What is the diagnosis and treatment for a 2-year history of constant pressure in the nose, eyes, outer cheekbones, jaws, and top of the head, accompanied by balance issues, dizziness, pulsatile tinnitus, regular tinnitus, muffled hearing, and jaw fatigue, with worsening symptoms upon movement and activity, despite normal test results, including a computed tomography (CT) scan and magnetic resonance imaging (MRI) of the head, and evaluations by multiple neurologists and healthcare providers?

Medical Advisory BoardAll articles are reviewed for accuracy by our Medical Advisory Board
Educational purpose only • Exercise caution as content is pending human review
Article Review Status
Submitted
Under Review
Approved

Last updated: January 3, 2026View editorial policy

Personalize

Help us tailor your experience

Which best describes you? Your choice helps us use language that's most understandable for you.

Spontaneous Intracranial Hypotension (SIH) is the Most Likely Diagnosis

Based on your 2-year history of constant positional pressure symptoms, audiovestibular complaints, and normal imaging, you most likely have spontaneous intracranial hypotension (SIH), which requires specialized CSF leak imaging that you have not yet received. 1

Why This Diagnosis Fits Your Presentation

Your symptom constellation is classic for SIH, despite normal standard imaging:

  • Positional pressure worsening: Your symptoms worsen when standing or lying flat on your back, with relief when lying on your stomach or left side—this orthostatic pattern is pathognomonic for CSF leak 1

  • Audiovestibular symptoms: Pulsatile tinnitus, regular tinnitus, muffled hearing, and ear pressure are well-recognized non-headache symptoms of SIH that occur in tandem with CSF leak 1

  • Dizziness and balance issues: These are common non-headache neurological symptoms in SIH patients 1

  • Pressure without severe headache: While most SIH patients have headache, some present predominantly with pressure sensation and other neurological symptoms 1

  • Normal standard MRI: Up to 20% of SIH patients have normal brain MRI, requiring specialized spinal imaging protocols to identify the CSF leak 1

Critical Diagnostic Gap in Your Workup

You have not had the appropriate imaging studies to diagnose SIH. Standard head CT and brain MRI do not evaluate for spinal CSF leaks. The 2023 multidisciplinary consensus guideline specifies that MRI-negative patients require 1:

  • Lateral decubitus CT myelography (LD-CTM) as the gold standard for identifying spinal CSF leaks
  • Lateral decubitus digital subtraction myelography (LD-DSM) as an alternative
  • Ultrafast CT myelography (UFCTM) for detecting CSF-venous fistulas

These specialized studies must be performed in the lateral decubitus (lying on side) position to detect subtle leaks that are missed on standard imaging 1.

Why Other Diagnoses Are Less Likely

While your pulsatile tinnitus initially suggests vascular pathology, several factors argue against this:

  • Bilateral symptoms: Pulsatile tinnitus from vascular causes (atherosclerotic disease, dural AVF, arterial dissection) is typically unilateral, whereas you describe bilateral regular tinnitus and diffuse pressure 2

  • Positional relief pattern: Vascular causes of pulsatile tinnitus do not improve with specific body positions; your dramatic positional variation points to CSF pressure dynamics 2

  • Normal vascular imaging: If you had CT or MRI of the head, these would have identified major vascular abnormalities like paragangliomas, large AVMs, or significant carotid disease 2

Ménière's disease is excluded by your symptom pattern—Ménière's causes episodic vertigo attacks lasting 20 minutes to 12 hours, not constant pressure 1. Your symptoms are continuous and positional, not episodic 1.

Immediate Next Steps

You need urgent referral to a specialized center with expertise in spontaneous intracranial hypotension. The 2023 guideline emphasizes that SIH management requires a multidisciplinary team including neuroradiology, neurology, and interventional spine specialists 1.

Required Specialized Imaging

Request the following studies specifically 1:

  • Lateral decubitus CT myelography (performed lying on your side, not supine)
  • If LD-CTM is negative, proceed to MRI of entire spine with fat-suppressed sequences looking for spinal longitudinal epidural collections (SLEC)
  • Consider ultrafast CT myelography if CSF-venous fistula is suspected

Treatment Options Once Diagnosed

If CSF leak is confirmed, treatment follows a stepwise approach 1:

  1. Conservative management initially: Bed rest, adequate hydration, caffeine supplementation
  2. Epidural blood patch (EBP): First-line interventional treatment, with follow-up at 10-14 days 1
  3. Targeted fibrin sealant patch: If leak location is identified and EBP fails
  4. Surgical repair: Reserved for refractory cases with identified leak site 1

Important Caveats

  • Post-treatment rebound headache: After successful CSF leak treatment, you may develop rebound intracranial hypertension causing temporary worsening of symptoms for 1-2 weeks—this is expected and self-limiting 1

  • Orthostatic rehabilitation: Given your 2-year history of limiting upright activity, you will likely need orthostatic rehabilitation to address deconditioning of both skeletal muscle and autonomic postural responses 1

  • Avoid certain medications: If you're taking migraine preventives, avoid topiramate, indomethacin, candesartan, and beta-blockers as these can lower CSF pressure and exacerbate SIH symptoms 1

If SIH Workup is Negative

Only if specialized CSF leak imaging is completely negative should you pursue alternative diagnoses:

  • Idiopathic intracranial hypertension (IIH): Can cause pulsatile tinnitus and pressure symptoms, though typically worsens when lying down (opposite of your pattern) 2

  • Superior semicircular canal dehiscence: Can cause pressure sensation and audiovestibular symptoms, diagnosed with high-resolution temporal bone CT 2

  • Persistent postural-perceptual dizziness (PPPD): A functional vestibular disorder that can develop after prolonged vestibular symptoms, but this is a diagnosis of exclusion after structural causes are ruled out with appropriate testing 3

The critical error in your care has been performing standard neuroimaging without the specialized spinal imaging protocols required to diagnose SIH. Your symptom pattern—particularly the dramatic positional variation with relief when lying on your stomach—is highly specific for CSF leak and demands proper evaluation before concluding "nothing is wrong" 1.

References

Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

Guideline

Differential Diagnosis of Pulsatile Tinnitus

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

Related Questions

How to manage dizziness in an elderly patient with stable vitals on multiple medications including Metoprolol, Ramipril, Citalopram, Amlodipine, and Dapagliflozin?
What is the next step in managing a 77-year-old male with a history of aortic stenosis, status post Transcatheter Aortic Valve Replacement (TAVR), Atrial Fibrillation (A-fib) on Xarelto (Rivaroxaban), Hypertension (HTN), and Hyperlipidemia (HLD), who presents with ongoing dizziness at rest and during activities despite recent valve replacement and normal prosthetic valve function?
What is the initial management for a patient presenting with dizziness and nausea?
What to do for a patient with a history of stroke, erectile dysfunction (ED), heart failure (ejection fraction (EF) 41-50%), and chronic obstructive pulmonary disease (COPD) who complains of dizziness after starting pindolol (beta-blocker) and decreasing the dose, with borderline orthostatic hypotension, while on diltiazem (calcium channel blocker)?
How to manage a 65-year-old male patient with hypertension, hyperlipidemia, and type 2 diabetes, taking hydrochlorothiazide (HCTZ) 100mg, metoprolol (Lopressor) 100mg twice daily, and Glipizide (Brand name: Glucotrol) 1mg before each meal, who presents with dizziness?
What is the best approach to manage a patient with chronic diarrhoea?
What tests can a healthcare provider order for a patient with a history of multiple sexual encounters with sex workers?
What are the dietary recommendations and health considerations for individuals following a modern nomad lifestyle?
What is the home remedy for a patient experiencing hypoglycemia (low blood sugar)?
What is the role of a low iodine diet in the management of a patient with hyperthyroidism, particularly prior to radioactive iodine treatment?
What is the preferred first-line treatment, alectinib (generic name) or lorlatinib (generic name), for a 50-70 year old adult patient with stage 4 anaplastic lymphoma kinase (ALK)-positive non-small cell lung cancer (NSCLC), possibly with a history of smoking or exposure to carcinogens, and considering potential comorbidities such as cardiovascular disease or diabetes?

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

Have a follow-up question?

Our Medical A.I. is used by practicing medical doctors at top research institutions around the world. Ask any follow up question and get world-class guideline-backed answers instantly.