The architect with neck pain and visual sensitivity
A 36-year-old architect with cyclical neck pain and discrete vertigo episodes — the most-likely-missed diagnosis.
Vignette
A 36-year-old architect has been told elsewhere she has cervicogenic dizziness. She has six episodes a year of spinning dizziness lasting 4–6 hours, usually preceded by 24 hours of neck and shoulder stiffness. During episodes she is photophobic and phonophobic, retreats to a darkened room, and is unable to work. Between episodes she is well. She has a long history of premenstrual headaches treated as 'tension headaches'. Her mother had migraine. She has been treated with two months of upper-cervical mobilisation, which she found pleasant but which has not changed her episode frequency or severity.
Examination and workup
Cervical examination is essentially normal — minimal segmental tenderness, full range of motion, negative cervical torsion test, normal JPE, normal SPNT. vHIT, VNG, calorics all normal. Audiogram symmetric. Between episodes she has no central oculomotor signs and no neurological signs. During an episode (witnessed by an attending colleague in clinic): horizontal nystagmus, no skew, no other neurological signs, severe photophobia, denies hearing change.
Question
Which is the most likely diagnosis?
Teaching point
The single most consequential differential point in this atlas: **vestibular migraine is the most-likely missed diagnosis in patients labelled 'cervicogenic'**. The Bárány Society 2022 position statement is explicit — migraine is by far the commonest cause for the combination of neck pain and vestibular symptoms. Before settling on a cervicogenic diagnosis, screen for vestibular migraine; in any patient with a credible migraine history and discrete attacks with light/sound sensitivity, vestibular migraine takes diagnostic precedence.
References
- 22 Seemungal BM, Agrawal Y, Bisdorff A, Bronstein A, Cullen KE, Goadsby PJ, et al. (2022). The Bárány Society position on 'Cervical Dizziness'. Journal of Vestibular Research, 32(6):487–499. link
- 37 Lempert T, Olesen J, Furman J, Waterston J, Seemungal B, Carey J, Bisdorff A, Versino M, Evers S, Newman-Toker D (2022). Vestibular migraine: Diagnostic criteria (Update). Consensus document of the Bárány Society and the International Headache Society. Journal of Vestibular Research, 32(1):1–6. link