What is the possible diagnosis and next steps for a 25-year-old female patient with a 3-week history of episodic dizziness triggered by movement and relieved by sleep, accompanied by crushing scalp pain, and recent nape pain, with physical exam findings including lateralization of Weber's test to the left ear?

Differential Diagnosis and Management

Most Likely Diagnosis

This patient most likely has vestibular migraine, with benign paroxysmal positional vertigo (BPPV) as a close differential, and the Weber lateralization finding raises concern for a concurrent otologic issue requiring further evaluation. 1

Clinical Reasoning

Vestibular Migraine Features Present

• The crushing, squeezing scalp pain is highly characteristic of migraine headache, meeting criteria for moderate-to-severe headache quality 1
• The episodic nature with symptoms lasting variable durations (relieved by sleep suggests hours-long episodes) fits the 5 minutes to 72 hours criterion for vestibular migraine 1, 2
• Movement-triggered dizziness with "spinning of the room" represents true vertigo, which occurs in vestibular migraine 1, 2
• Vestibular migraine has a lifetime prevalence of 3.2% and accounts for up to 14% of all vertigo cases, making it extremely common in young women 1, 2

BPPV Features Present

• The positional trigger (dizziness while supine with slight movement) and brief spinning sensation are classic for BPPV 1, 2
• BPPV episodes characteristically last less than 1 minute, which may fit the initial episode description 1, 2
• BPPV represents a "triggered episodic vestibular syndrome" - brief episodes triggered by specific head/body position changes 1, 3

Critical Red Flag: Weber Lateralization

• Weber's test lateralizing to the left ear indicates either conductive hearing loss on the left OR sensorineural hearing loss on the right 4, 5
• This finding is NOT consistent with typical BPPV (which has no hearing loss) or vestibular migraine (which has stable or absent hearing loss, not acute asymmetric loss) 1, 3
• This raises concern for labyrinthitis (vestibular neuritis with hearing loss), Ménière's disease, or superior canal dehiscence syndrome 1, 3

Immediate Next Steps

1. Perform Dix-Hallpike Maneuver (MANDATORY)

• The Dix-Hallpike maneuver is required to diagnose or exclude BPPV 1, 2
• Look for characteristic findings:
  • Peripheral (BPPV): Torsional and upbeating nystagmus with 5-20 second latency, crescendo-decrescendo pattern, fatigues with repeat testing, resolves within 60 seconds 1, 3
  • Central pathology red flags: Immediate onset, purely vertical nystagmus without torsional component, persistent without fatigue, downbeating nystagmus 1, 3

2. Formal Audiometry Testing (URGENT)

• The abnormal Weber test mandates formal hearing evaluation to characterize the type and degree of hearing loss 4, 5
• This will differentiate:
  • Conductive loss (suggests middle ear pathology)
  • Sensorineural loss (suggests inner ear/cochlear pathology including labyrinthitis, Ménière's disease, or superior canal dehiscence) 1, 3

3. Assess for Vestibular Migraine Diagnostic Criteria

• Determine if she has current or past history of migraine headaches meeting International Headache Society criteria 1
• Ask specifically about:
  • Family history of migraine 3
  • Photophobia, phonophobia, or visual aura during at least 50% of dizzy episodes 1, 3
  • Motion intolerance and light sensitivity as triggers 3
  • Whether she has had ≥5 episodes of vestibular symptoms 1

4. Evaluate for Ménière's Disease Features

• Ask about the classic triad: fluctuating hearing loss, tinnitus, and aural fullness 1, 3
• The key distinguishing feature from vestibular migraine is fluctuating hearing loss that worsens over time 3
• Ménière's episodes typically last hours (sustained vertigo attacks) 1, 3

Treatment Algorithm Based on Findings

If Dix-Hallpike Positive for BPPV:

• Perform canalith repositioning procedure (Epley maneuver) immediately 1, 6, 2
• Do NOT prescribe vestibular suppressants (meclizine, etc.) - they are inappropriate for BPPV 6, 2
• Consider vestibular rehabilitation if symptoms persist 6, 2

If Vestibular Migraine Confirmed:

• Initiate migraine prophylactic medications 2
• Provide education about triggers (motion, light sensitivity) 3
• Consider dietary modifications and lifestyle interventions 1

If Hearing Loss Confirmed on Audiometry:

• If sensorineural hearing loss with episodic vertigo, tinnitus, and aural fullness: Treat as Ménière's disease with dietary sodium restriction, diuretics, and vestibular rehabilitation 6, 3
• If acute unilateral hearing loss with vertigo: Consider labyrinthitis - may require vestibular rehabilitation and potentially corticosteroids 6, 4
• If conductive hearing loss pattern: Refer to ENT for evaluation of middle ear pathology 4

Critical Pitfalls to Avoid

Missing Central Causes

• The nape pain could represent posterior circulation pathology 1, 3
• Red flags demanding immediate neuroimaging include: severe postural instability with falling, new-onset severe headache with vertigo, any additional neurological symptoms (dysarthria, dysmetria, dysphagia, sensory/motor deficits), or failure to respond to appropriate peripheral vertigo treatments 1, 3
• Approximately 10% of cerebellar strokes present similar to peripheral vestibular disorders 1, 6

Overlooking Concurrent Disorders

• Patients can have multiple concurrent vestibular disorders (e.g., BPPV with vestibular migraine, or BPPV with Ménière's disease) 3
• The Weber lateralization finding suggests this patient may have overlapping pathology 4

Inappropriate Medication Use

• Vestibular suppressants should NOT be used for BPPV as they prevent central compensation 6, 2, 5
• Pharmacologic intervention is limited because it affects the CNS's ability to compensate for dizziness 5

Safety Counseling

• Fall risk is increased 12-fold in patients with vestibular symptoms 2
• Advise avoiding driving during symptomatic periods 2
• Recommend assistive devices if needed and home environment modifications to reduce fall risk 2