Vestibular findings in a young man with dizziness and headaches.

A 29-year-old man presented with complaints of dizziness and headaches. The dizziness had begun 1 year earlier, and it was accompanied by an off-balance feeling when he bent over or suddenly moved. Six months before his visit, the patient experienced periods of 24 to 48 hours when he would feel spells of imbalance when turning his head. The spells were intermittent and of varying intensity and associated nausea. He said the duration of the spells had recently increased.

The patient's headaches had begun 8 months prior to his visit. The pain originated in the neck and worked its way tip to the head, more so on the left side. The headaches preceded the dizziness, and the dizziness eventually became constant. Two weeks prior to presentation, he also began to experience a constant, high-pitched tinnitus in both ears. The tinnitus was not associated with his dizziness or headaches. The patient reported no subjective hearing loss or aural fullness. His medical history was significant for rheumatoid arthritis (diagnosed 3 months earlier), Reiter's syndrome, and seasonal allergy. He smoked 2 packs of cigarettes per day and ate 2 meals per day with no restrictions on selection. Clinical examination revealed that he had difficulty performing the sharpened tandem Romberg's test.

Electronystagmography identified no spontaneous, positional, or neck-torsion nystagmus. The alternate binaural bithermal caloric test elicited a normal reduced vestibular response (RVR) and directional preponderance. The simultaneous binaural bithermal caloric test elicited a type 2 response, indicating an RVR left.

Patients with a fundamental peripheral vestibular disorder frequently experience hemicranial headaches that originate on the same side as the vestibular abnormality. This patient's headaches began primarily on the left side of the neck and progressed to the head. The neurologic reflex produced by a peripheral vestibular disorder through the brainstem, instead of resulting in nystagmus, stimulates the vestibulospinal tract. The cervical muscles are the closest of the stimulated muscles. Because humans consciously keep our heads straight while the vestibulospinal reflex is active, the muscles go into spasm when they attempt to move the neck. This spasm produces the headaches commonly seen in patients with vestibular disorders.

In this patient, there is a vestibular system abnormality demonstrated. The pathophysiology of both the dizziness and headaches is from the same vestibular system abnormality.

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From Neurologic Associates, PC, New York City.