Need assessment and plan for a 35‑year‑old woman (G3P2) with sudden severe vertex headache, positional rotational dizziness, seven episodes of clear‑saliva vomiting, severe epigastric pain, normal exam, no past medical history, and unknown pregnancy status.

Assessment and Plan

This patient requires urgent neuroimaging with MRI brain without contrast to exclude subarachnoid hemorrhage or posterior circulation stroke before any other intervention, given her sudden-onset severe vertex headache (10/10), rotatory vertigo, and multiple episodes of vomiting. 1

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Assessment

Primary Concern: Life-Threatening Causes Must Be Excluded First

Sudden severe headache (thunderclap headache) with vertigo and vomiting is a red flag constellation that mandates immediate imaging. 1, 2 The clinical presentation includes:

• Sudden onset severe vertex headache (10/10) – reaching maximum intensity rapidly 3, 4
• Rotatory vertigo when standing – suggesting vestibular involvement 1
• Seven episodes of vomiting – indicating severe nausea/vestibular dysfunction 5
• Severe epigastric pain (9/10) – can accompany migraine or increased intracranial pressure 5
• Age 35, female, childbearing age – at risk for cerebral venous sinus thrombosis 1

Critical Diagnostic Considerations

The normal neurologic examination does NOT exclude posterior circulation stroke – 75-80% of patients with acute vestibular syndrome from posterior circulation infarction have no focal neurologic deficits. 1 This is a critical pitfall that must be avoided.

Differential diagnosis in order of urgency:

1. Subarachnoid hemorrhage (SAH) – 11.3% of thunderclap headaches are SAH; cannot be distinguished from benign causes on clinical grounds alone 3, 2
2. Posterior circulation stroke – accounts for 25% of acute vestibular syndrome cases 1
3. Cerebral venous sinus thrombosis – increased risk in women of childbearing age 1
4. Vestibular migraine – accounts for 14% of vertigo cases, often under-recognized in young women 1, 6
5. Benign paroxysmal positional vertigo (BPPV) – less likely given continuous symptoms and severity 5

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Plan

Immediate Actions (Within 1 Hour)

1. Obtain MRI brain without IV contrast immediately 1

• MRI has 4% diagnostic yield vs <1% for CT in isolated dizziness 1
• CT misses most posterior circulation infarcts and should NOT be used as first-line imaging 1
• If MRI is unavailable or significantly delayed, obtain non-contrast CT head as a bridge, but recognize its limited sensitivity 1

2. Document pregnancy status before imaging 1

• Last menstrual period: [DATE]
• Pregnancy test if indicated
• This influences imaging modality choice and medication selection

3. Hold all symptomatic treatment until life-threatening pathology is excluded 1

• Do NOT administer analgesics or antiemetics until after imaging
• Exception: IV fluids for hydration if hemodynamically stable

After Imaging Results

If MRI Shows Abnormality (SAH, Stroke, Thrombosis):

• Immediate neurology/neurosurgery consultation 1
• Activate stroke protocol if indicated 1
• Transfer to appropriate level of care

If MRI is Normal:

Perform bedside vestibular testing:

A. Dix-Hallpike maneuver bilaterally 5, 1

• Look for latency period 5-20 seconds, torsional upbeating nystagmus, symptoms resolving within 60 seconds 5
• If positive: diagnose BPPV and perform Epley maneuver immediately 5

B. HINTS examination (if trained) 1

• Head impulse test
• Nystagmus pattern
• Test of skew
• Central features require neurology consultation even with normal MRI 1

C. Orthostatic vital signs 1

• Check for postural hypotension (common cause of positional dizziness)
• Measure at 0,1, and 3 minutes standing

Symptomatic Management (Only After Normal Imaging)

For severe headache:

• Ketorolac 60 mg IM once 5, 1
  • Rapid onset, 6-hour duration, low rebound risk
  • Avoid opioids (meperidine, butorphanol) – risk of dependence and rebound headache 5

For nausea/vomiting:

• Metoclopramide 10 mg IV OR Prochlorperazine 10 mg IV 5, 1
  • Both provide antiemetic effect and synergistic analgesia
  • IV route preferred given multiple vomiting episodes 5

If vestibular migraine is suspected after exclusion of dangerous causes:

• Consider combination therapy: NSAID + triptan 5
  • Naproxen 500-550 mg PO + Sumatriptan 50-100 mg PO 5
  • Start treatment as soon as possible after headache onset 5
  • Avoid in pregnancy/breastfeeding – discuss risks first 5

Diagnostic Workup

1. Comprehensive audiologic examination 1, 6

• Pure tone audiometry and speech discrimination
• Document any hearing loss pattern
• Unilateral hearing changes mandate MRI if not already done 6

2. Laboratory testing (low yield but reasonable):

• Fingerstick glucose immediately (most common unexpected abnormality) 1
• Basic metabolic panel only if history suggests specific abnormalities 1
• Do NOT order routine comprehensive panels – rarely change management 1

Disposition and Follow-Up

If BPPV confirmed:

• Perform Epley maneuver (80% success rate after 1-3 treatments) 5, 1
• Counsel about recurrence risk and fall prevention 5
• Reassess within 1 month 5
• No imaging or medications needed for typical BPPV 5, 1

If vestibular migraine suspected (after normal imaging):

• Initiate migraine prophylaxis immediately 6
• Lifestyle modifications: hydration, regular meals, consistent sleep, stress management 5
• Identify and avoid migraine triggers 5
• Reassess within 2 weeks 6
• If symptoms persist, consider vestibular rehabilitation therapy 6

If no definitive diagnosis after normal workup:

• Neurology referral for further evaluation 1
• Consider vestibular rehabilitation therapy 1
• Monitor for medication overuse headache (≥15 days/month NSAIDs, ≥10 days/month triptans) 5

Critical Pitfalls to Avoid

• Do NOT assume normal neurologic exam excludes stroke 1, 6
• Do NOT rely on patient's description of "spinning" vs "lightheadedness" – focus on timing, triggers, and associated symptoms 1, 6
• Do NOT use CT instead of MRI when stroke is suspected 1
• Do NOT treat symptomatically before excluding life-threatening causes 1
• Do NOT use opioids or butalbital for migraine treatment 5

Patient Education

• Explain that sudden severe headache requires urgent evaluation to exclude dangerous causes 3, 2
• Counsel about fall risk (dizziness increases fall risk 12-fold) 1
• Discuss importance of returning immediately if symptoms worsen or new symptoms develop 5
• If migraine diagnosed, educate about medication overuse headache risk 5