What are the recommended diagnostic steps and treatments for a severe headache accompanied by tingling sensations in both ears?

Severe Headache with Bilateral Ear Tingling: Diagnostic and Treatment Approach

This presentation requires urgent evaluation to exclude secondary causes, particularly vascular abnormalities, before treating as a primary headache disorder. The combination of severe headache with bilateral tingling sensations in the ears is atypical and warrants systematic investigation.

Immediate Diagnostic Steps

Red Flag Assessment

Evaluate immediately for secondary headache indicators that necessitate urgent neuroimaging:

• Sudden onset or "thunderclap" quality of the headache 1, 2
• Focal neurologic signs beyond the ear tingling 3
• Age over 50 years at first presentation 2, 4
• Headache provoked by Valsalva maneuver, cough, or exertion 2
• Associated systemic symptoms (fever, weight loss, immunocompromised state) 2, 3
• Altered mental status or personality changes 3

Characterize the Tinnitus Component

The bilateral ear tingling must be classified as pulsatile versus nonpulsatile, as this fundamentally changes the diagnostic approach 1:

• If pulsatile (synchronous with heartbeat): This suggests potential vascular pathology including arteriovenous malformations, vascular masses, intracranial hypertension, or arterial dissection 1
• If nonpulsatile (continuous, non-rhythmic): This is more consistent with primary headache disorders but still requires evaluation if associated with severe headache 1

Required Clinical Examination

Perform targeted otoscopic examination to identify vascular retrotympanic masses before any imaging 1. Complete neurologic examination is mandatory to detect focal deficits 2, 3.

Imaging Strategy

For Pulsatile Bilateral Ear Symptoms with Severe Headache

CT angiography (CTA) of the head and neck with mixed arterial-venous phase is the first-line imaging study 1:

• Obtain imaging 20-25 seconds after IV contrast injection to capture both arterial and venous anatomy in a single acquisition 1
• Request temporal bone reconstructions from the CTA source images to evaluate for vascular variants, sigmoid sinus abnormalities, and jugular bulb dehiscence 1
• This approach provides comprehensive evaluation while minimizing radiation exposure compared to separate studies 1

Alternative: MRI/MRA with internal auditory canal protocol if contrast allergy or radiation concerns exist 1:

• Include thin-section heavily T2-weighted sequences to evaluate vascular loops 1
• Volumetric post-contrast T1-weighted images for transverse and sigmoid sinus assessment 1

For Nonpulsatile Symptoms

Imaging is NOT routinely indicated if the tinnitus is bilateral, nonpulsatile, and not associated with focal neurologic abnormalities or asymmetric hearing loss 1. However, given the severe headache component, MRI brain without and with contrast is appropriate to exclude intracranial pathology 2, 4.

Acute Treatment Approach

If Secondary Causes Are Excluded

First-line treatment for severe headache:

• NSAIDs (ibuprofen, diclofenac potassium, or naproxen sodium) are preferred initial therapy 1, 4
• Avoid NSAIDs if dengue or thrombocytopenia is suspected due to bleeding risk 5
• Acetaminophen alone is ineffective for migraine-type headaches 1

Second-line treatment if NSAIDs inadequate:

• Triptans (sumatriptan, rizatriptan, zolmitriptan) should be offered for moderate-to-severe headache 1
• Take early when headache is still mild for maximum efficacy 1
• Contraindicated in patients with cardiovascular disease, uncontrolled hypertension, or basilar/hemiplegic migraine 1, 4

Adjunctive therapy:

• Metoclopramide 10 mg orally for nausea and to improve gastric motility, administered 20-30 minutes before analgesics 1, 5
• Prochlorperazine can effectively relieve headache pain in addition to treating nausea 1

Critical Caveats

Limit acute medication use to no more than twice weekly to prevent medication-overuse headache 1, 6. Avoid opioids as they are ineffective for acute migraine and carry high risk of dependency and rebound headaches 1, 6.

Psychiatric Screening

Screen for severe anxiety, depression, or suicidal ideation, as patients with tinnitus and co-existing psychiatric illness have increased suicide risk and require prompt psychiatric intervention 1.

Follow-up Requirements

Refer to neurology or headache specialist if:

• Diagnosis remains uncertain after initial evaluation 7
• Headache persists despite appropriate acute treatment 7
• Focal neurologic signs develop 7
• Patient requires preventive therapy (≥2 attacks per month causing ≥3 days disability) 1

Audiometric examination is recommended for persistent bilateral tinnitus to document any hearing asymmetry 1.