What is the recommended follow-up for a patient with worsening migraines and recent episodes of dizziness, who underwent an outpatient non-urgency computed tomography (CT) scan, with no previous similar episodes, and is currently asymptomatic with no distress?

Follow-Up Management for Worsening Migraines with Dizziness After Outpatient CT

Your approach of ordering an outpatient non-urgent CT and providing red flag education was appropriate given the clinical presentation, and now the key is ensuring proper follow-up within 1-2 weeks with neurology or primary care while maintaining vigilance for concerning features that would warrant urgent re-evaluation. 1

Immediate Post-CT Management

CT Result Interpretation

• If CT is normal: This significantly reduces but does not eliminate the likelihood of serious intracranial pathology, as CT has inferior soft tissue contrast compared to MRI and may miss certain conditions like spontaneous intracranial hypotension or early cerebral venous thrombosis 1
• Consider MRI brain if symptoms persist or worsen: MRI is more sensitive for detecting clinically significant pathology in patients with worsening headaches and dizziness, particularly for conditions that can present with these symptoms before catastrophic deterioration 1

Scheduled Follow-Up Timeline

• Arrange neurology consultation within 1-2 weeks for patients with worsening migraine frequency and new-onset dizziness, as these features increase the odds of finding abnormalities on neuroimaging even when initial CT appears normal 1
• Earlier follow-up (within days) if: Patient develops any new neurologic symptoms, headache pattern changes further, or dizziness episodes increase in frequency 1

Red Flags Requiring Emergency Return

You correctly educated the patient on red flags. Specifically reinforce these features that warrant immediate ED return:

• Sudden severe headache ("thunderclap" or worst headache of life) 1
• New focal neurologic deficits: Weakness, numbness, vision changes, speech difficulties, or coordination problems 1
• Altered mental status or confusion 1
• Seizure activity 1
• Persistent vomiting that prevents oral intake 1
• Headache awakening patient from sleep (if this becomes a new pattern) 1
• Worsening with Valsalva maneuver (coughing, straining, bending) 1
• Fever with headache 1

Differential Diagnosis Considerations

Vestibular Migraine

• Most common cause of spontaneous episodic vertigo and should be high on your differential given the combination of worsening migraines and dizziness 2
• Dizziness episodes in vestibular migraine typically last minutes to hours and may occur with or without concurrent headache 3, 2
• Treatment: If vestibular migraine is confirmed, migraine prophylaxis (tricyclic antidepressants like nortriptyline, anticonvulsants like topiramate, or calcium channel blockers like verapamil) can effectively treat both headache and dizziness symptoms in 72% of patients 4, 5

Spontaneous Intracranial Hypotension (SIH)

• Critical pitfall: Can present with worsening non-orthostatic headaches and dizziness, may have normal initial CT, and can progress to life-threatening cerebral venous thrombosis 1
• Key feature: Smooth, diffuse dural and leptomeningeal enhancement on MRI brain with contrast 1
• If symptoms worsen despite normal CT, strongly consider MRI brain with contrast to evaluate for this potentially catastrophic condition 1

Central Positional Vertigo

• If dizziness is triggered by head movements but patient has atypical or absent nystagmus on Dix-Hallpike testing, this increases risk of central pathology 1
• MRI detects acute brain lesions in 11% of these cases versus only 6% with CT 1

Acute Symptom Management

For Breakthrough Headaches

• First-line: Combination of triptan (sumatriptan 50-100 mg) plus NSAID (naproxen 500 mg) provides superior relief compared to monotherapy 6, 7
• Alternative NSAIDs: Ibuprofen 400-600 mg or aspirin 500-1000 mg if naproxen unavailable 6, 8
• Avoid opioids and butalbital-containing medications due to risk of medication overuse headache and dependency 6, 7, 8

Medication Overuse Prevention

• Limit triptan use to <10 days per month 6
• Limit NSAID/acetaminophen use to <15 days per month 6

Lifestyle Modifications to Initiate Now

• Maintain adequate hydration and regular meals to prevent migraine triggers 6, 7
• Ensure consistent sleep patterns with sufficient sleep duration 6, 7
• Identify and avoid personal migraine triggers through headache diary 7
• Reduce stress through relaxation techniques 7

When to Escalate to MRI

Consider ordering MRI brain with and without contrast if:

• CT is normal but symptoms continue to worsen over the next 1-2 weeks 1
• Patient develops any new neurologic symptoms or signs 1
• Dizziness has atypical features (not clearly positional, not responding to vestibular maneuvers) 1
• MRI is more sensitive than CT for detecting clinically significant pathology in patients with progressive headache and dizziness, particularly for conditions like SIH, early venous thrombosis, or posterior fossa lesions 1

Common Pitfalls to Avoid

• Don't assume normal CT excludes all serious pathology: CT can miss early cerebral venous thrombosis, spontaneous intracranial hypotension, and small posterior fossa lesions 1
• Don't dismiss dizziness as purely vestibular: The combination of worsening migraines and new dizziness warrants neurologic evaluation even with normal imaging 1, 2
• Don't delay neurology referral: Rapid increase in headache frequency is a concerning feature that increases likelihood of underlying pathology 1