What is the best course of treatment for a patient presenting with head fullness, tightness along the forehead and ears, without vertigo or tinnitus?

Differential Diagnosis and Management of Head Fullness with Forehead and Ear Tightness

The most likely diagnoses for head fullness with tightness along the forehead and ears, in the absence of vertigo or tinnitus, are temporomandibular joint (TMJ) dysfunction, tension-type headache, or vestibular migraine, and initial management should focus on identifying TMJ dysfunction through jaw examination and treating with physical therapy, while considering migraine prophylaxis if headache features are prominent. 1, 2, 3

Primary Differential Diagnoses

Temporomandibular Joint Dysfunction

• TMJ dysfunction is a leading cause of ear fullness and pressure sensations without objective ear pathology, affecting up to 94.7% of patients presenting with unexplained ear fullness in tertiary care settings 2
• Patients with TMJ dysfunction commonly report ear fullness, tightness around the ears, and forehead pressure due to the anatomical proximity of the TMJ to ear structures and referred pain patterns 4, 3
• Key examination findings include: limited mandibular range of motion (normal >40mm), crepitation or clicking in the TMJ, pain on palpation of the TMJ (lateral and dorsal aspects), and trigger points in the masseter or temporalis muscles 3

Vestibular Migraine

• Vestibular migraine can present with head fullness, pressure sensations, and ear tightness without classic vertigo, particularly in patients with migraine history 1
• Unlike Ménière's disease, vestibular migraine typically presents with bilateral auditory complaints, motion intolerance, and light sensitivity rather than true spinning vertigo 1
• The absence of vertigo does not exclude vestibular migraine, as some patients experience only pressure sensations, head fullness, or vague dizziness 1

Eustachian Tube Dysfunction

• Intermittent Eustachian tube dysfunction (iETD) commonly causes isolated ear fullness and pressure sensations in the forehead and ear regions 5, 2
• Patients with isolated ear fullness (without pain) are more likely to have iETD than TMJ dysfunction 2

Diagnostic Approach

Initial Clinical Evaluation

• Perform targeted jaw examination: assess mandibular range of motion, palpate TMJ for tenderness and crepitation, examine masseter and temporalis muscles for trigger points 3
• Obtain detailed migraine history: inquire about prior headaches, family history of migraine, photophobia, phonophobia, and motion sensitivity even without current headache 1
• Perform pneumatic otoscopy to assess tympanic membrane mobility and identify middle ear dysfunction 5
• Examine for focal neurological abnormalities that would suggest central pathology 1

Audiometric Testing

• Obtain comprehensive audiologic examination to rule out asymmetric hearing loss that would require imaging workup 5, 6
• Audiometry helps differentiate between TMJ dysfunction (typically normal hearing), iETD (may show conductive loss), and Ménière's disease (sensorineural loss) 1

Imaging Considerations

• Imaging is NOT indicated for bilateral, non-pulsatile symptoms without focal neurological abnormalities, asymmetric hearing loss, or true vertigo 1, 5, 6
• If TMJ dysfunction is suspected clinically, panoramic radiograph or maxillary CT may reveal degenerative changes in the TMJ 3

Treatment Algorithm

First-Line Management for TMJ Dysfunction

• Initiate self-applied physical therapy: jaw stretching exercises and thermal packs (heat or ice) applied to the TMJ region 3
• Fabricate full-arch stabilization splint for nighttime wear to reduce jaw clenching and muscle tension 3
• Consider trigger point injections in masseter or temporalis muscles if prominent myofascial pain is present 3
• For refractory cases with confirmed TMJ osteoarthritis, intra-articular corticosteroid injection (triamcinolone acetonide 20mg) may provide significant relief 3

Migraine Management if Indicated

• For patients meeting vestibular migraine criteria or with prominent headache features, initiate migraine prophylaxis: first-line agents include propranolol (80-240mg/day), timolol (20-30mg/day), amitriptyline (30-150mg/day), or divalproex sodium (500-1500mg/day) 1
• Educate patients about migraine triggers including stress, fatigue, certain foods, and sensory stimuli 1
• Avoid overuse of acute medications (limit to twice weekly) to prevent medication-overuse headache 1

Eustachian Tube Dysfunction Management

• For iETD, conservative measures include nasal saline irrigation, nasal corticosteroids, and autoinflation techniques 5
• Ventilation tubes provide only temporary relief and are not recommended as first-line treatment 3

Critical Red Flags Requiring Urgent Evaluation

• Unilateral symptoms with asymmetric hearing loss on audiometry require MRI with contrast to exclude acoustic neuroma or other cerebellopontine angle lesions 1, 5
• Focal neurological abnormalities (facial numbness, weakness, ataxia) mandate urgent MRI to exclude stroke or mass lesion 1
• Sudden hearing loss developing over 72 hours requires urgent otolaryngology referral and consideration of systemic corticosteroids 5
• Truly pulsatile symptoms synchronous with heartbeat require vascular imaging (CTA or MRA) to exclude vascular malformations 1, 5

Common Pitfalls to Avoid

• Do not dismiss ear fullness as purely psychological without thorough evaluation for TMJ dysfunction, which is highly treatable 2, 3
• Do not routinely prescribe antidepressants, anxiolytics, or dietary supplements (Ginkgo biloba, zinc, melatonin) for unexplained head fullness, as these lack efficacy data for this indication 5, 6
• Do not order imaging for bilateral, non-pulsatile symptoms without hearing loss or neurological findings, as diagnostic yield is extremely low and not cost-effective 1, 5, 6
• Recognize that 5.3% of patients may have completely unexplained symptoms despite thorough workup; these patients benefit from counseling in the framework of functional neurologic disorders rather than repeated testing 2