How should I evaluate and manage a patient presenting with headache and dizziness?

Evaluation and Management of Headache and Dizziness

Begin by determining the temporal pattern of symptoms using the "timing and triggers" approach to categorize the patient into one of three key vestibular syndromes, as this classification directly guides both diagnosis and management. 1

Initial Categorization by Temporal Pattern

The most critical first step is classifying the presentation into one of three categories 1:

1. Acute Vestibular Syndrome (AVS)

• Continuous dizziness/vertigo lasting days, with nausea/vomiting, gait instability, nystagmus, and head-motion intolerance 1
• Key distinction needed: Vestibular neuritis (benign) vs. posterior circulation stroke (dangerous) 1
• Use HINTS examination (Head Impulse, Nystagmus, Test of Skew) when performed by trained examiners to distinguish central from peripheral causes 2
• MRI has 79.8% sensitivity and 98.8% specificity for central causes, while CT has only 28.5% sensitivity 3
• Neuroimaging is indicated only when red flags are present (see below) 2

2. Spontaneous Episodic Vestibular Syndrome

• Recurrent episodes of dizziness/vertigo lasting minutes to hours, occurring without specific triggers 1
• Primary considerations: Vestibular migraine vs. transient ischemic attack 1, 4
• Associated symptoms help differentiate: Headache, photophobia, phonophobia suggest vestibular migraine 4

3. Triggered Episodic Vestibular Syndrome

• Brief episodes (seconds to minutes) triggered by head position changes 1
• Use Dix-Hallpike and supine roll test to differentiate benign paroxysmal positional vertigo (BPPV) from posterior fossa lesions 1

Red Flags Requiring Neuroimaging

Obtain MRI (preferred over CT) only when these red flags are present 2:

History Red Flags:

• Thunderclap headache (subarachnoid hemorrhage) 2
• Atypical aura (TIA, stroke, epilepsy) 2
• Recent head trauma (subdural hematoma) 2
• Progressive headache (space-occupying lesion) 2
• Headache aggravated by Valsalva or position changes 2
• New onset at age >50 years (consider temporal arteritis) 2

Examination Red Flags:

• Unexplained fever (meningitis) 2
• Neck stiffness (meningitis, subarachnoid hemorrhage) 2
• Focal neurological deficits 2
• Impaired memory or altered consciousness 2

Important caveat: Noncontrast CT misses approximately 71.5% of strokes in acute dizziness presentations; MRI still misses approximately 20% if obtained very early after symptom onset 3

Migraine-Specific Evaluation

When Migraine is Suspected:

Apply ICHD-3 diagnostic criteria 2:

• Recurrent headaches lasting 4-72 hours 2
• At least two of: unilateral location, pulsating quality, moderate-to-severe intensity, aggravation by routine activity 2
• At least one of: nausea/vomiting, photophobia, phonophobia 2
• Note: Bilateral pain occurs in ~40% of migraine patients 2

Screen for medication overuse headache (MOH) risk factors (in order of impact) 2:

• Headache frequency ≥7 days/month 2
• Migraine diagnosis 2
• Frequent use of anxiolytics, analgesics (including opioids), or sedative-hypnotics 2
• History of anxiety or depression with musculoskeletal or GI symptoms 2
• Physical inactivity 2

Assess for comorbidities that influence treatment selection 2:

• Anxiety, depression, sleep disturbances 2
• Obesity (favors topiramate) 2
• Chronic pain conditions 2

Acute Treatment Algorithm

First-Line: NSAIDs 2

• Acetylsalicylic acid, ibuprofen, or diclofenac potassium 2
• Paracetamol alone is ineffective 2
• Advise early use when headache is still mild 2

Second-Line: Triptans 2

• Use when NSAIDs provide inadequate relief 2
• Most effective when taken early during mild headache phase 2
• Do not use during aura phase 2
• If one triptan fails, try others as response varies 2
• For relapses: Combine triptan with fast-acting NSAID (naproxen sodium, ibuprofen lysine, or diclofenac potassium) 2
• Contraindications: Uncontrolled hypertension, basilar/hemiplegic migraine, cardiovascular disease risk 2

Third-Line: Ditans or Gepants 2

• Only after adequate trial of triptans (no/insufficient response in ≥3 consecutive attacks) 2
• Lasmiditan (ditan): Comparable efficacy to triptans but causes driving impairment for ≥8 hours 2
• Ubrogepant or rimegepant (gepants) 2

Adjunct Therapy 2

• Prokinetic antiemetics (domperidone or metoclopramide) for nausea/vomiting 2

Avoid 2:

• Oral ergot alkaloids (poorly effective, potentially toxic) 2
• Opioids and barbiturates (questionable efficacy, dependency risk, rebound headache risk) 2

Preventive Therapy Indications

Consider preventive therapy when 2:

• ≥2 attacks per month causing disability lasting ≥3 days/month 2
• Contraindication to or failure of acute treatments 2
• Acute medication use >2 times per week 2
• Uncommon migraine conditions (hemiplegic, prolonged aura, migrainous infarction) 2

Preventive Medication Options:

For Episodic Migraine:

• Strong recommendations: Candesartan or telmisartan 2; Erenumab, fremanezumab, or galcanezumab (CGRP antibodies) 2
• Weak recommendations: Topiramate 2; Propranolol 2; Valproate 2; Lisinopril 2; Memantine 2; Oral magnesium 2

For Chronic Migraine:

• Evidence-based options: Topiramate (first choice due to cost), onabotulinumtoxinA, CGRP monoclonal antibodies 2
• Refer to specialist care for chronic migraine management 2

Tailor choice based on comorbidities 2:

• Obesity: Topiramate (causes weight loss) 2
• Depression/sleep disturbances: Amitriptyline 2

Patient Education Requirements

Provide comprehensive education on 2:

• Migraine as a chronic disease requiring ongoing management 2
• Realistic expectations: Treatment mitigates disability but does not cure migraine 2
• MOH risk: Frequent acute medication use (>2 days/week) increases risk 2
• Correct medication use, potential adverse effects, and when to seek re-evaluation 2
• Use headache diaries to track frequency, severity, duration, disability, treatment response, and adverse effects 2

Special Considerations

Dizziness during migraine phases 5:

• Prodromal phase: 9.0% report dizziness, 3.3% report vertigo 5
• Headache phase: 35.7% report dizziness, 33.9% report vertigo 5
• Vestibular testing may identify peripheral or central vestibular dysfunction in headache patients with dizziness 6

Follow-up management 2:

• Primary care should manage long-term after specialist stabilization 2
• Return to primary care once sustained efficacy achieved for 6 months without substantial adverse effects 2
• Emphasize patient self-efficacy in judging when return visits are necessary 2