In a 26‑year‑old male with acute neck pain, continuous headache, two brief vertiginous episodes lasting about one minute, one episode of vomiting, normal vital signs, normal otoscopic and cardiac examination, Weber test lateralized to the right ear, and no focal neurological deficits, what are the likely diagnoses and immediate management steps?

Vertebral Artery Dissection Must Be Excluded First

In this 26-year-old male with acute continuous neck pain, brief vertiginous episodes, vomiting, and lateralized Weber test, vertebral artery dissection is the most critical diagnosis to rule out immediately with urgent CTA or MRA of the neck vessels, followed by consideration of vestibular migraine, BPPV, and cervicogenic dizziness.

Immediate Red-Flag Assessment

This patient presents with a constellation of symptoms that overlap significantly with vertebral artery dissection:

• Unilateral neck pain ("pain in the nape") is the hallmark presenting symptom of vertebral artery dissection, occurring in approximately 50% of cases and often described as continuous, aching pain in the posterior neck. 1

• Vertebral artery dissection classically presents with headache, neck pain, vertigo, nausea, visual disturbances, or syncope—this patient has four of these six features. 1

• The patient's age (26 years) places him in the highest-risk demographic, as vertebral artery dissection accounts for 10-15% of ischemic strokes in younger patients. 1

• Unilateral headache and/or neck pain, especially when accompanied by vertigo, is statistically associated with definite vertebral artery dissection (P = 0.040 for unilateral pain; P = 0.012 for vertigo). 2

• Isolated transient vertigo can precede vertebrobasilar stroke by weeks to months, with typical episodes lasting less than 30 minutes without hearing loss. 1, 3

Critical Next Step: Urgent Vascular Imaging

Order CTA or MRA of the neck vessels immediately—do not wait for symptom progression. 1

• Carotid duplex ultrasonography may miss dissections beginning cephalad to the angle of the mandible; contrast-enhanced CTA and MRA are superior modalities for vertebral artery visualization. 1

• The Weber test lateralizing to the right ear mandates formal audiometry to characterize conductive versus sensorineural hearing loss, but vascular imaging takes priority over audiologic workup. 4

• If vascular imaging is negative, proceed with the diagnostic algorithm below. 1

Secondary Differential Diagnoses (After Dissection Excluded)

Vestibular Migraine (Most Likely if Dissection Ruled Out)

• 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 adults. 3

• The patient's headache description—"continuous, akin to fatigued muscles, aggravated by lack of sleep"—meets criteria for moderate-to-severe headache quality characteristic of migraine. 1

• Diagnostic criteria require: episodic vestibular symptoms lasting 5 minutes to 72 hours, current or history of migraine, and migraine features (headache, photophobia, phonophobia, visual aura) during at least 50% of dizzy episodes. 1, 3

• The two brief vertiginous episodes ("akin to feeling a slight earthquake for 1 minute") fit the 5-minute to 72-hour duration window. 1

• Key distinguishing feature: vestibular migraine has stable or absent hearing loss, whereas Ménière's disease has fluctuating sensorineural hearing loss that worsens over time. 4

Benign Paroxysmal Positional Vertigo (BPPV)

• BPPV accounts for 42% of peripheral vertigo cases and characteristically produces episodes lasting less than 1 minute triggered by specific head-position changes. 4

• The patient's two 1-minute episodes could represent BPPV, but the continuous neck pain is atypical. 4

• Perform bilateral Dix-Hallpike maneuver immediately: 4

  • Positive findings: torsional and upbeating nystagmus with 5-20 second latency, crescendo-decrescendo pattern, fatigues with repeat testing, resolves within 60 seconds. 4
  • If positive, perform Epley maneuver immediately (80% success rate after 1-3 treatments). 4
  • Do not prescribe vestibular suppressants for BPPV—they prevent central compensation. 4

• If Dix-Hallpike is negative, perform supine roll test to detect lateral-canal BPPV (10-15% of BPPV cases). 4

Cervicogenic Dizziness

• Cervicogenic dizziness is triggered by rotation of the head relative to the body while upright, not by changes in head position relative to gravity (which triggers BPPV). 5

• The patient's neck pain "akin to fatigued muscles" could suggest cervical proprioceptive dysfunction. 5

• This is a diagnosis of exclusion—rule out dissection, vestibular migraine, and BPPV first. 5

Examination Findings That Require Urgent MRI Brain

Watch for any of these red flags during follow-up:

• Severe postural instability with falling (not just subjective imbalance). 4

• Pure vertical nystagmus (up-beating or down-beating) without torsional component. 4

• Direction-changing nystagmus without changes in head position. 4

• Baseline nystagmus present without provocative maneuvers. 4

• Nystagmus that does not fatigue with repeated testing and is not suppressed by visual fixation. 4, 3

• Any additional neurologic symptoms: dysarthria, dysmetria, dysphagia, sensory or motor deficits, diplopia, Horner's syndrome. 1, 3

• Failure to respond to appropriate peripheral vertigo treatments (e.g., Epley maneuver for BPPV). 4

Audiologic Workup

• The Weber test lateralizing to the right ear mandates formal audiometry to distinguish conductive loss (middle ear pathology, superior canal dehiscence) from sensorineural loss (Ménière's disease, labyrinthitis). 4

• If fluctuating sensorineural hearing loss is documented, consider Ménière's disease (classic triad: episodic vertigo lasting hours, fluctuating hearing loss, tinnitus, aural fullness). 4

• If hearing is normal or stable, vestibular migraine remains most likely. 4

Imaging Recommendations

• Do not order routine CT head or MRI brain if vascular imaging is negative, Dix-Hallpike is positive for BPPV, and no red flags are present—diagnostic yield is less than 1%. 4

• CT temporal bone is indicated only if conductive hearing loss is confirmed on audiometry to evaluate for otosclerosis, ossicular chain erosion, or superior canal dehiscence. 4

Common Pitfalls to Avoid

• Do not dismiss unilateral neck pain in a young patient with vertigo—vertebral artery dissection can present with isolated headache and neck pain before stroke symptoms develop. 2, 6

• Do not assume BPPV without performing Dix-Hallpike and supine roll tests—the symptom pattern (continuous neck pain, only two brief episodes) is atypical for BPPV. 4

• Do not overlook the smoking history (0.2 pack-year)—although modest, tobacco use is a recognized risk factor for arterial dissection. 1

• Approximately 10% of cerebellar strokes present similar to peripheral vestibular disorders—maintain high suspicion if symptoms worsen or new neurologic signs emerge. 4, 3

Follow-Up Plan

• Reassess within 1 month to document symptom resolution or persistence. 4

• If symptoms persist or worsen, repeat Dix-Hallpike test and escalate to MRI brain with diffusion-weighted imaging if red flags develop. 4

• If vestibular migraine is diagnosed, consider dietary modifications, lifestyle interventions, and prophylactic migraine therapy. 4