What are the potential causes and treatment options for a patient with a history of stroke, now experiencing headaches and tinnitus (ringing in the ears) 4 months post-stroke?

Post-Stroke Headache and Tinnitus at 4 Months

These symptoms 4 months post-stroke require systematic evaluation to distinguish between stroke-related complications, vascular causes, and unrelated conditions, with imaging decisions guided by the specific characteristics of each symptom rather than their mere presence.

Initial Assessment Priorities

Headache Evaluation

• Determine headache characteristics: onset pattern, severity, location, quality, and any associated neurological symptoms 1
• Assess for "red flags" including sudden severe headache, focal neurological deficits, or altered consciousness that would suggest acute cerebrovascular events 2, 3
• Measure blood pressure, as hypertension is common post-stroke and can cause headache 3
• Post-stroke headaches are common but require differentiation from new vascular events, medication effects, or tension-type headaches 1

Tinnitus Characterization

• Classify the tinnitus as pulsatile versus non-pulsatile, and unilateral versus bilateral, as this fundamentally determines the diagnostic approach 2
• Perform otoscopic examination to exclude cerumen impaction, middle ear infection, or masses 2
• Document any associated hearing loss, as asymmetric hearing loss changes the evaluation pathway 2
• Obtain audiometric testing if hearing impairment is suspected, as 67-90% of stroke patients have undiagnosed hearing loss 2

Imaging Decisions Based on Symptom Characteristics

For Pulsatile Tinnitus

• Temporal bone CT and CT angiography (CTA) are appropriate first-line studies to evaluate for vascular masses, aberrant vascular anatomy, or dural arteriovenous fistula 2
• MRI with MR angiography may be considered as a noninvasive alternative to screen for intracranial vascular malformations 2
• Pulsatile tinnitus can be a harbinger of hemorrhagic or ischemic stroke and warrants vascular evaluation 4

For Non-Pulsatile Unilateral Tinnitus

• MRI of the internal auditory canals is the most appropriate imaging test when there is no clinically evident cause, to evaluate for retrocochlear processes such as vestibular schwannoma 2

For Bilateral/Symmetric Non-Pulsatile Tinnitus

• Imaging is usually not appropriate in the absence of other symptoms such as asymmetric hearing loss, neurological deficits, or head trauma 2
• This presentation is commonly related to medications, noise-induced hearing loss, or presbycusis, which do not require imaging 2

Neurological Deficit Assessment

When Tinnitus Accompanies Neurological Symptoms

• If new neurological deficits are present, imaging should be guided by the ACR Appropriateness Criteria for Cerebrovascular Disease rather than the tinnitus itself 2
• Perform National Institutes of Health Stroke Scale (NIHSS) assessment to quantify any neurological deficits 2, 5
• Obtain urgent brain MRI with diffusion-weighted imaging, which is more sensitive than CT for detecting acute posterior circulation strokes 6, 5

Headache with Neurological Deficit

• New or worsening headache with focal neurological signs 4 months post-stroke requires immediate brain imaging (CT or MRI) to exclude recurrent stroke, hemorrhage, or other complications 3, 1
• Blood pressure must be assessed immediately, as systolic BP >220 mmHg strongly suggests intracerebral hemorrhage 3

Management Approach

Hearing Impairment Management

• Refer to audiology for comprehensive audiometric testing 2
• Verify that hearing aids are functional if the patient owns them, as only 21% of stroke patients with hearing loss use amplification 2
• Implement communication strategies: face the patient when speaking, minimize background noise 2

Vascular Risk Factor Control

• Assess for increased carotid artery stiffness, as this is significantly associated with both tinnitus formation and severity, and may indicate increased stroke risk 7
• Optimize blood pressure control, as hypertension is present in 40-80% of stroke patients and contributes to both headache and vascular complications 3
• Consider antiplatelet therapy optimization if not already on appropriate secondary stroke prevention 8

Critical Pitfalls to Avoid

• Do not assume all post-stroke symptoms are benign or expected; new headaches or tinnitus may indicate recurrent vascular events 4, 1
• Do not order imaging for bilateral non-pulsatile tinnitus without other concerning features, as this is low-yield 2
• Do not overlook simple causes like cerumen impaction or medication side effects before pursuing extensive workup 2
• Recognize that 86% of stroke patients have undocumented hearing impairments that significantly impact care and quality of life 2

Special Consideration for Platelet Dysfunction

• In rare cases, fluctuating hearing loss with headache post-stroke may indicate platelet hyperaggregability requiring specific treatment with antiplatelet agents 9
• Consider this diagnosis if symptoms worsen with physiologic stresses like exercise or illness 9