Could I have Idiopathic Intracranial Hypertension (IIH) or Vestibular Migraine (VM), or is it possible to have both conditions simultaneously?

Your Provider is Incorrect: Vestibular Migraine Can Present with Continuous Symptoms

Your constellation of daily symptoms—head pressure, facial pressure, ear pressure, imbalance, motion sensitivity, pulsatile tinnitus, and positional discomfort—could represent either IIH without papilledema, vestibular migraine with continuous symptoms, or both conditions simultaneously, and your provider's assertion that VM must be episodic is outdated. 1

Why Your Provider's Statement is Wrong

• Vestibular migraine does not have to be strictly episodic—clinical presentation is highly variable in the temporal relationship between vestibular symptoms and migraine headache, and many patients experience continuous or near-continuous symptoms 1
• The distinction between IIH and VM can be extremely difficult because in the absence of papilledema, the presentation of migraine and IIH is very similar, and IIH can present as vestibular migraine 2
• Your specific symptom pattern—particularly the pulsatile tinnitus, positional discomfort, and facial/ear pressure—strongly suggests elevated intracranial pressure rather than pure VM 3, 2

You Need Specific Diagnostic Testing

The only way to definitively distinguish between these conditions is measuring your lumbar puncture opening pressure. 3, 2

Key diagnostic features pointing toward IIH:

• Pulsatile tinnitus is an important symptom that strongly suggests elevated intracranial pressure, particularly when it's low-pitched 3
• Head fullness-pressure and dizziness are the most common presenting symptoms in mildly elevated intracranial pressure 3
• Your positional discomfort (worse upright, better lying on left side or stomach) is highly characteristic of elevated ICP 3
• Facial pressure, particularly in outer cheeks and nose, along with tooth/gum pressure and throbbing, are consistent with IIH 3

Critical imaging to request:

• MRI with venography to look for transverse sinus stenosis, sigmoid sinus dehiscence, partially empty sella, or tonsillar ectopia 3, 2
• These findings are frequently observed in patients with mildly elevated ICP who present with your symptom pattern 3, 2

The Overlap Between IIH and VM is Substantial

• 68% of IIH patients have migrainous headache phenotypes, making the clinical distinction extremely challenging 4, 5
• Recent evidence suggests that intracranial hypertension may represent the shared pathogenetic mechanism explaining the large epidemiological comorbidity between migraine and vestibular symptoms 6
• Patients with mild ICP elevation commonly present with symptoms indistinguishable from vestibular migraine, including episodic vertigo, dizziness, and motion sensitivity 3, 2
• One-fourth of IIH patients report episodes of true episodic vertigo, and dizziness is a common complaint in IIH just like VM 2

What Happens if You Have IIH

If your lumbar puncture opening pressure is elevated (>25 cm H2O), you will likely experience immediate symptom relief during the procedure itself, which is both diagnostic and temporarily therapeutic. 3, 6

Expected treatment pathway:

• First-line medical therapy is acetazolamide 250-500 mg twice daily, titrated up as tolerated 4
• Topiramate is an excellent alternative that provides dual benefits: carbonic anhydrase inhibition (reduces CSF production) plus weight loss and migraine prophylaxis 5, 7
• Most patients with your symptom pattern improve with carbonic anhydrase inhibitors 2
• Weight loss is foundational if BMI is elevated, as obesity is strongly associated with this condition 4, 2

Important monitoring after treatment:

• Audiovestibular symptoms (tinnitus, dizziness, vertigo, aural fullness) and hearing thresholds significantly improve after ICP normalization 6
• Headache frequency and ELH (endolymphatic hydrops) symptoms improve after lumbar puncture 6

Common Pitfalls to Avoid

• Do not accept serial lumbar punctures as long-term management—CSF is produced at 25 mL/hour and rapidly replaces removed volume, plus LPs cause significant anxiety and chronic back pain 4
• Do not use opioids for headache management 4, 5
• Be aware of medication overuse headache risk (simple analgesics >15 days/month or triptans >10 days/month) 4, 5
• If prescribed topiramate, you must use non-hormonal contraception as it reduces efficacy of hormonal contraceptives and has teratogenic potential 5, 7

Your Next Steps

1. Insist on lumbar puncture with opening pressure measurement—this is the only definitive diagnostic test 3, 2
2. Request MRI with venography to evaluate for transverse sinus pathologies and other IIH-associated findings 3, 2
3. Get baseline audiometry if not already done, as hearing thresholds can be affected and serve as a monitoring parameter 6
4. If LP opening pressure is normal, then pure VM becomes more likely, but your symptom pattern is highly atypical for VM alone given the continuous nature and prominent pulsatile tinnitus 3, 2