What is the diagnosis and treatment for dizziness lasting 1 month with occipital headaches for 2 months?

Differential Diagnosis and Management of Chronic Dizziness with Occipital Headache

The most likely diagnosis is vestibular migraine, and first-line treatment should be NSAIDs (ibuprofen, naproxen, or diclofenac) for acute episodes, with consideration for preventive therapy using beta-blockers (propranolol, metoprolol) or topiramate if symptoms occur ≥2 days per month despite optimized acute treatment. 1

Critical Diagnostic Considerations

Primary Differential: Vestibular Migraine vs. Ménière's Disease

Vestibular migraine is the leading diagnosis given the prolonged duration of dizziness (1 month) with occipital headaches (2 months). 1

Key distinguishing features:

• Vestibular migraine: Attacks lasting hours (can range from minutes to >24 hours), hearing loss less likely, patients often have migraine history with photophobia more common than visual aura 1
• Ménière's disease: Attacks lasting 20 minutes to 12 hours with fluctuating hearing loss, tinnitus, and aural fullness occurring immediately before, during, or after vertigo attacks 1

Red Flags Requiring Urgent Investigation

Occipital headache in any patient warrants diagnostic caution, as isolated occipital and cervical pain are not characteristic of typical primary headache disorders. 1

If the patient is over age 50, aggressively investigate secondary causes including:

• Temporal arteritis (check ESR and C-reactive protein) 2
• Subarachnoid hemorrhage (non-contrast head CT within 6 hours) 2
• Posterior circulation stroke 2
• Chiari I malformation (MRI with sagittal T2-weighted sequence of craniocervical junction) 1

Diagnostic Workup

Essential History Elements

Ask specifically about:

• Vertigo characteristics: True spinning sensation vs. vague dizziness (lightheadedness suggests non-vestibular cause) 1
• Attack duration: Seconds (BPPV), minutes to hours (vestibular migraine), 20 minutes-12 hours (Ménière's) 1
• Positional triggers: Head position changes suggest BPPV 1
• Otologic symptoms: Fluctuating hearing loss, tinnitus, aural fullness during attacks suggest Ménière's 1
• Migraine features: Photophobia, phonophobia, nausea, pulsating quality, unilateral location 1
• Occipital pain triggers: Valsalva maneuver worsening suggests Chiari malformation 1

Physical Examination

Perform:

• Dix-Hallpike maneuver: For triggered episodic dizziness to diagnose BPPV 3, 4
• HINTS examination (head-impulse, nystagmus, test of skew): If acute vestibular syndrome present to differentiate vestibular neuritis from stroke 4
• Neurologic examination: Focal deficits, ataxia, dysarthria suggest central cause 1
• Blood pressure measurement: Rule out orthostatic hypotension 3
• Tinel's sign over occipital nerves: Positive suggests occipital neuralgia 5, 6

Imaging Indications

MRI brain without contrast is preferred over CT for evaluating chronic dizziness with occipital headache. 1

Obtain MRI if:

• New onset headache after age 50 2
• Occipital headache worsened by Valsalva (evaluate for Chiari malformation) 1
• Focal neurologic deficits 1
• Progressive symptoms 1
• Atypical features not fitting vestibular migraine or Ménière's 1

Treatment Algorithm

Acute Management

First-line acute therapy: NSAIDs (ibuprofen 400-600mg, naproxen 500-550mg, or diclofenac potassium 50mg) taken early in the attack 1

Second-line acute therapy: Triptans (sumatriptan 50-100mg orally) if NSAIDs fail after three consecutive attacks 1

Adjunct therapy: Prokinetic antiemetics (metoclopramide 10mg or domperidone 10mg) for nausea/vomiting 1

Avoid: Opioids, barbiturates, and oral ergot alkaloids due to poor efficacy and risk of dependency 1

Preventive Therapy Indications

Consider preventive treatment if the patient remains adversely affected ≥2 days per month despite optimized acute therapy. 1, 7

Additional indications:

• Severe attack intensity or prolonged duration 1
• Overuse of acute medications (≥10 days/month for triptans, ≥15 days/month for simple analgesics) 7
• Significant disability affecting quality of life 1

Preventive Medication Selection

First-line preventive options: 1

• Beta-blockers: Propranolol 80-240mg daily, metoprolol 100-200mg daily, or atenolol 50-100mg daily
• Topiramate: Start 25mg daily, titrate slowly to 100-200mg daily in divided doses
• Candesartan: 16mg daily

Second-line options: 1

• Amitriptyline: 25-150mg at bedtime
• Flunarizine: 5-10mg daily (where available)

Third-line options (for chronic migraine ≥15 headache days/month): 7

• CGRP monoclonal antibodies: Erenumab, fremanezumab, or galcanezumab as monthly subcutaneous injections

Assess efficacy after 2-3 months for oral preventives, 3-6 months for CGRP antibodies. 1, 7

Alternative Diagnoses to Consider

Occipital Neuralgia

If pain is paroxysmal, lancinating, and follows occipital nerve distribution with positive Tinel's sign: 5

• Diagnostic/therapeutic: Greater occipital nerve block with local anesthetic ± corticosteroid
• Treatment: Gabapentin, carbamazepine, or tricyclic antidepressants
• Refractory cases: Pulsed radiofrequency or occipital nerve stimulation

Benign Paroxysmal Positional Vertigo (BPPV)

If dizziness is positional, lasting <1 minute (seconds), without hearing loss: 1

• Diagnosis: Positive Dix-Hallpike maneuver
• Treatment: Epley maneuver (canalith repositioning) 3

Vestibular Neuritis

If acute prolonged vertigo (12-36 hours) without hearing loss: 1

• Treatment: Vestibular rehabilitation, short-term vestibular suppressants (meclizine 25mg three times daily for 3-5 days maximum) 8, 3

Common Pitfalls to Avoid

• Do not assume migraine without thorough investigation in patients over 50 with new-onset symptoms 2
• Do not rely on symptom quality alone (vertigo vs. lightheadedness) to guide diagnosis; use timing and triggers instead 4
• Do not abandon preventive therapy prematurely; full benefit may take 2-3 months to manifest 1, 7
• Do not prescribe long-term vestibular suppressants (meclizine, dimenhydrinate) as they impair central compensation and prolong recovery 3
• Do not miss medication overuse headache in patients using acute medications ≥10 days/month (triptans) or ≥15 days/month (simple analgesics) 7