Electronystagmography in a woman with dizziness, tinnitus, and headache.

A 34-year-old woman came to the office with a 5-year history of recurrent dizziness. She said her spells would occur at any time during the day and that they had become worse over the preceding year. She said she would experience a sensation of "whirling" inside her head, with or without nausea. Associated with the dizziness was a severe "pounding" headache in the left temple area that would last for approximately 1 hour. She said she was incapacitated by the dizziness, which "zapped" (fatigued) her. She reported no aural fullness or hearing loss (although there was a family history of hearing loss), but she had experienced intermittent tinnitus for the preceding year. She described the tinnitus as a high-pitched ringing that was louder on the left. She had been taking birth control pills for 14 years.

Magnetic resonance imaging with contrast was negative for any abnormality. Clinical examination revealed only difficulty performing the sharpened tandem Romberg's test. Electronystagmography found no spontaneous, positional, or neck-torsion nystagmus. The alternate binaural bithermal test elicited a less active warm response in the left ear, with a reduced vestibular response (RVR) of 24%. The simultaneous binaural bithermal test elicited a clear-cut type 4 response, with a right-beating warm response and possibly a not-so-clear-cut type 2 RVR left. Findings on audiometry were completely normal for both pure tones and speech. Acoustic immittance testing yielded a shallow tympanogram on the left, with normal reflexes and no decay of the acoustic stapedial reflex.

These findings are consistent with a left peripheral vestibular disorder. The fact that the louder tinnitus and the headache occurred on the same side supports the identification of the left side as the source of the dizziness. The patient's headache appears to have been caused by an exaggeration of the vestibulocollic reflex.