What could be causing constant pressure in my head, face, and neck, accompanied by balance issues, motion sensitivity, and throbbing sensations, despite normal CT scans, MRI, and previous diagnoses of migraine, IIH, and new daily persistent headache?

Evaluation for Idiopathic Intracranial Hypertension Without Papilledema

Your constellation of constant pressure, positional worsening, motion sensitivity, and balance disturbance strongly suggests idiopathic intracranial hypertension (IIH) without papilledema, and you should undergo lumbar puncture with opening pressure measurement regardless of normal neuroimaging and absence of optic disc swelling. 1, 2

Why IIH Remains the Leading Diagnosis

Your symptom pattern is highly characteristic of elevated intracranial pressure despite normal imaging:

• Constant pressure sensation in the head, face, and neck that correlates directly with balance issues is a hallmark of elevated CSF pressure 2, 3
• Positional worsening (lying down, Trendelenburg position, quick movements) is pathognomonic for CSF pressure disorders 4
• Motion sensitivity and disequilibrium occur because elevated ICP affects vestibular function and creates a sensation of being pushed or off-balance 2
• Morning predominance of symptoms (the "throbbing like feeling on a rocking boat" when lying down) is classic for IIH, as CSF pressure increases in supine position 4

Critical Diagnostic Gap

The absence of papilledema does NOT exclude IIH. 2, 5 The ACR guidelines explicitly state that papilledema may be absent despite significantly elevated ICP, especially in certain presentations 2. Your physicians' reluctance to diagnose IIH without papilledema represents outdated thinking—up to 5-10% of IIH cases present without optic disc swelling 3, 5.

You were never tested with lumbar puncture, which is the definitive diagnostic test. 1, 2 Opening pressure >200 mm H₂O confirms elevated ICP regardless of imaging or fundoscopic findings 2. This is the single most important missing piece in your workup.

Why Your Upcoming Tests Are Appropriate

Your scheduled MRV and vestibular testing are reasonable next steps:

• MRV can identify venous sinus stenosis, which occurs in many IIH patients and may guide treatment decisions including potential venous sinus stenting 1
• However, MRV has suboptimal sensitivity—one study showed sensitivity <0.5 in detecting significant stenosis associated with pressure gradients 1
• VNG testing will help differentiate central versus peripheral vestibular dysfunction 1

Treatment Implications

If lumbar puncture confirms elevated opening pressure (>200 mm H₂O):

• Acetazolamide or spironolactone are first-line CSF pressure-lowering medications 4
• Your trial of gabapentin is unlikely to help if the underlying problem is elevated CSF pressure rather than primary migraine 3
• Amitriptyline failure doesn't rule out IIH—it's used for migraine prophylaxis, not pressure reduction 3, 6

One case series of women with similar presentations (constant daily headache, positional worsening, normal imaging) showed all patients responded to CSF pressure-lowering medications after failing migraine treatments 4.

Why Previous Diagnoses May Be Incorrect

• "Vestibular migraine" was appropriately ruled out by your physician since your symptoms are constant rather than episodic 1
• New daily persistent headache (NDPH) is increasingly recognized as a heterogeneous diagnosis that may actually represent unrecognized IIH without papilledema in many cases 7, 6
• Chronic migraine diagnosis may be inaccurate given your prominent pressure and balance symptoms rather than typical migraine features 5, 6

Recommended Action Plan

1. Insist on lumbar puncture with opening pressure measurement at your upcoming vestibular specialist appointment 1, 2
2. If opening pressure is elevated (>200 mm H₂O), trial of acetazolamide 500-1000 mg daily or spironolactone is warranted 4
3. If MRV shows venous sinus stenosis >50%, consider catheter angiography with manometry to assess for pressure gradients that might benefit from stenting 1
4. If opening pressure is normal, consider spontaneous intracranial hypotension (low pressure), which can paradoxically cause similar symptoms and requires different imaging (spine MRI for CSF leak) 1

The two-year duration of constant symptoms without resolution strongly argues against primary headache disorders and supports a structural/pressure-related etiology requiring specific treatment targeting CSF dynamics 3, 5, 4.