College Student With Episodes of Dizziness and Nausea

March 8, 2019

This young woman is otherwise healthy and doesn’t drink or abuse drugs. What’s in your differential diagnosis?

THE CASE

A 21-year-old college student has had episodes of dizziness that last for 12 to 48 hours. She describes a sensation of spinning, accompanied by nausea, dry heaving, and impaired balance. She has no vision loss or neurological deficits before, during, or after the events.

Two episodes occurred during her second semester in college and at least three more during her sophomore year. They increased in frequency during the first semester of her junior year. The episodes are often preceded by stress, but they have also occurred without any precipitating event. Her most recent episodes occurred during the week of her midterm examinations. She said that she had been under stress and had not been sleeping well that week.

During one episode, she fell while walking to class. A friend accompanied her to the student health office, where she was seen and transferred to a nearby emergency department. The results of a brain CT scan were normal, and she was given a prescription for meclizine to take as needed. She used it at the onset of her next two episodes, but it was not helpful.

She decided to move back home for a semester and is taking two online classes. While living at home, she had one episode of dizziness, which was accompanied by a mild headache.

The patient is otherwise healthy, but she is very upset about her dizziness and is concerned about her ability to graduate from college.

Medical and family history

When she was a child, she had episodes of cyclical vomiting and received a tentative diagnosis of abdominal migraine. The episodes had stopped by the time she was 13 years old. She does not drink alcohol or smoke and has not used any recreational drugs. She does not take over-the-counter or prescription medications except for meclizine.

Her father has Ménière disease. Her mother has a possible diagnosis of lupus.

Physical examination

The patient appears well-nourished and is no acute distress. She is alert and cooperative. No skin discoloration or lesions are evident, and the results of cardiac, respiratory, and abdominal examinations are normal.

Neurological examination

She has normal extraocular movements with no facial asymmetry. Pupils are equal, round, and reactive to light with no asymmetry or papilledema. Motor strength is 5/5 and reflexes are intact in bilateral upper and lower extremities. Coordination is normal without ataxia or dysmetria. Sensory examination is normal to light touch, pinprick, vibration, and proprioception, and gait is normal.

Diagnostic tests

A brain MRI scan with contrast is normal. The results of a hearing test are also normal.

What’s in your differential diagnosis? >>

DIAGNOSIS: MÉNIÈRE DISEASE VERSUS VESTIBULAR MIGRAINE

The patient was given a diagnosis of Ménière disease versus vestibular migraine. Although she has a family history of Ménière disease, she does not have several of the typical characteristics of the disease, such as tinnitus and hearing loss. She had abdominal migraines as a child, which suggests that she could also be having migraines as a young adult. Unfortunately, the symptoms of these two conditions are similar, and there is no definitive test to rule out either condition.

Discussion

Vestibular migraines most often begin in a person’s 20s or 30s. Symptoms include severe vertigo, nausea, vomiting, and unsteadiness. Head pain, fatigue, photophobia, and phonophobia may accompany some episodes. A family or personal history of migraine can help point to the diagnosis. Treatment options include over-the-counter anti-inflammatory medications and/or triptans. Preventive strategies may be helpful, including lifestyle modification and medical prophylaxis, such as acetazolamide, a diuretic.1

Ménière disease can present with dizziness, tinnitus, and hearing loss. Diagnosis requires the presence of recurrent vertiginous episodes, hearing loss, tinnitus, or fullness in the ear. However, these symptoms may not all be present at the onset of the disease. So, while this patient does not have ear problems, they may develop at some point in the future, potentially leading to an eventual diagnosis of Ménière disease. A hearing test and vestibular evoked potentials can be helpful in the diagnosis.

According to the International Consensus for Recommendations for Ménière’s Disease Treatment (ICON), the recommended treatments include diuretics, betahistine (which is not available in the United States), and local pressure therapy. Intratympanic injection of corticosteroids is recommended as second-line treatment, and endolymphatic sac surgery or intratympanic injection of gentamicin is recommended as third-line therapy.2 Interestingly, patients with Ménière disease have an improved quality of life when treated with medications used for vestibular migraine.3

The fact that this patient has experienced stress and sleep deprivation prior to her episodes supports a diagnosis of migraine, although these factors can precipitate symptomatic episodes in patients who have Ménière disease as well.

Migraines are treatable, while Ménière disease is more difficult to manage. This patient was given a prescription for sumatriptan. Her physician asked her to observe her response to the triptan to see if it could alleviate her symptoms when taken during an episode. She did not have further episodes for several months and did not use (or need to take) the sumatriptan. Her improvement may have been related to better sleep, lower stress, or spontaneous resolution of her condition.

Take-home points

• Vestibular migraine and Ménière disease are difficult to distinguish.

• Lifestyle modification can alleviate episodic symptoms, potentially prolonging a definitive diagnosis.

• Treatment of vestibular migraine can improve quality of life for patients with a diagnosis of Ménière disease.

References:

1. Çelebisoy N, Gökçay F, Karahan C, et al. Acetazolamide in vestibular migraine prophylaxis: a retrospective study. Eur Arch Otorhinolaryngol. 2016;273:2947-2951. doi: 10.1007/s00405-015-3874-4

2. Nevoux J, Barbara M, Dornhoffer J, et al. International consensus (ICON) on treatment of Ménière's disease. Eur Ann Otorhinolaryngol Head Neck Dis. 2018;135(1S):S29-S32. doi: 10.1016/j.anorl.2017.12.006

3. Ghavami Y, Haidar YM, Moshtaghi O, et al. Evaluating quality of life in patients with Meniere’s disease treated as migraine. Ann Otol Rhinol Laryngol. 2018;127:877-887. doi: 10.1177/0003489418799107