Most Likely Diagnosis: Vestibular Migraine (Migraine with Aura)
This 34-year-old male with severe unilateral eye pain preceding headache, vomiting, brief disequilibrium, and a similar episode one year ago most likely has vestibular migraine (migraine with aura), and should be treated acutely with combination therapy of a triptan plus NSAID while initiating preventive therapy given the recurrent pattern. 1
Diagnostic Reasoning
Why This Is Vestibular Migraine
Eye pain as aura: The bilateral eye pain (worse on left, 10/10) that preceded the headache by hours represents a sensory aura symptom—the patient himself identified it as a "possible aura"—which is consistent with migraine with aura occurring in approximately one-third of migraine patients 1
Headache characteristics meet ICHD-3 criteria: The "splitting" headache starting from the eyes, radiating to the occiput, then lateralizing to the left side (9/10 intensity), lasting >4 hours, with associated vomiting, fulfills diagnostic criteria for migraine without aura (unilateral location, severe intensity, associated nausea/vomiting) 1
Vestibular symptoms: The brief "earthquake-like sensation of balance" lasting <10 seconds occurring twice when standing up represents vestibular symptoms that characterize vestibular migraine, which is the most common neurologic cause of vertigo in adults and accounts for approximately 10% of patients with vertigo and dizziness 2, 3, 4
Recurrent pattern: Similar episodes 1 year and 1 month ago establish the recurrent nature required for migraine diagnosis (≥5 attacks for migraine without aura) 1
Normal examination: The completely normal neurologic, otologic, and cardiac examination with negative Dix-Hallpike, Kernig, and Brudzinski signs, no glaucomatous cupping, and no papilledema effectively rules out secondary causes 1
Why This Is NOT Other Diagnoses
Not cluster headache: Cluster headache requires attacks lasting 15–180 minutes (not >24 hours), frequency of 1–8 attacks daily (not isolated episodes separated by months), and restlessness/agitation during attacks (this patient preferred to sleep) 5, 6
Not Ménière's disease: Ménière's disease requires documented hearing loss and tinnitus in addition to vertigo episodes lasting 20 minutes to 12 hours; this patient has no auditory symptoms and his disequilibrium lasted only <10 seconds 1
Not acute angle-closure glaucoma: The resolution of eye pain with sleep and paracetamol, normal intraocular pressure implied by absence of glaucomatous cupping, and bilateral (not strictly unilateral) eye pain exclude glaucoma 1
Not carotid dissection or giant cell arteritis: The episodic pattern with complete resolution between attacks, young age (34 years), and absence of continuous pain or focal neurological deficits rule out vascular causes 6
Acute Management
First-Line Combination Therapy
Sumatriptan 50–100 mg PLUS naproxen sodium 500 mg taken immediately at headache onset provides superior efficacy compared to either agent alone, with 130 additional patients per 1,000 achieving sustained pain relief at 48 hours 7
Early administration is critical: Treating when pain is still mild results in approximately 50% pain-free response at 2 hours versus only 28% when treatment is delayed until pain is moderate-to-severe 7
Alternative Acute Options If Combination Therapy Fails
Try a different triptan after 2–3 failed episodes with sumatriptan, because failure of one triptan does not predict failure of others: rizatriptan 10 mg (fastest oral triptan, peak in 60–90 minutes), eletriptan 40 mg, or zolmitriptan 2.5–5 mg 7
Subcutaneous sumatriptan 6 mg provides the highest efficacy (59% complete pain relief at 2 hours) with onset within 15 minutes, particularly useful for rapid progression or significant nausea 1, 7
Adjunctive Antiemetic Therapy
- Metoclopramide 10 mg taken 20–30 minutes before the triptan-NSAID combination provides direct analgesic effects through central dopamine receptor antagonism beyond its antiemetic properties 7
Critical Frequency Limitation
- Limit all acute medications to ≤2 days per week (≤10 days per month) to prevent medication-overuse headache, which paradoxically increases headache frequency and can lead to daily headaches 1, 7
Preventive Therapy Initiation
Indications for Starting Prevention NOW
This patient meets criteria for preventive therapy because he has experienced ≥2 migraine attacks producing significant disability (vomiting, inability to work, prompting clinic visit) 1
Recurrent pattern over 1 year with at least 3 documented episodes (1 year ago, 1 month ago, current) establishes the need for prophylaxis rather than relying solely on acute treatment 1
First-Line Preventive Options
Propranolol 80–240 mg/day (start 40 mg twice daily, titrate every 2 weeks) has the strongest evidence as a first-line preventive agent with FDA approval for migraine prophylaxis 7
Topiramate 50–200 mg/day (start 25 mg at bedtime, increase by 25 mg weekly) is the only oral preventive with proven efficacy in chronic migraine and has strong evidence for episodic migraine 7
Amitriptyline 30–150 mg/day (start 10–25 mg at bedtime, titrate weekly) is preferred when comorbid anxiety, depression, or sleep disturbances are present 7
Timeline for Preventive Efficacy
Oral preventives require 2–3 months for full efficacy assessment; do not abandon therapy prematurely 7
Reassess treatment response at 2–3 months using a headache diary to document frequency, severity, and acute medication use 1
Vestibular Symptom Management
Specific Considerations for Vestibular Migraine
Vestibular symptoms in migraine (the brief disequilibrium episodes) typically respond to the same preventive medications used for headache prophylaxis; no separate vestibular-specific therapy is required 2, 3, 4
Vestibular suppressants (meclizine, dimenhydrinate) may be used acutely during attacks with prominent vertigo but should not be used chronically 3
Prophylactic migraine medication has been shown to prevent the development and worsening of central ocular motor dysfunction in vestibular migraine patients 8
Diagnostic Workup
No Neuroimaging Required
MRI is NOT indicated in this case because the patient has no red-flag features: no thunderclap onset, no progressive worsening, no atypical aura, no focal neurological deficits, no fever, normal vital signs, and a clear recurrent pattern consistent with primary headache 1, 6
Red flags that WOULD require MRI include thunderclap headache, atypical aura, recent head trauma, impaired memory/consciousness, progressive worsening, or new-onset headache after age 50 1, 6
Recommended Monitoring
Headache diary (paper or smartphone app) should be started immediately to track attack frequency, duration, severity, associated symptoms, triggers, and acute medication use 1
Follow-up in 2–4 weeks to assess response to acute therapy and tolerance of preventive medication, then every 2–3 months during preventive therapy titration 1
Critical Pitfalls to Avoid
Do not prescribe opioids (codeine, tramadol, hydrocodone) for migraine because they provide questionable efficacy, carry high risk of dependence, precipitate rebound headaches, and worsen long-term outcomes 7
Do not allow daily or near-daily acute medication use because this creates medication-overuse headache; if the patient needs acute treatment >2 days/week, immediately escalate preventive therapy 1, 7
Do not dismiss the vestibular symptoms as unrelated to migraine; vestibular migraine is a distinct entity requiring the same migraine-specific treatment approach 1, 2, 3, 4
Do not confuse this with cluster headache based on the severe unilateral pain; the attack duration (>24 hours vs. 15–180 minutes), preference for rest (vs. restlessness), and episodic pattern (months apart vs. daily during cluster periods) clearly distinguish migraine 5, 6
Do not order unnecessary neuroimaging in the absence of red flags, as this increases cost, radiation exposure, and risk of incidental findings leading to further unwarranted testing 1
Patient Education and Lifestyle Modification
Identify and avoid triggers: Sleep deprivation (implied by "after watching television"), stress, alcohol, caffeine withdrawal, and specific foods can precipitate attacks 1
Maintain regular sleep schedule: Consistent sleep-wake times reduce migraine frequency 1
Limit caffeine intake to ≤200 mg/day (approximately 2 cups of coffee) consumed before noon to prevent caffeine-withdrawal migraine 7
Provide realistic expectations: Preventive therapy aims for ≥50% reduction in attack frequency, not complete elimination; most patients require 2–3 months to see benefit 1, 7