What could be causing my episodes of vestibular dysfunction, characterized by a feeling of being forcefully pushed to the side, followed by a sensation of being propelled across the room, without vertigo or spinning, and impaired balance, in a younger to middle-aged adult with no apparent cognitive impairment?

Episodic Lateral Pulsion Without Spinning: Differential Diagnosis and Management

Your symptoms of forceful lateral pushing sensations lasting seconds, triggered by movement, without true spinning vertigo, most likely represent either vestibular migraine or an atypical presentation of BPPV, though central causes including posterior circulation stroke must be urgently excluded if you have any neurological symptoms.

Understanding Your Symptom Pattern

Your description is critical for diagnosis. The American Academy of Otolaryngology-Head and Neck Surgery emphasizes that timing and triggers matter more than the specific words patients use to describe dizziness 1.

Key Distinguishing Features of Your Presentation:

• Duration: Episodes lasting "a few seconds" place you in the triggered episodic vestibular syndrome category, which typically indicates BPPV (lasting <1 minute) 1, 2
• Trigger: Movement-induced symptoms suggest either BPPV or vestibular migraine 1
• Quality: The sensation of being "forcefully pushed" or "propelled" without spinning is actually more characteristic of vestibular migraine than classic BPPV 3
• Balance impairment: Inability to walk straight during episodes occurs in both conditions 1

Most Likely Diagnoses (In Order of Probability)

1. Vestibular Migraine (Most Likely Given Your Description)

Vestibular migraine accounts for up to 14% of all vertigo cases and has a lifetime prevalence of 3.2% 1, 2. Your symptoms align closely with this diagnosis:

• Patients with vestibular migraine predominantly describe visual and postural motion-evoked dizziness rather than spinning 3
• Common descriptions include "feeling the ground slipping from under their feet" (40.6%), "feeling like there is an earthquake or swaying" (27.7%), and "sensation of rocking on a boat" (26.7%) 3
• Episodes are triggered by routine head/body movements and moving visual stimuli 3
• Brief attacks lasting seconds (60.4% of patients) are typical, though the overall episode may last hours 3

Diagnostic criteria require 1:

• ≥5 episodes of vestibular symptoms lasting 5 minutes to 72 hours
• Current or history of migraine headaches
• ≥1 migraine symptom during at least 50% of dizzy episodes (headache, light sensitivity, sound sensitivity, visual aura)
• Other causes ruled out

2. Benign Paroxysmal Positional Vertigo (BPPV)

While BPPV is the most common cause of vertigo overall, your lack of spinning sensation makes this less typical 1. However:

• BPPV causes brief (<1 minute) episodes triggered by specific head position changes 1, 2
• The sensation is classically spinning, but atypical presentations exist 1
• Diagnosis requires the Dix-Hallpike maneuver or supine roll test to be performed by a clinician 1

3. Central Nervous System Causes (MUST BE EXCLUDED)

Up to 25% of patients with acute vestibular symptoms have stroke, rising to 75% in high-risk populations 4. Red flags requiring urgent evaluation include:

Dangerous Nystagmus Patterns 1, 4:

• Downbeating nystagmus (especially without torsional component)
• Direction-changing nystagmus without head position changes
• Gaze-holding, direction-switching nystagmus
• Baseline nystagmus without provocative maneuvers

Other Neurological Warning Signs 1:

• Dysarthria (slurred speech)
• Dysmetria (coordination problems)
• Dysphagia (swallowing difficulty)
• Sensory or motor loss
• Horner's syndrome signs

Critical pitfall: Up to 80% of stroke patients with vestibular symptoms may have NO focal neurologic signs 2, 4, so absence of obvious deficits does not rule out stroke.

Immediate Action Steps

1. Seek Medical Evaluation for Proper Diagnosis

You need a clinician to perform:

• Dix-Hallpike maneuver to diagnose or exclude BPPV 1
• HINTS examination (Head Impulse, Nystagmus, Test of Skew) if acute vestibular syndrome is present—this has 100% sensitivity for stroke when properly performed 2, 4
• Focused neurological examination including posterior circulation assessment 2

2. Provide This History to Your Clinician

• Exact duration of each episode (seconds vs minutes vs hours) 1, 2
• Specific triggers (rolling over in bed, looking up, bending down, or spontaneous) 1
• Any history of migraine headaches (34% of BPPV patients have migraine history) 2
• Associated symptoms: hearing loss, tinnitus, aural fullness, headache, light/sound sensitivity 1
• Recent head trauma 1, 5
• Current medications (many cause dizziness) 1, 2

3. When to Seek Emergency Care

Go to the emergency department immediately if you develop 1, 4:

• Sudden severe headache
• Slurred speech or difficulty swallowing
• Weakness or numbness
• Vision changes
• Severe imbalance preventing walking
• Persistent vomiting

Treatment Considerations

If Vestibular Migraine Is Diagnosed:

• Vestibular suppressants (like meclizine) are typically ineffective—only 12.9% of vestibular migraine patients get temporary relief 3
• Migraine prophylactic medications are the appropriate treatment 3
• Avoid typical migraine triggers 3

If BPPV Is Diagnosed:

• Canalith repositioning procedures (Epley maneuver) are highly effective 1
• Vestibular rehabilitation therapy 1
• Observation is an option as BPPV can resolve spontaneously 1

If Central Cause Is Found:

• Urgent stroke protocol with appropriate imaging (MRI, not CT, as CT frequently misses posterior circulation strokes) 2, 4
• Neurology consultation 1

Important Safety Considerations

Fall risk is increased 12-fold in patients with vestibular symptoms 2, 4. Until diagnosed and treated:

• Avoid driving during symptomatic periods 1
• Use assistive devices if needed 1
• Modify home environment to reduce fall risk 1
• Avoid heights and dangerous machinery 1

Why Imaging May Not Be Immediately Necessary

Neuroimaging has little value in typical BPPV, with MRI not contributing to diagnosis in a cohort of 2,374 patients 2. However, imaging should be obtained if 2:

• Additional neurologic symptoms atypical for BPPV
• Suspected BPPV but inconclusive positional testing
• Any focal neurologic deficits
• Failure to respond to appropriate vestibular treatments 1