What is the differential diagnosis for an adult female with years‑long daily headaches, intermittent tinnitus, brief transient visual blackouts lasting seconds, and recent episodic dizziness that improves when she supports her head with her hand, without syncope?

Differential Diagnosis for Years-Long Daily Headaches with Episodic Dizziness, Tinnitus, and Transient Visual Blackouts

This presentation most strongly suggests vestibular migraine (VM) or chronic migraine with vestibular features, particularly given the daily headaches, episodic dizziness, tinnitus, and the characteristic improvement with head support. 1

Primary Diagnostic Considerations

Vestibular Migraine (Most Likely)

Vestibular migraine is the most common neurologic cause of vertigo in adults and frequently presents with the constellation of symptoms described. 2

Key features supporting this diagnosis:

• Daily headaches persisting for years meet criteria for chronic migraine (≥15 headaches/month for ≥3 months) 1
• Episodic dizziness that comes "out of nowhere" represents spontaneous episodic vestibular syndrome, characteristic of VM 1
• Tinnitus occurs in 27-38% of VM patients, even with unilateral symptoms 3, 4
• Improvement with head support suggests cervical muscle tension and postural triggers common in VM 1
• Brief visual blackouts (seconds) without syncope may represent visual aura or orthostatic component of migraine 1

Chronic Migraine with Vestibular Features

• Chronic migraine is diagnosed when headaches occur ≥15 days/month for ≥3 months, with ≥8 days meeting migraine criteria 1
• The daily nature of headaches strongly suggests chronic rather than episodic migraine 1

Secondary Diagnostic Considerations

Cervicogenic Vertigo

• Improvement with head support is a red flag for cervicogenic contribution 1
• Cervicogenic headache is provoked by cervical movement rather than pure posture, with reduced cervical range of motion and myofascial tenderness 1
• This may coexist with migraine rather than being mutually exclusive 1

Ménière's Disease (Less Likely)

• Ménière's disease typically presents with discrete episodic attacks of sustained vertigo (not brief seconds), fluctuating hearing loss, aural fullness, and tinnitus 1
• The absence of documented hearing loss and the brief nature of visual symptoms make this less likely 1
• However, 59% of Ménière's patients have migrainous features, and 21-25% have concomitant VM 4

Vertebrobasilar Insufficiency (Must Exclude)

• Isolated transient vertigo can be the initial symptom of vertebrobasilar insufficiency, potentially preceding stroke by weeks to months 1
• Brief visual blackouts (seconds) with tinnitus could represent posterior circulation transient ischemic attacks 1
• The absence of syncope and other neurologic deficits makes this less likely but does not exclude it 1
• Vascular risk factors (age, hypertension, atrial fibrillation) increase suspicion 1

Spontaneous Intracranial Hypotension (Consider)

• "End of day" or "second half of the day" headache with improvement lying flat is characteristic 1
• However, true orthostatic headache should be absent/mild on waking and onset within 2 hours of becoming upright 1
• The years-long duration makes this less likely unless there is chronic CSF leak 1

Postural Orthostatic Tachycardia Syndrome (PoTS)

• Dizziness with postural component and improvement when supporting head could suggest autonomic dysfunction 1
• Requires formal standing test documenting heart rate increase >30 bpm 1

Critical Red Flags Requiring Urgent Evaluation

The following features warrant immediate neuroimaging and vascular assessment:

• Brief visual blackouts could represent posterior circulation ischemia 1
• New or changing pattern of dizziness ("more recently comes out of nowhere") suggests evolving pathology 1
• Years of daily headaches with new vestibular symptoms requires exclusion of posterior fossa mass lesions 1

Recommended Diagnostic Approach

Initial Assessment

• Document headache frequency using headache diary to confirm chronic migraine (≥15 days/month) 1
• Assess for migraine features: unilateral location, pulsating quality, moderate-severe intensity, photophobia, phonophobia, nausea 1
• Perform formal standing test to evaluate for PoTS or orthostatic hypotension 1
• Assess cervical range of motion and myofascial tenderness 1

Neuroimaging

• MRI head without IV contrast is recommended to exclude posterior circulation infarct, posterior fossa mass, and other structural causes 1
• The diagnostic yield is low (~4%) in isolated dizziness, but vascular risk factors and combined symptoms increase yield 1
• MRA head and neck should be considered given concern for vertebrobasilar insufficiency 1

Audiometric Testing

• Formal audiometry to document any hearing loss that would support Ménière's disease 1

Common Pitfalls to Avoid

• Do not dismiss daily headaches as "just tension headaches" without assessing for chronic migraine criteria 1
• Do not assume brief visual symptoms are benign without excluding posterior circulation ischemia, especially with vascular risk factors 1
• Do not overlook the overlap between VM and Ménière's disease—up to 25% have both conditions 4
• Do not attribute all symptoms to anxiety without excluding organic causes, though anxiety commonly coexists with VM 1, 2
• Do not miss cervicogenic contribution—improvement with head support is a specific clue 1