What could be causing my constant head pressure, dizziness, balance issues, and pulsatile tinnitus despite trying amitriptyline, metoprolol, and gabapentin?

Evaluation of Persistent Head Pressure, Dizziness, and Pulsatile Tinnitus Refractory to Migraine Prophylaxis

Your pulsatile tinnitus is a critical red flag that demands urgent vascular imaging—this symptom indicates an underlying structural or vascular abnormality in over 70% of cases, and potentially life-threatening causes like dural arteriovenous fistula, arterial dissection, or idiopathic intracranial hypertension must be ruled out immediately. 1, 2

Immediate Diagnostic Priority: Pulsatile Tinnitus Workup

Your pulsatile tinnitus fundamentally changes the diagnostic approach and requires urgent imaging evaluation, regardless of whether your provider can hear it (objective) or only you can hear it (subjective). 1, 2

First-Line Imaging Strategy

Order CT angiography (CTA) of the head and neck with contrast as the initial study. 1, 2 This captures both arterial and venous pathology in a single acquisition and evaluates for:

• Dural arteriovenous fistulas (8% of pulsatile tinnitus cases) - can lead to hemorrhagic or ischemic stroke if untreated and may present with isolated pulsatile tinnitus before catastrophic hemorrhage 1, 2
• Arterial dissection - potentially life-threatening and requires urgent identification 1, 2
• Atherosclerotic carotid artery disease - the most frequent cause at 17.5% of cases, resulting from turbulent flow 1, 2
• Idiopathic intracranial hypertension (IIH) - the second most common cause of pulsatile tinnitus, particularly critical in your demographic if you are a young woman with obesity and headaches 1, 2
• Sigmoid sinus diverticulum or dehiscence - commonly associated with intracranial hypertension 1

Alternative First-Line Imaging

If paragangliomas, glomus tumors, or jugular bulb abnormalities are suspected based on otoscopic examination showing a vascular retrotympanic mass, order high-resolution CT temporal bone (non-contrast) instead. 1, 2

If Initial Imaging is Negative

If CTA is negative but clinical suspicion remains high, proceed to MRI brain with contrast and MR angiography (MRA) to evaluate for vascular malformations not identified on initial imaging or cerebellopontine angle lesions. 1, 2

Why Your Migraine Prophylaxis Has Failed

Your lack of response to amitriptyline, metoprolol, and gabapentin strongly suggests that vestibular migraine may not be your primary diagnosis, despite meeting some clinical criteria. 3 The presence of pulsatile tinnitus is not a typical feature of vestibular migraine and points toward a structural or vascular etiology that requires different treatment. 1, 2

Distinguishing Vestibular Migraine from Other Causes

Vestibular migraine typically presents with: 3

• Episodic vestibular symptoms (not constant 24/7 symptoms like yours)
• Migraine according to International Headache Society criteria
• Photophobia, phonophobia, or visual aura during vertiginous episodes
• Variable duration of vertigo (short <15 minutes or prolonged >24 hours)
• Mild or absent hearing loss that is stable over time

Your constant, unremitting symptoms for two years do not fit the episodic pattern of vestibular migraine. 3

Critical Differential Diagnoses to Rule Out

Idiopathic Intracranial Hypertension (Pseudotumor Cerebri)

This is the second most common cause of pulsatile tinnitus and presents with: 1, 2

• Persistent headache and head pressure (matches your symptoms)
• Pulsatile tinnitus (matches your symptoms)
• Visual obscurations or vision changes
• Typically occurs in obese women of childbearing age
• Greatest risk is irreversible vision loss if missed 4

If you are a young woman with obesity, this diagnosis must be ruled out urgently. 1, 4

Dural Arteriovenous Fistula

This accounts for 8% of pulsatile tinnitus cases and is life-threatening: 1, 2

• Can present with isolated pulsatile tinnitus before catastrophic hemorrhage
• Requires high index of suspicion and appropriate vascular imaging
• Can lead to hemorrhagic or ischemic stroke if untreated

Atherosclerotic Carotid Artery Disease

The most frequent cause at 17.5% of cases: 1, 2

• Results from turbulent flow in stenotic vessels
• May be accompanied by other vascular risk factors
• Carotid duplex ultrasound can help delineate extracranial carotid stenosis 2

Highly Vascularized Skull Base Tumors

Paragangliomas and glomus tumors account for 16% of pulsatile tinnitus cases: 1, 2, 5

• Appear as vascular retrotympanic masses on otoscopy
• Require otoscopic examination to avoid delayed diagnosis
• Best visualized on high-resolution CT temporal bone

Common Pitfalls to Avoid

• Dismissing pulsatile tinnitus as benign - identifiable causes exist in >70% of cases and some are life-threatening 1, 2, 6, 7, 8
• Missing dural AVF - can present with isolated pulsatile tinnitus before catastrophic hemorrhage 1, 2
• Overlooking intracranial hypertension - particularly in young, overweight women with headaches, can lead to permanent vision loss 1, 2, 4
• Inadequate otoscopic examination - can lead to delayed diagnosis of vascular retrotympanic masses 1, 2

Additional Diagnostic Considerations

Concurrent Vestibular Disorders

Multiple vestibular disorders can coexist, so even if one diagnosis is confirmed, others should not be excluded without proper evaluation. 3

Medication-Induced Intracranial Hypertension

Review your medication list for drugs associated with drug-induced intracranial hypertension, including: 4

• Vitamin A derivatives
• Tetracycline-class antibiotics
• Lithium
• Corticosteroids

Cervical Vertigo

Symptoms may be triggered by rotation of the head relative to the body while upright (as opposed to vertigo triggered by changes in head position relative to gravity). 3

Next Steps

1. Obtain urgent CTA head and neck with contrast (or high-resolution CT temporal bone if vascular retrotympanic mass seen on otoscopy) 1, 2
2. Comprehensive audiologic examination including pure tone audiometry, speech audiometry, and acoustic reflex testing to document any asymmetric hearing loss 1
3. Thorough otoscopic examination to evaluate for vascular retrotympanic masses 1, 2
4. Assess for vision changes or visual field defects to screen for intracranial hypertension 1, 4
5. If imaging is negative but symptoms persist, proceed to MRI brain with contrast and MRA 1, 2

The correlation you've noticed between head pressure and balance issues suggests a common underlying pathology affecting both symptoms—this pattern, combined with pulsatile tinnitus, makes a vascular or structural cause highly likely and demands immediate imaging evaluation. 1, 2, 7