to-shin, gait assessment) 5
• Assessment for nystagmus at rest and with gaze 5, 6

Vestibular-Specific Testing

For patients with vertigo 5, 6:

• Dix-Hallpike maneuver: Diagnoses BPPV (episodic vertigo triggered by head position changes) 5, 6
• HINTS examination (head-impulse, nystagmus, test of skew): Distinguishes peripheral from central causes in acute vestibular syndrome; central findings require urgent neuroimaging 5, 6

Cardiovascular Examination

• Orthostatic blood pressure measurement: Rule out presyncope from orthostatic hypotension 5, 6
• Cardiac auscultation: Assess for arrhythmias or structural disease 5

Diagnostic Testing

When Neuroimaging Is Indicated

MRI brain with and without contrast is the preferred modality for subacute presentations 1:

• Unexplained abnormal neurological examination findings 3, 1
• Atypical features not meeting strict migraine criteria 3, 1
• Progressive worsening headache 1
• New-onset headache in patients >50 years 1
• Headache awakening patient from sleep or worsened by Valsalva (insufficient evidence but conservative approach recommends imaging) 3

Non-contrast CT head is indicated for 1:

• Acute severe headache presenting <6 hours from onset (subarachnoid hemorrhage; sensitivity 95% on day 0) 1
• Acute trauma 1

Neuroimaging is NOT routinely indicated for patients with normal neurological examination and typical migraine features 3, 1

Laboratory Testing

Selective use based on clinical suspicion 1:

• ESR/CRP: If temporal arteritis suspected (patients >50 years with new-onset headache, scalp tenderness, jaw claudication); note ESR can be normal in 10-36% of cases 1
• Morning TSH and free T4: If hypothyroidism suspected (cold intolerance, lightheadedness) 1

Diagnostic Tools

• Headache diary: Essential for documenting frequency, duration, triggers, associated symptoms, and medication use; reduces recall bias and increases diagnostic accuracy 1, 2
• ID-Migraine questionnaire (3-item): Sensitivity 0.81, specificity 0.75 for migraine screening 1

Diagnostic Formulation

Migraine Without Aura

Requires ALL of the following 1, 2:

• ≥5 lifetime attacks lasting 4-72 hours (untreated or unsuccessfully treated)
• ≥2 pain characteristics: Unilateral location, pulsating quality, moderate-to-severe intensity, OR aggravation by routine physical activity
• ≥1 associated symptom: Nausea/vomiting OR photophobia AND phonophobia

Migraine With Aura

Requires recurrent aura symptoms with 2, 4:

• Visual, sensory, speech/language, motor, brainstem, or retinal symptoms
• ≥3 characteristics: Gradual spread over ≥5 minutes, two or more symptoms in succession, at least one unilateral symptom, at least one positive symptom, aura accompanied by or followed by headache within 60 minutes

Note: Visual aura can occur without subsequent headache and remains part of the migraine spectrum 2

Vestibular Migraine

Consider when patient has both migraine history and vertigo 3, 2:

• ≥5 episodes of moderate-to-severe vestibular symptoms lasting 5 minutes to 72 hours
• Migraine features present in ≥50% of episodes (headache with migraine characteristics, photophobia, phonophobia, visual aura)
• Visual auras more common than in typical migraine 2
• Hearing complaints typically bilateral and related to sound processing rather than true hearing loss 3, 2

Important distinction: 35% of Ménière's disease patients also meet criteria for vestibular migraine, making differentiation challenging 2

Chronic Migraine

Diagnosed when 1, 2:

• ≥15 headache days/month for >3 months
• ≥8 days/month meeting migraine criteria

Medication-Overuse Headache

Coexists with chronic migraine when 1, 2:

• ≥15 headache days/month
• Regular overuse: Non-opioid analgesics ≥15 days/month OR triptans/combination medications ≥10 days/month for ≥3 months

Management Approach

Acute Migraine Treatment

For mild-to-moderate attacks 3:

• NSAIDs (ibuprofen, naproxen sodium) or aspirin-acetaminophen-caffeine combination: First-line treatment; administer as early as possible during attack 3
• Acetaminophen alone is ineffective 3

For moderate-to-severe attacks or NSAID failure 3:

• Triptans (sumatriptan, rizatriptan, zolmitriptan, naratriptan): Contraindicated in uncontrolled hypertension, basilar or hemiplegic migraine, or cardiac disease risk 3
• Dihydroergotamine (DHE): Intranasal administration has good efficacy and safety 3

For nausea/vomiting 3:

• Antiemetics: Treat accompanying nausea 3
• Consider nonoral route when nausea/vomiting present early 3

Critical warning: Frequent use of triptans, ergotamines, opiates, or analgesics may cause medication-overuse headaches 3

Preventive Therapy Indications

Consider preventive treatment when 3:

• ≥2 migraine attacks per month producing disability for ≥3 days/month
• Rescue medication use >2 times per week
• Failure of or contraindications to acute treatments
• Uncommon migraine conditions (prolonged aura, migrainous infarction, hemiplegic migraine)

First-line preventive agents 3:

• Propranolol 80-240 mg/day or timolol 20-30 mg/day (common adverse effects: dizziness, nausea, fatigue, depression, insomnia) 3
• Amitriptyline 30-150 mg/day (particularly effective for mixed migraine and tension-type headache; adverse effects: weight gain, drowsiness, anticholinergic symptoms) 3
• Divalproex sodium 500-1,500 mg/day or sodium valproate 800-1,500 mg/day (effective for prolonged or atypical aura; adverse effects: hair loss, tremor, weight gain, teratogenic) 3

BPPV Treatment

If Dix-Hallpike maneuver confirms BPPV 5, 6:

• Canalith repositioning procedure (Epley maneuver): Most effective treatment 5, 6

Vestibular Neuritis Treatment

For spontaneous vertigo without hearing loss 5:

• Vestibular suppressant medications (short-term use only to avoid delaying central compensation) 5
• Vestibular rehabilitation: Essential for recovery 5, 6

Ménière's Disease Treatment

For vertigo with unilateral hearing loss, tinnitus, and aural fullness 3, 5:

• Salt restriction and diuretics 5

Referral Criteria

Emergency Admission

Immediate referral when 1:

• Any red flag present (thunderclap headache, focal neurological deficits, altered consciousness, neck stiffness with fever, etc.)
• Patient unable to self-care without help

Urgent Neurology Referral (Within 48 Hours)

• Suspected spontaneous intracranial hypotension (orthostatic headache) 1
• Patient unable to self-care but has help available 1

Routine Neurology Referral (2-4 Weeks)

• Suspected primary headache disorder with uncertain diagnosis 1
• First-line treatments fail 1

Rheumatology Referral

• Suspected giant cell arteritis 1

Common Pitfalls to Avoid

• Relying on patient's description of "dizziness" type: Patients have difficulty describing quality; focus instead on timing, triggers, and associated symptoms 5, 6
• Missing medication-overuse headache: Always document frequency of ALL acute medications including over-the-counter agents 3, 1
• Ordering unnecessary neuroimaging: Not indicated for typical migraine with normal neurological examination 3, 1
• Failing to use headache diary: Retrospective recall consistently underestimates attack frequency and characteristics 1, 2
• Overlooking vestibular migraine: Consider in patients with both migraine history and episodic vertigo lasting 5 minutes to 72 hours 3, 2
• Assuming loss of consciousness is migraine: This is NEVER a migraine symptom and requires alternative diagnosis 3, 2
• Missing chronic migraine: Systematically assess whether patient has ≥15 headache days/month for >3 months 1, 2