What could be causing my constant head pressure, ear fullness, balance issues, and pulsatile tinnitus, despite being diagnosed with new daily persistent headache?

Evaluation of Constant Head Pressure, Vestibular Symptoms, and Pulsatile Tinnitus

Your symptom constellation—constant 24/7 head pressure, pulsatile tinnitus, ear fullness, severe balance dysfunction, and visible pulse in peripheral vision—strongly suggests idiopathic intracranial hypertension (IIH) without papilledema, which occurs in a subset of patients and requires urgent evaluation with lumbar puncture and opening pressure measurement. 1, 2, 3

Why Your Symptoms Don't Fit Typical Primary Headache Disorders

Your presentation is atypical for both Ménière's disease and vestibular migraine because:

• Ménière's disease requires episodic vertigo lasting 20 minutes to 12 hours with fluctuating hearing loss, not constant 24/7 symptoms 4
• Vestibular migraine requires episodic symptoms (5 minutes to 72 hours) occurring in discrete attacks, not continuous daily symptoms 4, 1
• New Daily Persistent Headache (NDPH) typically presents as continuous headache but should not have this degree of vestibular dysfunction, pulsatile tinnitus, or visible pulsations 4

Critical Red Flags Pointing to IIH Without Papilledema

Your specific symptoms are classic for elevated intracranial pressure:

• Pulsatile tinnitus is present in the majority of IIH patients and represents transmitted intracranial vascular pulsations 2, 3
• Seeing your pulse in peripheral vision (visual pulsations) indicates venous congestion from elevated pressure 2
• Constant pressure sensation rather than throbbing pain is common in IIH 2, 3
• Severe balance dysfunction and motion sensitivity can occur from vestibular nerve compression or dysfunction in IIH 3
• Absence of papilledema does NOT exclude IIH—approximately 6% of IIH patients never develop optic disc swelling, likely due to anatomical variations in optic nerve sheath structure 3, 5

Immediate Diagnostic Workup Required

You need the following evaluations urgently:

• Lumbar puncture with opening pressure measurement is the definitive diagnostic test—IIH is diagnosed when opening pressure exceeds 25 cm H₂O in adults with otherwise normal CSF 2, 3
• MRI brain with MR venography to exclude venous sinus thrombosis, dural arteriovenous malformation, or mass lesions that can mimic IIH 2, 6
• Formal ophthalmologic examination including optical coherence tomography (OCT) to document baseline optic nerve status, even without visible papilledema 2, 3

Alternative Diagnoses to Exclude

If opening pressure is normal, consider:

• Dural arteriovenous malformation draining into venous sinuses can cause identical symptoms (constant headache, pulsatile tinnitus, papilledema or not) and requires MR angiography or conventional angiography for diagnosis 6
• Spontaneous intracranial hypotension presents with constant pressure but typically improves lying flat and worsens upright (opposite pattern from your description) 4
• Vascular loop compression of cranial nerves VII/VIII can cause pulsatile tinnitus and balance issues but wouldn't explain constant head pressure 7

Why This Matters for Your Prognosis

Untreated IIH can cause permanent vision loss in up to 25% of patients, even when papilledema is absent or minimal. 2, 3 The constant elevated pressure damages optic nerve axons over time through chronic compression. Your two-year duration of symptoms places you at significant risk for irreversible visual field defects even if your current vision seems normal.

Treatment Approach If IIH Is Confirmed

Management priorities based on severity:

• Weight loss of 5-10% (if applicable) can normalize intracranial pressure in many patients 2
• Acetazolamide (starting 500-1000 mg daily, titrating to 2000-4000 mg daily) is first-line medical therapy to reduce CSF production 2
• Serial lumbar punctures for temporary relief while medications take effect 2
• Surgical intervention (optic nerve sheath fenestration or CSF diversion shunt) if vision deteriorates despite medical management 2
• Venous sinus stenting may be considered if venous stenosis is identified on imaging 2

Common Pitfall in Your Case

The diagnosis of "new daily persistent headache" may have delayed appropriate investigation. NDPH is a diagnosis of exclusion that should only be made after secondary causes—particularly IIH—have been definitively ruled out with lumbar puncture. 4, 1 The presence of pulsatile tinnitus, visual pulsations, and severe vestibular symptoms makes primary headache disorder unlikely and demands investigation for elevated intracranial pressure.

Next Steps

Request referral to a neuro-ophthalmologist or headache specialist experienced in IIH who can coordinate lumbar puncture with opening pressure measurement. Do not accept reassurance based solely on normal optic discs—absence of papilledema does not exclude this diagnosis, and delayed treatment risks permanent vision loss. 3, 5