The patient, a 17 year old male, reports vertigo and lightheadedness. The episodes start with a brief 30-45 second period where he is unaware of what is happening around him. He then has a visual disturbance, where he sees a “trail” behind the image he is looking at when he moves his head. He describes it as the room tilting, or vibrating, rather than spinning. He also has a warm sensation and pressure in the back of his head. This has been reported over a fairly long duration, at least for a year.
Additionally there are times when he stands up that everything goes black and then resolves slowly in 20-30 seconds.
He has recent migraine headache history beginning two months ago according to the neurologist’s report, but longer according to the ENT report. These start with blinding light and dizziness and frontal area headache in addition to the almost constant pressure and warm sensation in the back of his head. Visual objects have a white outline around them. These episodes resolve with medication, ice packs to the head and trying to sleep. These are occurring 3-4 times per month.
His migraine headaches with photophobia and nausea are triggered by sleeping in late and possibly by consuming too much sugar. The headaches are treatable with Maxalt, but he is having difficulty obtaining that drug on his insurance plan.
The ENT reports indicates that one time this year, following an upper respiratory infection, he had nausea and vomiting without any headache or nausea, and this occurred for about a month.
He has a 10 year history of middle ear infections and has had tubes as recently as one year ago.
He has high blood pressure, medically treated. He had heart testing early in life, with negative results. He has random episodes of shortness of breath not related to physical exertion.
He has been on Adderall for two years.
He had a fall down carpeted stairs at 8 months with no evidence of sustained injury. He says as a very young child he had episodes where his “vision would flip upside down” but he could not describe it further.
He reports mild anxiety to the ENT and denies anxiety to the neurologist. His mother paints a different picture, saying he has significant anxiety but that various attempts at counseling have only made things worse. This began at age 10 when his parents were divorcing. His father has serious illness in his medical history: lung disease, aneurysm, hypertension, cardiac disease and cancer.
He reports that his hands are always “asleep or really cold and clammy.” He has hot flashes and cold chills not related to room temperature. He says his appetite is good. He has some insomnia – he has difficulty falling asleep, awakens during the night but then usually falls back to sleep.
His most recent hearing test showed normal hearing – pure tone thresholds 15 dB HL or less, no air-bone gaps and normal tympanograms.
His neurologic examination results were within normal limits.
Case credits: this case was donated by Patricia Gaffney, AuD. It is a de-identified case she was given.