What could be causing my head pressure, palpitations in the head, and dry eyes?

Head Pressure, Pulsatile Sensations, and Dry Eyes: Diagnostic Approach

Your symptoms of head pressure with pulsatile sensations ("feeling heartbeat in head") combined with dry eyes warrant evaluation for elevated intracranial pressure, particularly pseudotumor cerebri (idiopathic intracranial hypertension), though other causes including medication effects and primary dry eye disease must also be considered. 1, 2

Immediate Evaluation Priorities

Critical Red Flags to Assess

The combination of head pressure with pulsatile sensations raises concern for elevated intracranial pressure. You need urgent evaluation if you have:

• Visual changes or transient visual obscurations (brief episodes of vision loss lasting seconds) - present in nearly 90% of pseudotumor cerebri cases 2
• Pulsatile tinnitus (whooshing sound in ears synchronized with heartbeat) 2
• Horizontal double vision (diplopia), often from sixth nerve palsy 2
• Papilledema on eye examination (optic nerve swelling) 1, 2
• Progressive worsening of headache or vision 3

Key Demographic Risk Factors

Pseudotumor cerebri predominantly affects overweight females of childbearing age, though it can occur in males and prepubertal children 1

Recommended Diagnostic Workup

Primary Imaging Study

MRI of the brain and orbits with and without contrast is the most appropriate initial imaging study for evaluating suspected elevated intracranial pressure 1, 2. This should include:

• MR venography (MRV) to evaluate for venous outflow obstruction 2
• Coronal fat-saturated T2-weighted orbital sequences to assess optic nerve sheath dilation 1, 2

Key MRI Findings Suggesting Elevated Intracranial Pressure

If present, these findings support the diagnosis:

• Empty or partially empty sella (typical finding in raised intracranial pressure) 2
• Posterior globe flattening (56% sensitivity, 100% specificity) 2
• Dilated optic nerve sheaths 1, 2
• Tortuous or enhancing optic nerves (68% sensitivity for tortuosity) 2
• Intraocular protrusion of optic nerve (40% sensitivity, 100% specificity) 2

Lumbar Puncture Considerations

If MRI shows findings consistent with elevated intracranial pressure, lumbar puncture with opening pressure measurement is diagnostic 2:

• Opening pressure >250 mm H₂O defines idiopathic intracranial hypertension and requires urgent intervention 2
• Pressures of 180-250 mm H₂O are concerning but may not require immediate treatment 2
• CSF analysis should be normal (no elevated white cells or organisms, distinguishing this from meningitis) 2
• The procedure itself may provide therapeutic benefit by removing 20-30 mL of CSF 2

Dry Eye Evaluation and Management

Medication Review

Multiple medications can cause or worsen dry eye disease 4:

• Antihistamines, antidepressants, and antianxiety medications are strongly associated with dry eye 1, 4
• Diuretics and anticholinergics increase dry eye risk 4
• Systemic retinoids (like isotretinoin for acne) cause dry eye 4
• Topical glaucoma medications with benzalkonium chloride are particularly problematic 4

Important exception: ACE inhibitors are actually associated with lower risk of dry eye and may improve tear function 4, 5

Environmental and Lifestyle Factors

Address these modifiable risk factors 1, 4:

• Extended screen time with reduced blink rate 4
• Low humidity environments (air conditioning, heating, wind) 1, 4
• Smoking (strongly associated with dry eye) 1, 4
• Direct air drafts - use side shields on glasses 1

Initial Dry Eye Treatment

Start with preservative-free artificial tears 1, 3:

• Use preservative-free formulations if applying more than 4 times daily 1
• Preserved drops used >4 times daily cause corneal epithelial breakdown 4
• Consider gels or ointments for longer-lasting effect, though they may blur vision 1
• Implement environmental modifications: humidifiers, reduced screen time, avoiding direct airflow 3

When to Seek Ophthalmology Consultation

Refer to ophthalmology if 3:

• Moderate or severe eye pain develops 3
• No response to over-the-counter lubricating drops 3
• Progressive worsening of vision 3
• Symptoms significantly impact quality of life 3

Alternative Diagnoses to Consider

Benign Positional Causes

Benign paroxysmal positional vertigo (BPPV) can cause head pressure and disorientation but typically presents with:

• Distinct triggered spells of vertigo lasting seconds to minutes 1
• Symptoms triggered by specific head positions (lying down, rolling over, looking up) 1
• Does NOT cause constant dizziness, hearing loss, or fainting 1
• Diagnosed with bedside Dix-Hallpike or supine roll testing 1

Low Intracranial Pressure

Spontaneous intracranial hypotension presents differently:

• Orthostatic headache (worse when upright, better lying down) 6, 7
• CSF opening pressure <60 mm H₂O 6, 7
• Often follows minor trauma 6
• MRI shows diffuse pachymeningeal enhancement and brain "sagging" 6

Clinical Pitfalls to Avoid

• Do not dismiss pulsatile head sensations as anxiety - this can be a cardinal symptom of elevated intracranial pressure 2
• Do not assume all dry eye is benign - severe cases can lead to corneal scarring, ulceration, and vision loss 1
• Do not use preserved artificial tears frequently - they worsen the problem beyond 4 applications daily 1, 4
• Meningeal enhancement on MRI after lumbar puncture is normal and should not be confused with pathology 1

Systematic Approach Summary

1. Urgent ophthalmology evaluation if you have visual changes, papilledema, or progressive symptoms 3, 2
2. MRI brain/orbits with contrast and MRV if elevated intracranial pressure suspected 1, 2
3. Lumbar puncture with opening pressure if MRI shows concerning findings 2
4. Comprehensive medication review - discontinue or substitute dry eye-causing medications when possible 4
5. Initiate preservative-free artificial tears and environmental modifications immediately 1, 3
6. Consider systemic evaluation for Sjögren's syndrome if dry eye is severe or occurs in younger patients/males 1