What is the likely cause and best treatment for persistent pressure headaches with associated balance issues, dizziness, and tinnitus, despite normal imaging studies and lack of response to gabapentin?

Likely Diagnosis and Management

Based on your constellation of symptoms—persistent pressure headaches with pulsatile tinnitus, motion sensitivity, eye pain with movement, and temporary relief from neck massage despite normal imaging—you most likely have spontaneous intracranial hypotension (SIH) or vestibular migraine, and you need urgent neurology referral for specialized vestibular examination and consideration of MRI brain with contrast to evaluate for dural enhancement. 1

Why Your Diagnosis Has Been Missed

Your case illustrates a critical diagnostic pitfall: over half of patients with spontaneous intracranial hypotension have normal lumbar puncture opening pressure, and at least 25% have normal imaging studies 2. The second provider who diagnosed IIH without testing was likely incorrect—your symptom pattern (pressure relieved by lying down, worsened by motion, associated with neck tension) is opposite to typical IIH presentation 2.

Key Diagnostic Features You're Exhibiting

• Pressure that improves with neck massage suggests cervicogenic component 1
• Pulsatile tinnitus can occur in both high AND low pressure states, as well as vestibular migraine 3, 2
• Motion sensitivity and dizziness with head turning are hallmarks of vestibular dysfunction, not sinus disease 1
• Eye pain with movement and heavy sensation suggests either intracranial pressure disorder or vestibular migraine 1, 2
• Constant ear pressure requiring popping is consistent with Eustachian tube dysfunction that can accompany vestibular migraine 1

What You Need Now

Immediate Next Steps

You need MRI brain WITH contrast (not just without) to look for dural enhancement, which is the key finding in spontaneous intracranial hypotension 1. Your previous imaging may have been without contrast, which would miss this finding 1.

Request urgent neurology referral for:

• HINTS examination (Head Impulse, Nystagmus, Test of Skew)—this has 100% sensitivity for detecting central causes of dizziness 1
• Dix-Hallpike maneuver and supine roll test to definitively exclude atypical BPPV 1
• Evaluation for vestibular migraine, which presents with dizziness, temple/neck tension, and motion sensitivity 1

Why Gabapentin Failed

Gabapentin is ineffective for tinnitus in most patients 4, 5. Multiple randomized controlled trials show no significant benefit over placebo for isolated tinnitus 4, 5. There is insufficient evidence to recommend gabapentin for tinnitus treatment 5. Your lack of response actually supports that your problem is NOT a nerve injury-type condition, but rather a structural or vestibular issue 4.

Most Likely Diagnoses to Pursue

1. Spontaneous Intracranial Hypotension (Primary Suspect)

This can present with NON-ORTHOSTATIC headaches (not just positional), dizziness, neck pain, and skull base symptoms 1. The fact that neck massage provides temporary relief strongly suggests this 1.

Critical point: Only 34% of SIH patients have opening pressure ≤60 mm CSF, and 5% actually have pressures ≥200 mm CSF 2. This means your normal imaging and the absence of classic orthostatic features do NOT exclude this diagnosis 2.

If MRI shows diffuse dural and leptomeningeal enhancement, you may need epidural blood patch 1. This procedure has been shown effective and well-tolerated even in older patients 3.

2. Vestibular Migraine (Strong Alternative)

Vestibular migraine is characterized by dizziness with headache, photophobia, phonophobia, and temple/neck tension 1. Your extreme motion sensitivity and "eyes can't keep up" symptom is classic for vestibular migraine 1.

Critical management point: Vestibular migraine requires migraine prophylaxis and lifestyle modifications, NOT vestibular suppressants 1. This is why gabapentin failed—it's the wrong drug class 1.

The Idiopathic Intracranial Hypertension Treatment Trial found that most participants had headache phenotypes resembling migraine or tension-type headache, with no "typical" characteristic pattern 2. This means your symptoms could represent chronic migraine that has been misattributed to sinus disease 2.

Red Flags Requiring Emergency Evaluation

Seek immediate emergency care if you develop:

• New severe headache different from your current symptoms 1
• Focal neurological deficits 1
• Sudden hearing loss 1
• Inability to stand or walk 1
• New or worsening asymmetric weakness 1

Why Sinus Surgery Failed

Your symptom pattern is NOT consistent with sinus disease: sinus pathology does not cause pulsatile tinnitus, motion-triggered dizziness, eye pain with movement, or balance issues 1. The "pressure in sinuses" you feel is likely referred sensation from intracranial pressure changes or vestibular dysfunction 1, 2.

Common Pitfalls to Avoid

• Do not accept "nothing is wrong" when you have disabling symptoms for 2 years 2
• Do not assume normal CT excludes serious pathology—CT has only 20-40% sensitivity for posterior circulation problems 1
• Do not continue gabapentin—it has proven ineffective for your condition 4, 5
• Do not pursue more sinus interventions—this is not sinus disease 1

Specific Action Plan

1. Schedule MRI brain WITH and WITHOUT contrast within days 1
2. Request urgent (not routine) neurology referral 1
3. Stop gabapentin and discuss with your provider 4, 5
4. Keep symptom diary noting: time of day symptoms worst, position changes, medication trials, and any triggers 1
5. If dural enhancement found on MRI, discuss epidural blood patch with neurology 1
6. If vestibular migraine diagnosed, start migraine prophylaxis (topiramate, propranolol, or amitriptyline), not vestibular suppressants 1, 6

Patients with long-standing "chronic migraine" who do not improve with conventional headache treatment should be reconsidered for CSF pressure disorders 2. Your case fits this pattern exactly 2.