What are the differential diagnoses and treatment options for post-auricular pulsating headaches?

Post-Auricular Pulsating Headache: Differential Diagnoses

Post-auricular pulsating headache requires immediate evaluation for vascular abnormalities, particularly pulsatile tinnitus-related causes, as these may require urgent medical, endovascular, or surgical intervention. 1

Life-Threatening Causes to Rule Out First

• Vascular abnormalities including paragangliomas, aberrant arterial or venous anatomy, vascular malformations, and dural arteriovenous fistulas can present as pulsatile symptoms in the post-auricular region and require prompt identification 1
• Giant cell arteritis must be excluded in patients over 50 years with new-onset headache, particularly with scalp tenderness or jaw claudication, as delay in treatment can lead to permanent vision loss 2
• Intracranial hypertension manifesting as headache that worsens with coughing, sneezing, or exercise should be considered 2
• Subarachnoid hemorrhage presenting with thunderclap headache may be accompanied by altered sensations and requires immediate evaluation 2
• Stroke or TIA presenting with focal neurological symptoms, particularly in patients over 50 years with sudden onset 3
• Cerebral venous thrombosis can present with progressive headache and may be precipitated by conditions like spontaneous intracranial hypotension 4

Common Secondary Causes

Vascular and Structural Causes

• Pulsatile tinnitus from vascular masses, jugular bulb abnormalities, abnormal condylar and mastoid emissary veins, or atherosclerotic carotid artery disease with turbulent flow 1
• Sigmoid sinus wall diverticulum or anomalies commonly associated with intracranial hypertension 1
• Persistent petrosquamosal sinus or other venous variants 1
• Arterial dissection affecting vessels in the post-auricular region 1

Otologic Causes

• Mastoiditis which can cause post-auricular pain and swelling, particularly following otitis media 1
• Middle ear pathology including adenomatous middle ear tumors or paragangliomas presenting as vascular retrotympanic masses 1

Primary Headache Disorders

• Migraine without aura if patient has recurrent moderate-to-severe headache with at least two of: unilateral location, pulsating quality, moderate-to-severe intensity, or aggravation by routine activity, PLUS nausea/vomiting and/or photophobia/phonophobia 3, 5
• Chronic migraine if headache occurs ≥15 days/month for >3 months 6

Red Flags Requiring Immediate Imaging

• Age ≥50 years with new severe headache 2, 7
• Focal neurological symptoms or signs 2, 7
• Altered consciousness, memory, or personality 2
• Neck stiffness or limited neck flexion 2
• Witnessed loss of consciousness 2
• Onset during exertion 2, 7
• Progressive worsening over time 2, 7
• Headache brought on by Valsalva maneuver or cough 7
• Systemic signs/symptoms or secondary risk factors such as cancer or HIV infection 7

Diagnostic Approach

Initial Evaluation

• Complete neurological examination including mental status, cranial nerves, motor/sensory function, reflexes, coordination, and gait to identify red flag features 4, 7
• Otologic examination to determine if a vascular retrotympanic mass is present 1
• Audiometric examination if tinnitus is present 1
• Vital signs assessment including orthostatic blood pressure and heart rate 3

First-Line Imaging

• Temporal bone CT is recommended as first-line study in the setting of a vascular retrotympanic mass or subjective pulsatile tinnitus to determine if a paraganglioma, adenomatous middle ear tumor, or variant vascular anatomy is present 1
• CT angiography (CTA) of head and neck with contrast is supported as first-line imaging given concerns for possible underlying vascular process, including dural AVF, arterial dissection, or sigmoid sinus anomalies 1
• Non-contrast head CT if presenting <6 hours from acute severe headache onset 2

Advanced Imaging

• MRI brain with and without contrast for subacute presentations or when tumor/inflammatory process suspected 2, 7
• Dedicated temporal bone CT reconstructions can be created from high-resolution source CTA images without additional radiation exposure 1

Additional Testing

• ESR/CRP if temporal arteritis suspected 2
• Lumbar puncture if CT negative but subarachnoid hemorrhage still suspected 2

Critical Pitfalls to Avoid

• Do not dismiss pulsatile quality without thorough vascular evaluation, as this is not typical of primary headaches and may indicate underlying vascular pathology requiring intervention 1
• Do not rely solely on imaging without considering complete clinical picture including temporal relationship and associated symptoms 2
• Do not miss temporal arteritis in elderly patients, as this represents a medical emergency 2
• Do not overlook medication-overuse headache in patients with chronic daily headache, as only 20% of patients meeting criteria are properly diagnosed 4
• Correlation with physical examination before imaging is essential to appropriately distinguish patients with objective tinnitus related to muscle spasm or myoclonus from those where a vascular cause is suspected 1