What is the best course of treatment for my symptoms of constant pressure in the head, face, and ears, pulsatile tinnitus, balance issues, and dizziness, which have been persistent for 2 years despite various tests and treatments for new daily persistent headache and migraine?

Comprehensive Evaluation for Persistent Craniofacial Pressure and Vestibular Symptoms

You need immediate referral to a neurotologist or otolaryngologist specializing in vestibular disorders for evaluation of possible idiopathic intracranial hypertension (IIH), superior semicircular canal dehiscence, or other structural causes, given your pulsatile tinnitus, constant pressure requiring ear popping, and motion-triggered dizziness that have persisted despite multiple negative imaging studies. 1

Critical Red Flags Requiring Immediate Investigation

Your symptom constellation suggests a vestibular or pressure-related disorder rather than primary headache:

• Pulsatile tinnitus in one ear is a red flag requiring imaging specifically of the venous sinuses and temporal bones, not just standard brain MRI 1
• Constant need to pop ears with pressure suggests Eustachian tube dysfunction or elevated intracranial pressure 1
• Motion-triggered dizziness with specific head positions requires Dix-Hallpike testing for BPPV and evaluation for superior canal dehiscence 1
• Balance issues correlating with pressure may indicate vestibular dysfunction requiring specialized testing 1

Essential Diagnostic Workup You Still Need

Vestibular and Otologic Testing

• Comprehensive audiologic examination is mandatory for unilateral pulsatile tinnitus and should have been done promptly 1
• Videonystagmography (VNG) or electronystagmography to assess vestibular function 1
• High-resolution CT of temporal bones to evaluate for superior semicircular canal dehiscence, which can cause pressure sensation, autophony, and motion sensitivity 1
• MR or CT venography specifically to evaluate venous sinus thrombosis or stenosis, as pulsatile tinnitus suggests vascular involvement 1

Pressure-Related Evaluation

• Lumbar puncture with opening pressure measurement is essential if IIH is suspected, especially with constant pressure, pulsatile tinnitus, and visual symptoms 2, 3
• Formal ophthalmologic examination including fundoscopy to evaluate for papilledema 3

Why Your Current Diagnosis May Be Incorrect

New Daily Persistent Headache (NDPH) Concerns

• NDPH diagnosis requires that patients recall the exact date their headache began, and the headache is continuous from onset 2, 4, 5
• Your description of symptoms being "consistent 24/7" for 2 years fits the temporal pattern 2
• However, only 11.1% of NDPH patients report an antecedent trigger, and your symptom complex (pressure, vestibular symptoms, pulsatile tinnitus) suggests secondary causes must be excluded first 4, 3
• NDPH is likely not a single entity but a syndrome with different etiologies, and identification of a specific trigger might provide opportunity for improvement 3

Critical Distinction

Your symptoms emphasize pressure and vestibular dysfunction more than headache pain, which is atypical for primary headache disorders 1

Treatment Approach While Awaiting Specialist Evaluation

If NDPH Diagnosis is Confirmed After Excluding Secondary Causes

Prophylactic medication trial:

• Topiramate is first-line for chronic daily headache with the strongest evidence 1, 6
• Amitriptyline 50-100mg at bedtime may help both headache and sleep (you report only 4-5 hours) 6, 7
• Consider trial of doxycycline 100mg + montelukast 10mg twice daily for 3 months, which has shown success in some NDPH cases 2

CGRP monoclonal antibodies:

• Erenumab, fremanezumab, or galcanezumab may be considered, as one case report showed complete resolution of NDPH with migraine-like features using erenumab 8
• These require 3-6 months to assess efficacy 9

Address Medication Overuse

• You must limit acute medications to fewer than 15 days/month for simple analgesics and fewer than 10 days/month for triptans 6
• Medication overuse is present in up to 73% of chronic headache patients and reduces effectiveness of preventive treatments 6, 9

Non-Pharmacological Management

• Vestibular rehabilitation therapy if vestibular dysfunction is confirmed 1
• Cognitive behavioral therapy for chronic pain management 6
• Sleep optimization - your 4-5 hours is inadequate and worsens headache 9
• Regular aerobic exercise 40 minutes three times weekly has efficacy comparable to topiramate 6, 7

Common Pitfalls to Avoid

• Do not accept "nothing is wrong" when pulsatile tinnitus is present - this requires vascular imaging 1
• Standard brain MRI is insufficient - you need dedicated temporal bone imaging and venography 1
• Neck muscle tightness providing temporary relief suggests cervicogenic component that may benefit from physical therapy 7
• Motion sensitivity and eye pain with movement are not typical migraine features and warrant vestibular evaluation 1

Follow-Up and Monitoring

• Maintain a detailed symptom diary tracking pressure intensity, vestibular symptoms, and medication use 6
• Reassess treatment response every 3 months as chronic headache requires long-term management 6
• If prophylactic medication fails after adequate trial (2-3 months at therapeutic dose), switch to alternative class 6, 9

The key message: Your symptom pattern suggests a structural or vestibular cause that requires specialized evaluation beyond standard neurology workup. Do not accept reassurance until pulsatile tinnitus, constant ear pressure, and positional dizziness are specifically investigated with appropriate testing.