What is the workup for a 38-year-old male presenting to the Emergency Room (ER) with vertigo, complaining that the room is spinning, and experiencing a headache?

From the Guidelines

The workup for a 38-year-old male presenting with dizziness, vertigo (room spinning), and headache should begin with a thorough history and physical examination focusing on neurological and vestibular systems, as recommended by the most recent guidelines 1. The initial assessment should include vital signs, neurological examination including cranial nerves, cerebellar function, and nystagmus evaluation.

• Laboratory tests should include complete blood count, basic metabolic panel, and glucose level to rule out metabolic causes.
• Imaging studies should include a CT scan of the head to rule out stroke, hemorrhage, or mass lesions, with consideration for MRI brain with contrast if symptoms persist or neurological findings are concerning, as suggested by the American College of Radiology 1.
• Additional tests may include electrocardiogram to assess for cardiac arrhythmias, and vestibular testing such as the Dix-Hallpike maneuver to evaluate for benign paroxysmal positional vertigo (BPPV) 1.
• If symptoms suggest peripheral vertigo, symptomatic treatment with antiemetics like ondansetron 4mg IV/PO or antihistamines like meclizine 25mg every 6-8 hours may be appropriate.
• For severe symptoms, a short course of vestibular suppressants like diazepam 2-5mg every 8 hours may be considered, as recommended by the clinical practice guideline for benign paroxysmal positional vertigo 1. This comprehensive approach helps differentiate between central causes (stroke, multiple sclerosis) and peripheral causes (vestibular neuritis, BPPV, Meniere's disease) of vertigo, ensuring appropriate management of potentially serious conditions while providing symptomatic relief, in line with the American Academy of Otolaryngology-Head and Neck Surgery guidelines 1.

From the Research

Initial Assessment

The patient presents with dizziness and a headache, symptoms that can be associated with various conditions. According to 2, dizziness is a frequent complaint after head trauma, and its differential diagnosis can be divided into non-vestibular, central vestibular, and peripheral vestibular causes.

Diagnostic Approach

When evaluating a patient with dizziness, it is essential to consider the timing of events and triggers of dizziness to develop a differential diagnosis, as stated in 3. The physical examination should include:

• Orthostatic blood pressure measurement
• A full cardiac and neurologic examination
• Assessment for nystagmus
• The Dix-Hallpike maneuver for patients with triggered dizziness
• The HINTS (head-impulse, nystagmus, test of skew) examination when indicated

Potential Causes

The patient's symptoms could be related to:

• Peripheral vestibular disorders, such as Benign Paroxysmal Positional Vertigo (BPPV), as mentioned in 2 and 3
• Central vestibular disorders, as discussed in 2
• Headaches, which can be primary or secondary, as described in 4 and 5

Headache Evaluation

When evaluating the patient's headache, it is crucial to consider:

• A careful history and physical examination to diagnose primary or secondary headache, as stated in 4 and 5
• Imaging is generally not warranted, unless there are red flags or concerns for secondary headache, as mentioned in 4 and 5
• Avoiding medication overuse headaches by limiting the frequency of acute therapy, as advised in 4 and 5

Next Steps

Based on the patient's presentation, the next steps could include:

• Further evaluation to determine the cause of dizziness and headache
• Consideration of vestibular testing or imaging studies if necessary, as mentioned in 2 and 3
• Management of symptoms, including treatment of headaches and vestibular rehabilitation, as discussed in 3 and 4