What are the next steps for a patient with a history of migraines, currently on migraine medication, who experiences an episode of lightheadedness, tingling, and numbness all over their body?

Immediate Evaluation for Acute Neurological Symptoms

This patient requires urgent evaluation to rule out serious neurological causes, particularly stroke, transient ischemic attack, or other central nervous system pathology, as lightheadedness with diffuse tingling and numbness represents red flag symptoms that cannot be attributed to migraine alone. 1, 2

Critical Red Flags Requiring Immediate Assessment

This presentation demands urgent evaluation because:

• Diffuse body-wide tingling and numbness is NOT a typical migraine aura, which is usually focal, unilateral, and follows a characteristic march pattern 2
• Central causes such as stroke or multiple sclerosis must be excluded through neurological examination looking for dysarthria, dysmetria, dysphagia, sensory/motor loss, or Horner's syndrome 2
• Loss of consciousness or true syncope would never be a symptom of migraine and points to cardiovascular or other serious pathology 1

Specific Examination Findings to Assess

Perform a focused neurological examination looking for:

• Direction-changing nystagmus without head position changes, gaze-holding nystagmus, or downbeating nystagmus on Dix-Hallpike - these indicate central pathology 2
• Focal motor or sensory deficits, coordination abnormalities (dysmetria), speech difficulties (dysarthria), or swallowing problems (dysphagia) 2
• Cardiovascular assessment including orthostatic vital signs to evaluate for presyncope versus true vertigo 1

Differential Diagnosis Algorithm

First: Rule Out Life-Threatening Causes

1. Stroke or TIA: Sudden onset, focal deficits, central nystagmus patterns 2
2. Anaphylaxis: Although lightheadedness can occur with anaphylaxis, the absence of urticaria, angioedema, respiratory compromise, or known trigger makes this less likely 1
3. Cardiac syncope: True loss of consciousness without recollection of the event 1

Second: Consider Vestibular Causes

• Vestibular migraine: Requires ≥5 episodes of vestibular symptoms lasting 5 minutes to 72 hours, with migrainous features during at least 50% of episodes 2
• Ménière's disease: Distinguished by documented low-to-mid-frequency sensorineural hearing loss and vertigo attacks lasting 20 minutes to 12 hours 2
• BPPV: Provoked by specific head positions 1

Third: Evaluate for Migraine-Related Phenomena

• Typical migraine aura: Should be focal, gradual in onset (developing over 5-60 minutes), and followed by headache 2
• Vestibular migraine: Photophobia, phonophobia, and visual auras are common; bilateral auditory symptoms more common than unilateral 2

Immediate Next Steps

If any red flags are present, obtain urgent neuroimaging (MRI preferred over CT) and neurology consultation. 2

If examination is reassuring and symptoms have resolved:

• Detailed characterization of the episode: Exact duration, whether symptoms were truly spinning vertigo versus lightheadedness/presyncope, pattern of numbness (focal versus diffuse, unilateral versus bilateral) 1
• Review current migraine medication: Assess for medication overuse (simple analgesics ≥15 days/month or triptans ≥10 days/month can cause medication overuse headache) 3
• Assess for vestibular migraine criteria: Ask about previous similar episodes, duration of vestibular symptoms, and presence of migrainous features during attacks 2

Management Based on Diagnosis

If Vestibular Migraine is Confirmed:

• First-line preventive treatment: Beta blockers (propranolol, metoprolol, atenolol), topiramate 50-100 mg daily, or candesartan 2, 3
• Lifestyle modifications: Regular sleep schedule, stress reduction, adequate hydration, limiting caffeine/alcohol, regular exercise 2
• Acute attack management: Vestibular suppressants (meclizine, diphenhydramine) for short-term use only during attacks, NOT for long-term management 2
• Avoid vestibular suppressants chronically as they can worsen long-term outcomes 2

If Episodic Migraine Without Vestibular Features:

• Reassess preventive therapy indication: Consider if migraine affects quality of life ≥2 days/month despite optimized acute treatment 3
• Optimize acute treatment: NSAIDs for mild-moderate attacks; triptans for moderate-severe attacks, taken early in the attack 3, 4

Critical Pitfalls to Avoid

• Do not attribute diffuse neurological symptoms to migraine without excluding central causes first 2
• Do not dismiss lightheadedness as "just anxiety" in a migraine patient - this requires thorough evaluation 1
• Do not prescribe long-term vestibular suppressants - they impair central compensation and worsen outcomes 2
• Do not overlook medication overuse headache - limit simple analgesics to <15 days/month and triptans to <10 days/month 3
• Do not use opioids or barbiturates for migraine management due to dependency risk and medication overuse headache 2, 3