A 76-Year-Old Man With Episodic Vestibular Syndrome and Skew Deviation

A 76-year-old man presented with a 2-week history of intermittent episodic rotational vertigo accompanied by blurred vision, vomiting, and imbalance. Neurologic examination revealed no sensory, motor, or cranial nerve deficits. However, the head impulse, nystagmus, and test of skew (HINTS) exam demonstrated right-beating nystagmus that intensified with visual suppression, a vertical skew deviation with right hyperphoria, and a normal vestibulo-ocular reflex (VOR) on video head impulse testing (vHIT), except for clustered refixation saccades for rotations in the plane of the left horizontal semicircular canal. Following a thorough workup, a posterior fossa stroke was ruled out and the patient was diagnosed with vestibular migraine (VM) and Meniere's Disease (MD). This case highlights the diagnostic considerations for episodic vestibular syndrome (EVS) in a patient with significant cardiovascular risk factors. We discuss the differential diagnosis, emphasizing the need for thorough history, targeted examination, and imaging to refine diagnostic interpretation, particularly in the context of positive skew deviation.