What is the best course of management for a 44-year-old female patient with chronic headaches, nausea, vomiting, dizziness described as vertigo, insomnia, and a history of bilateral tubal ligation, who presents with large perforated tympanic membranes, and has a neurological examination showing stronger sensation on the left side across all branches of the trigeminal nerve (CN V)?

Management of Complex Presentation with Chronic Headache, Vertigo, and Tympanic Membrane Perforation

This patient requires urgent ENT and neurology referral for comprehensive evaluation of her tympanic membrane perforations with asymmetric trigeminal nerve findings, which suggest possible structural pathology requiring neuroimaging before initiating headache treatment. 1

Immediate Diagnostic Priorities

Rule Out Secondary Causes First

The combination of large tympanic membrane perforations, asymmetric trigeminal nerve sensation, and chronic headache with vertigo mandates neuroimaging before assuming a primary headache disorder. 1, 2

• Obtain MRI brain with contrast immediately to evaluate for cerebellopontine angle tumors, vestibular schwannoma, or other structural lesions that could explain both the ear pathology and asymmetric cranial nerve findings 1
• The American Academy of Otolaryngology guidelines specify that asymmetric hearing loss with vertigo requires imaging to exclude vestibular schwannoma or other CPA lesions 1
• Unexplained neurologic findings (asymmetric CN V sensation) with headache constitute a red flag requiring neuroimaging per American Family Physician guidelines 1, 2

Complete Audiometric Evaluation

• Perform formal audiometry with Weber and Rinne testing to characterize the hearing loss pattern, as the large tympanic membrane perforation with Weber lateralization suggests conductive hearing loss that may be contributing to symptoms 1
• The perforated tympanic membrane with blood spots requires otoscopic documentation and assessment for chronic otitis media, cholesteatoma, or other middle ear pathology 1

Differential Diagnosis Framework

Primary Considerations Given Clinical Features

Vestibular migraine is the most likely primary diagnosis if structural pathology is excluded, as this patient has headaches with nausea/vomiting plus vertigo described as "spinning and earthquakes" lasting hours 1

• Vestibular migraine presents with attacks lasting hours (can be minutes to >24 hours) with vertigo, nausea, and headache, though hearing loss is less common than in Ménière's disease 1
• The insomnia and late sleeping hours are important modifiable triggers that worsen migraine frequency 1, 3

However, the ear pathology complicates this picture significantly:

• Ménière's disease typically presents with fluctuating hearing loss, tinnitus, aural fullness, and episodic vertigo lasting 20 minutes to hours, but the large tympanic membrane perforations are atypical 1
• Labyrinthitis could explain vertigo with hearing loss but typically presents acutely (>24 hours of continuous vertigo) rather than episodically 1
• The asymmetric trigeminal sensation is NOT explained by any primary vestibular disorder and raises concern for structural lesion 1

Management Algorithm After Imaging

If Neuroimaging is Normal

Step 1: Address Medication Overuse First

• Screen for overuse of OTC analgesics, caffeine, or any acute headache medications - using acute treatments more than 2 days per week or 10 days per month causes medication overuse headache and prevents prophylactic therapy from working 3, 1
• If medication overuse is present, implement structured withdrawal: non-opioid medications can be stopped abruptly or weaned within one month 3

Step 2: Initiate Prophylactic Therapy

For chronic migraine (≥15 headache days per month for ≥3 months with ≥8 days meeting migraine criteria), start topiramate as first-line prophylaxis 1, 3

• Topiramate is the only agent with randomized controlled trial evidence specifically for chronic migraine prophylaxis 1
• Alternative evidence-based options include gabapentin, candesartan, venlafaxine, or amitriptyline, though topiramate has the strongest evidence 3
• Do not increase amitriptyline without specialist input in post-traumatic or complex headache populations due to poor compliance and questionable efficacy 3

Step 3: Acute Treatment Protocol

• For moderate-to-severe attacks: prescribe triptan + NSAID + antiemetic with prokinetic properties (e.g., metoclopramide) 1, 3
• Strictly limit triptan use to maximum 2 days per week or 10 days per month to prevent medication overuse headache 1, 3
• Never prescribe opioids or butalbital compounds - these lead to dependency and rebound headaches 1, 3
• For severe nausea/vomiting, consider non-oral triptan formulations (nasal spray, subcutaneous) 1

Step 4: Mandatory Lifestyle Modifications

• Implement sleep hygiene protocols immediately - the late sleeping hours and insomnia are major modifiable triggers 3
• Limit caffeine intake, ensure regular meals with adequate hydration 3
• Consider behavioral interventions: cognitive-behavioral therapy, mindfulness, or yoga 3

If Prophylaxis Fails After 8-12 Weeks

Refer to headache specialist for:

• Consideration of botulinum toxin A injections for chronic migraine 3
• CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab) 3
• Comprehensive reassessment of modifiable factors and medication overuse patterns 3

Management of Ear Pathology (Concurrent with Above)

ENT referral is mandatory for:

• Large tympanic membrane perforations with blood spots require evaluation for chronic otitis media, cholesteatoma, or other pathology 1
• Surgical repair (tympanoplasty) may be indicated if perforations are causing conductive hearing loss and recurrent infections 1
• The ear pathology may be contributing to vertigo symptoms independently of migraine 1

Critical Pitfalls to Avoid

• Do not assume primary headache disorder without neuroimaging when asymmetric cranial nerve findings are present 1, 2
• Do not miss medication overuse - this is the most common reason prophylactic therapy fails 3
• Do not delay specialist referral if initial prophylactic therapy fails after adequate trial, as chronic migraine causes substantial disability that worsens with delayed treatment 3
• Do not repeat neuroimaging without new red flags once structural pathology is excluded 3
• Do not ignore the sleep disorder - insomnia and irregular sleep are powerful migraine triggers that must be addressed 3

Follow-Up Timeline

• Neurology appointment within 2 weeks for neuroimaging review and treatment initiation 3
• ENT appointment within 2-4 weeks for ear pathology evaluation 1
• Reassess prophylactic therapy efficacy at 8-12 weeks 1, 3
• If no improvement with first prophylactic agent, refer to headache specialist rather than cycling through multiple medications in primary care 3