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Endgames Case Review

Recurrent vertigo associated with headaches

BMJ 2018; 363 doi: (Published 31 October 2018) Cite this as: BMJ 2018;363:k1807
  1. Georgios Kontorinis, consultant ear, nose, and throat surgeon and neurotologist1,
  2. Alok Tyagi, consultant neurologist2,
  3. John A Crowther, consultant ear, nose, and throat surgeon and neurotologist1
  1. 1Department of Otolaryngology, Queen Elizabeth University Hospital, Glasgow, UK
  2. 2Department of Neurology, Institute of Neurological Sciences, Queen Elizabeth University Hospital, Glasgow, UK
  1. Correspondence to G Kontorinis gkontorinis{at}

A 37 year old woman attended the otolaryngology department with episodes of dizziness (“a feeling of swaying”), occasional rotatory vertigo, and unilateral right sided headaches that usually occurred once a week and had been ongoing for six weeks. Her symptoms could last several hours and were sometimes preceded with the appearance of transient flashing lights. Some episodes were associated with short lasting blurred vision and occasional nausea. Her symptoms were unrelated to head or neck movements but could deteriorate with tiredness, bright light exposure, or high coffee consumption. They would improve after several hours if she could lie down in a dark room. The headaches would usually follow the dizziness/vertigo. There was catamenial exacerbation of her symptoms but no phonophobia, hearing problems, or tinnitus.

She had a history of similar episodes a few years ago that had gradually settled without medication.

Clinical examination was unremarkable. She underwent magnetic resonance imaging (MRI) of the brain and inner ear (fig 1).

Fig. 1

Axial fast imaging using steady state acquisition (FIESTA) MRI of the internal auditory meatus and the brain (A) with a focus on the internal auditory meatus (B) 

Fig. 2

No abnormalities seen on axial FIESTA-MRI. IAM: internal auditory meati. CPA: cerebellopontine angles bilaterally (no vestibular schwannoma). (1) White arrows point to the cochleovestibular nerves in the IAM. (2) Loop of the anterior-inferior cerebellar artery. (3) The labyrinth (in this section with the lateral semicircular canal). (4) Long dotted arrows show the cochlea. (5) White X marks the anterior end of …

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