What are the differential diagnoses for a 15-year-old patient presenting with migraine and vertigo?

Differential Diagnoses for a 15-Year-Old with Migraine and Vertigo

Vestibular migraine is the most likely diagnosis in a 15-year-old presenting with both migraine and vertigo, given its high prevalence (3.2% lifetime) and typical onset in adolescence or young adulthood. 1, 2

Primary Differential: Vestibular Migraine

Vestibular migraine should be the leading consideration when migraine and vertigo co-occur in an adolescent. 3

Diagnostic Criteria to Assess:

• ≥5 episodes of vestibular symptoms (vertigo, dizziness, head-motion intolerance) lasting 5 minutes to 72 hours 3, 2
• At least 50% of episodes must have migraine features: moderate-to-severe headache with unilateral location, pulsating quality, photophobia, phonophobia, or visual aura 2, 4
• Current or past history of migraine meeting International Headache Society criteria 3, 2
• Headache may be absent during vertigo attacks, making diagnosis challenging—look for other migrainous features like photophobia, phonophobia, or visual aura 5, 6

Key Clinical Features in Adolescents:

• Age of migraine onset typically around 23 years, vertigo onset around 38 years in adults, but pediatric precursors (motion sickness, benign paroxysmal vertigo) predict earlier onset 7
• Motion sickness reported in 42.8% of vestibular migraine patients, often predating adult symptoms 7
• Internal vertigo (73%) more common than external vertigo (25%) 7
• Nausea (59.9%), photophobia (44.4%), and phonophobia (38.9%) are the most common accompanying symptoms 7
• Auditory symptoms may occur but are typically bilateral and mild, unlike Ménière's disease 3, 2

Critical Differential: Migraine Without Aura vs. Migraine With Aura

Migraine Without Aura (More Common):

• ≥5 attacks lasting 4-72 hours (note: 2-72 hours in patients <18 years) 3
• At least 2 of 4 characteristics: unilateral location, pulsating quality, moderate-to-severe intensity, aggravation by routine activity 3
• At least 1 of: nausea/vomiting OR photophobia and phonophobia 3

Migraine With Aura:

• ≥2 attacks with fully reversible aura symptoms: visual, sensory, speech/language, motor, brainstem, or retinal 3
• Aura symptoms spread gradually over ≥5 minutes, last 5-60 minutes, and are followed by headache within 60 minutes 3
• Brainstem aura can include vertigo as a specific manifestation 5, 8

Other Important Differentials to Exclude

Benign Paroxysmal Positional Vertigo (BPPV):

• Brief episodes (<1 minute) triggered by specific head position changes 1
• No hearing loss, no headache 1
• Most common cause of vertigo overall, but less likely with concurrent migraine history 1
• Failure to respond to canalith repositioning maneuvers suggests alternative diagnosis 1

Ménière's Disease:

• Episodes lasting 20 minutes to 12 hours 1, 2
• Fluctuating low-to-mid-frequency sensorineural hearing loss on audiometry (key distinguishing feature) 2
• Tinnitus and aural fullness more prominent than in vestibular migraine 3, 2
• Accounts for ~10% of vertigo cases 1
• Important caveat: 35% of Ménière's patients also meet criteria for vestibular migraine, creating diagnostic overlap 2

Central Causes (MUST ACTIVELY EXCLUDE):

Posterior Circulation Stroke/Vertebrobasilar Insufficiency:

• Life-threatening and can mimic peripheral vertigo 1
• 75-80% of stroke patients with acute vestibular syndrome have NO focal neurologic deficits, making stroke easy to miss 1
• Red flags: dysarthria, dysmetria, dysphagia, sensory/motor loss, Horner's syndrome 1
• Nystagmus red flags: downbeating without torsional component, direction-changing without head position changes, direction-switching with gaze 1
• Hearing loss usually absent in stroke (unlike Ménière's) 1

Multiple Sclerosis:

• Can present with vertigo and nausea/vomiting 1
• Consider in adolescents with relapsing-remitting neurologic symptoms 1

Intracranial Tumors:

• Progressive symptoms, baseline nystagmus without provocative maneuvers 1
• Failure to respond to conservative management should raise concern 1

Idiopathic Intracranial Hypertension Without Papilledema (IIHwop):

• Elevated CSF opening pressure ≥20 cm H₂O on lumbar puncture (performed on ≥2 occasions) 4
• Strong association with obesity (average BMI 37.4) 4
• Headache typically progressively more severe and frequent, often chronic daily headache 4
• Red flags: pulsatile tinnitus, chronic progressive headache, transient visual obscurations 4

Episodic Ataxia Type 2:

• Genetic channelopathy causing episodic vertigo and ataxia 5
• Consider with family history of similar symptoms 5

Benign Paroxysmal Vertigo of Childhood:

• Pediatric migraine precursor occurring in infancy/childhood 7
• Predicts earlier onset of vestibular migraine in adulthood 7

Diagnostic Algorithm

1. Establish temporal relationship between vertigo and migraine features (headache, photophobia, phonophobia, visual aura) 5, 6
2. Count episodes: ≥5 episodes lasting 5 minutes to 72 hours strongly suggests vestibular migraine 3, 2
3. Assess for auditory symptoms:
   • Documented low-to-mid-frequency hearing loss on audiometry → consider Ménière's disease 2
   • Bilateral, mild, or absent hearing loss → favors vestibular migraine 2
4. Screen for red flags suggesting central causes:
   • Focal neurologic deficits, abnormal nystagmus patterns, progressive symptoms → urgent neuroimaging 1
5. Assess for IIHwop red flags in obese adolescents:
   • Pulsatile tinnitus, chronic progressive headache → neuroimaging and lumbar puncture with opening pressure 4
6. Perform Dix-Hallpike maneuver:
   • Torsional upbeating nystagmus → BPPV 1
   • Downbeating without torsional component → red flag for central cause 1

Common Pitfalls to Avoid

• Do not assume headache must accompany vertigo attacks—only 50% of vestibular migraine episodes require migraine features 2, 5
• Do not dismiss central causes based on absence of focal deficits—75-80% of posterior circulation strokes present without them 1
• Do not overlook family history—70.2% of vestibular migraine patients have family history of migraine, 66.3% have family history of vertigo 7
• Do not confuse "difficulty processing sound" (vestibular migraine) with true hearing loss (Ménière's disease) 3, 2
• Do not forget that 35% of Ménière's patients also meet vestibular migraine criteria—consider noninvasive therapeutic trials before invasive interventions 2