What are the causes of head pressure?

Causes of Head Pressure

Head pressure can be caused by primary headache disorders (migraines, tension headaches), intracranial pressure abnormalities (high or low), vascular disorders, or structural lesions, with proper diagnosis requiring careful evaluation of accompanying symptoms and neurological signs. 1, 2

Primary Causes of Head Pressure

Migraine

• Often misdiagnosed as "sinus headache" in up to 62% of cases 1
• Features include:
  • Pulsating pain, often unilateral
  • Associated with nausea, photophobia, phonophobia
  • May include cranial autonomic symptoms (rhinorrhea, lacrimation) 1
  • Can be triggered by position changes in some cases

Tension-Type Headache

• Bilateral pressure sensation
• Band-like tightness around the head
• Usually not associated with significant neurological symptoms

Benign Paroxysmal Positional Vertigo (BPPV)

• Can cause head pressure with positional changes
• Triggered by specific head movements
• Associated with brief spinning sensations 1

Secondary Causes - Intracranial Pressure Abnormalities

Increased Intracranial Pressure

• Key clinical features:

  • Headache worse when lying down or with Valsalva maneuvers
  • Morning headache or headache awakening patient from sleep
  • Associated with papilledema in 60% of cases 1
  • May have transient visual obscurations, diplopia (sixth nerve palsy) 3
  • Neurological signs including gait disturbance, abnormal reflexes 1

• Common causes:

  • Idiopathic intracranial hypertension (pseudotumor cerebri) - especially in overweight females 1, 3
  • Brain tumors - 94% have abnormal neurological findings 1
  • Cerebral venous thrombosis 1
  • Hydrocephalus
  • Meningitis/encephalitis

Decreased Intracranial Pressure

• Key clinical features:

  • Orthostatic headache (worse when upright, better when lying down) 4, 3, 5
  • Associated with nausea, neck pain, interscapular pain
  • May have tinnitus, hearing changes, or cranial nerve palsies 5

• Common causes:

  • Spontaneous CSF leak (often at spine level) 4, 5
  • Post-lumbar puncture headache
  • CSF shunt over-drainage 4
  • Diskogenic microspurs causing dural tears 2

Vascular Causes

Cerebral Venous Thrombosis

• Risk factors include:
  • Hypercoagulable states
  • Pregnancy/postpartum period
  • Oral contraceptives
  • Cancer (4% of cases) 1
  • Dehydration

Arterial Disorders

• Arterial dissection
• Vasculitis
• Reversible cerebral vasoconstriction syndrome
• Medication overuse (triptans can cause cerebral vasospasm) 6

Hypertension

• Severe sustained or malignant hypertension can cause headache 7
• Paroxysmal hypertension can trigger head pressure 7
• May worsen existing migraine or transform episodic to chronic headache 7

Structural/Anatomical Causes

Chiari Malformation

• Cerebellar tonsil herniation through foramen magnum 1
• Headache typically worsens with Valsalva maneuvers
• More common in children >3 years with scoliosis 1

Sinusitis

• Often overdiagnosed as cause of headache
• True sinusitis features include:
  • Purulent nasal discharge
  • Fever
  • Facial tenderness
  • Abnormal sinus imaging

Cervical Spine Disorders

• Cervical spondylosis
• Facet joint arthropathy
• Occipital neuralgia 8

Red Flags Requiring Urgent Evaluation

• Sudden-onset, severe "thunderclap" headache
• New headache after age 50
• Progressive worsening headache
• Headache with fever, neck stiffness, or rash
• Headache with focal neurological deficits or altered mental status
• Headache following head trauma
• Headache with papilledema or visual changes 1

Diagnostic Approach

1. For suspected increased intracranial pressure:

   • MRI brain with contrast is preferred over CT 1
   • Look for:
     • Empty sella
     • Flattening of posterior globes
     • Dilated optic sheaths
     • Venous sinus engorgement 1, 2

2. For suspected CSF leak/intracranial hypotension:

   • MRI brain and complete spine (with and without contrast) 4
   • Note: CSF pressure may be normal in over 50% of cases 2
   • β2-transferrin testing of fluid if rhinorrhea/otorrhea present 4

3. For suspected vascular causes:

   • MRI with MR venography if cerebral venous thrombosis suspected 1
   • CT angiography or MR angiography for arterial disorders

Remember that neuroimaging in patients with typical features of primary headache disorders rarely contributes to diagnosis or management 1. However, imaging is warranted when secondary causes are suspected based on clinical presentation.