What could be causing my persistent facial pressure, sinus and nasal symptoms, and vestibular disorders, despite clear sinus scans and lack of response to gabapentin (Neurontin)?

Persistent Facial Pressure and Vestibular Symptoms with Clear Sinus Imaging

Your symptoms of persistent facial pressure, sinus fullness, and vestibular symptoms despite clear sinus scans strongly suggest a primary headache disorder—most likely vestibular migraine—rather than chronic rhinosinusitis, and gabapentin is not an evidence-based treatment for this condition. 1

Why Your Current Diagnosis May Be Wrong

Facial Pain Without Sinus Disease

• Facial pain alone is rarely caused by chronic rhinosinusitis (CRS), and clear sinus scans essentially rule out CRS as the primary cause of your symptoms. 1
• The European Position Paper on Rhinosinusitis explicitly states that facial pain without other nasal complaints or abnormalities on examination should not be addressed as a sinus problem. 1
• Multiple rhinosinusitis guidelines emphasize that when sinus imaging is clear, the sinuses are not involved in causing facial pain. 1

The Migraine Misconception

• Your provider's statement that migraines must be episodic is incorrect—vestibular migraine and chronic migraine can present with continuous or near-continuous symptoms. 1
• Vestibular migraine has a prevalence of 3.2% and may represent up to 14% of vertigo cases, making it a common cause of persistent vestibular symptoms. 2
• The European guidelines specifically identify "midfacial segment pain" as a recognized clinical entity that can present with persistent facial pressure and is often misdiagnosed as sinus disease. 1

Why Gabapentin Isn't Helping

• Gabapentin is FDA-approved only for epilepsy and postherpetic neuralgia—it has no established role in treating vestibular migraine or primary headache disorders causing facial pain. 3, 4
• While one small case report described gabapentin-responsive audiovestibular symptoms in two patients with suspected 8th nerve compression, this represents an extremely rare vascular compression syndrome, not the typical presentation you describe. 5
• Gabapentin's primary adverse effects include somnolence, fatigue, ataxia, and dizziness—symptoms that could actually worsen your vestibular complaints. 3, 4, 6

What You Actually Need

Proper Diagnostic Evaluation

• Request evaluation by a neurologist specializing in headache and facial pain, not continued sinus-focused treatment. 1
• Document the pattern of your symptoms: Are they truly constant, or do they fluctuate in intensity? Do specific triggers worsen them (stress, sleep deprivation, certain foods, hormonal changes)? 1
• Determine if your vertigo is provoked by positional changes relative to gravity (lying down, rolling over, bending) or occurs spontaneously—this distinction is critical. 2, 7

Evidence-Based Treatment Options

• For vestibular migraine or midfacial segment pain, first-line treatment includes amitriptyline and/or triptans, not gabapentin. 1
• Treatment success for midfacial segment pain was achieved in 50% of patients within 18 months, though most required combination drug therapy. 1
• A team-based approach involving neurology, possibly otolaryngology for vestibular assessment, and potentially pain management is recommended for refractory cases. 1

Critical Red Flags to Rule Out

Central Nervous System Pathology

• If you have nystagmus that changes direction without head position changes, downward nystagmus, or nystagmus present without provocative maneuvers, you need urgent neuroimaging. 2, 7
• Approximately 3% of patients with failed vestibular treatment have underlying CNS disorders, and 10% of cerebellar strokes present similarly to peripheral vestibular processes. 2, 7
• MRI of the brain with contrast, especially evaluating the posterior fossa, is the appropriate imaging study if central pathology is suspected. 2

Persistent BPPV or Other Vestibular Disorders

• If your vestibular symptoms are truly positional (provoked by specific head movements), you need repeat Dix-Hallpike testing, as 8-50% of patients have persistent BPPV after initial treatment failure. 7, 8
• Treatment failures with vestibular symptoms commonly occur in patients with head trauma or vestibular neuritis, where widespread vestibular dysfunction coexists. 1
• Vestibular rehabilitation therapy should be considered to promote central compensation if peripheral vestibular dysfunction is confirmed. 8

Immediate Action Steps

1. Stop attributing your symptoms to sinus disease when imaging is clear—this delays proper diagnosis and treatment. 1
2. Request referral to a headache neurologist, not continued ENT management for presumed sinus disease. 1
3. Document your symptom pattern carefully: constant vs. fluctuating, triggers, associated symptoms (photophobia, phonophobia, nausea), and relationship to head position. 1, 2
4. Discuss discontinuing gabapentin with your provider, as it lacks evidence for your condition and may be causing additional vestibular side effects. 3, 4, 6