Differential Diagnosis for Daily Headache with Dizziness

Initial Critical Step: Rule Out Secondary Causes

The American Academy of Otolaryngology-Head and Neck Surgery suggests that focal neurological deficits, such as diplopia, dysarthria, numbness, and weakness, require urgent evaluation 1
The Mayo Clinic recommends evaluating for secondary causes that could threaten morbidity and mortality before considering primary headache disorders 2

The International Headache Society defines chronic migraine as ≥15 headache days per month for ≥3 months, with ≥8 days meeting migraine criteria, and the American Headache Society suggests that each headache must last ≥4 hours 2, 3, 4
The American Academy of Otolaryngology-Head and Neck Surgery states that vestibular migraine presents with ≥5 episodes of moderate-to-severe vestibular symptoms lasting 5 minutes to 72 hours, with migraine features occurring in ≥50% of episodes 1, 5

The American Academy of Otolaryngology-Head and Neck Surgery describes Ménière's disease as episodic vertigo lasting 20 minutes to 12 hours, with fluctuating hearing loss, tinnitus, and aural fullness, and can closely mimic vestibular migraine 1, 5
The American Academy of Neurology suggests that benign paroxysmal positional vertigo (BPPV) is characterized by brief episodes of vertigo triggered by specific head movements, and the Dix-Hallpike maneuver and supine roll test can be used for diagnosis 6, 7

The American Heart Association recommends categorizing dizziness by timing rather than patient's subjective description, including acute vestibular syndrome, triggered episodic, spontaneous episodic, and chronic vestibular syndrome 6, 7
The American Academy of Neurology suggests that imaging is NOT routinely indicated for most cases of dizziness with headache, but MRI brain is indicated when abnormal neurological examination is present, HINTS examination suggests central cause, or high vascular risk with acute vestibular syndrome 6, 7

The American Academy of Otolaryngology-Head and Neck Surgery advises against relying on patient descriptions of "spinning" versus "lightheadedness" and instead focusing on timing and triggers 7
The American Heart Association warns against assuming a normal neurologic exam excludes stroke, as 75-80% of patients with posterior circulation infarct from acute vestibular syndrome have no focal neurologic deficits 7

The American College of Radiology notes that posterior‑circulation transient ischemic attack or stroke remains the primary concern even when MRI appears normal, because standard MRI lacks sensitivity for small acute infarcts unless diffusion‑weighted imaging is performed within 1–2 days of symptom onset. 8
The American College of Radiology recommends that vertebrobasilar insufficiency—presenting with transient occipital symptoms, visual disturbance, and dizziness—may require conventional (dynamic) angiography to assess vessel patency in various neck positions when clinical suspicion is high. 8
The American College of Radiology advises that vertebral‑artery dissection, which can manifest as occipital headache, visual symptoms, and vertigo, be evaluated with CT angiography or conventional angiography for definitive diagnosis. 8

The American College of Radiology advises obtaining MR angiography of the head and neck to evaluate for vertebrobasilar insufficiency, vertebral‑artery dissection, or other posterior‑circulation vascular malformations when a vascular etiology is suspected. [8][9]
The American College of Radiology states that conventional angiography may be necessary for dynamic assessment of the posterior circulation when positional vertebrobasilar insufficiency is suspected, as static CTA or MRA cannot adequately evaluate positional changes. 8