541: Post-traumatic headache masking BPPV after mild traumatic brain injury: a case of vestibular agnosia

Topic: Clinical Science
Subtopic: Pain category (ICD-11), Chronic secondary headache, Physiotherapy (e.g. exercise, rehab), Physiotherapy, Pain in special populations (e.g. neonates, children, teens, elderly, neurodegenerative diseases)

Background and Aims: After mild traumatic brain injury (mTBI), symptom clusters consistent with post‑traumatic headache, visual strain, cervical, and fatigue often dominate clinical triage, potentially delaying identification of co‑occurring vestibular disorders. This case describes a worker with prominent headache provoked by screen/reading tasks and positional dizziness without classic vertigo. We aimed to show how reduced perception of self‑motion (“vestibular agnosia”) can mask objective benign paroxysmal positional vertigo (BPPV) and how guideline‑based vestibular screening can reduce overall symptom burden and disability in a medically complex, yet stable individual.

Methods: A male worker sustained a ladder fall with mTBI and concurrent orthopedic injury with prolonged post‑event amnesia. Assessment included symptom profiling (Rivermead Post‑Concussion Symptoms Questionnaire), cervical screening, bedside oculomotor examination (near point of convergence, saccades, vestibulo‑ocular reflex) and positional testing (Dix–Hallpike and supine roll). Exercise tolerance was screened using a Buffalo Concussion Treadmill Test–guided protocol to inform graded aerobic rehabilitation. Management integrated canalith repositioning when indicated plus staged vestibular and aerobic rehabilitation.

Results: Rivermead score was 24/64 at intake with headache/visual strain, fatigue and cognitive fog prominent. Despite no vertigo reporting, and initial presenting referral was for headache management, Dix–Hallpike elicited transient torsional upbeating nystagmus consistent with posterior canal BPPV, supporting BPPV with reduced symptom awareness (vestibular agnosia). Canalith repositioning (Epley) was performed and repeated as indicated; subsequent Dix–Hallpike and roll testing became negative. Positional nystagmus resolved and the patient returned to full daily function; Rivermead improved to 0/64 at discharge. The patient experienced a rapid and near-complete resolution of blurred vision and improved near point convergence.

Conclusions: In concussion care, post‑traumatic headache and global symptom burden may bias triage away from vestibular testing. Objective eye‑movement findings and structured positional assessment can identify treatable BPPV even when vertigo perception is reduced. Integrating guideline‑based vestibular screening and canalith repositioning into pain‑focused rehabilitation pathways may shorten symptom duration, improve function, and reduce disability attributed to chronic secondary headache phenotypes.

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Calzolari E, Chepisheva M, Smith RM, et al. Vestibular agnosia in traumatic brain injury and its link to imbalance. Brain. 2021;144(1):128–143. doi:10.1093/brain/awaa386.

Cedras, A. M., Dion, J., Saj, A., Champoux, F., & Maheu, M. (2025). Vestibular agnosia: Toward a better understanding of its mechanisms. Audiology Research, 15(1), 15. https://doi.org/10.3390/audiolres15010015

McCormick K, Kolar B. Research Letter: Rate of BPPV in Patients Diagnosed With Concussion. Journal of Head Trauma Rehabilitation. 2023;38(6):434–438. doi:10.1097/HTR.0000000000000867.

Smith RM, Marroney N, Beattie J, et al. Treating benign paroxysmal positional vertigo in acute traumatic brain injury: a prospective, randomised clinical trial assessing safety, feasibility, and efficacy. BMJ Neurology Open. 2024;6(1):e000598. doi:10.1136/bmjno-2023-000598.

Presenting Author: Jason Taddeo
Submitting Author: Jason Taddeo

Senior Author: Jason Taddeo

IASP 2026 Global Year theme of Neuropathic Pain: No