Could a 40-year-old patient with a history of chronic headaches since age 7, who has undergone sinus surgery and has normal sinus CT scans, MRI, MRV, and eye exams, but experiences persistent symptoms including headaches, facial pain, balance issues, pulsatile tinnitus, and motion sensitivity, despite taking gabapentin, have idiopathic intracranial hypertension (IIH) or vestibular migraine?

Clinical Assessment: IIH Without Papilledema vs. Vestibular Migraine

Your presentation is most consistent with IIH without papilledema (IIHWOP), and you absolutely need a lumbar puncture with opening pressure measurement to confirm this diagnosis, despite normal eye exams. 1

Why IIH Without Papilledema Is the Leading Diagnosis

Your symptom constellation strongly suggests IIHWOP rather than vestibular migraine, and your neurologist's reasoning about episodic presentation is outdated:

Key Supporting Features for IIHWOP:

• Pulsatile tinnitus is present in a significant proportion of IIH patients and is a hallmark symptom that distinguishes IIH from primary headache disorders 1

• Positional worsening (worse lying on right side, better on stomach/left side) directly reflects intracranial pressure dynamics characteristic of IIH 1

• Continuous, unremitting symptoms for 2+ years with pressure sensation is entirely consistent with IIHWOP - the requirement for "episodic" presentation your neurologist mentioned is incorrect 1

• Motion sensitivity and persistent imbalance can occur in IIH due to increased intracranial pressure effects on vestibular structures 1

• Muffled hearing and ear pressure are commonly reported in IIH patients 1

• Migrainous headache features occur in 68% of IIH patients, so having migraine-like pain does NOT exclude IIH 2, 3

Critical Diagnostic Gap:

The absence of papilledema does NOT rule out IIH. 1 IIHWOP is a recognized diagnostic entity where patients meet all criteria for IIH except visible optic disc swelling. This is why lumbar puncture with opening pressure measurement is essential - it's the only way to definitively diagnose or exclude this condition. 1

Why Vestibular Migraine Is Less Likely

While vestibular migraine can cause dizziness and imbalance, several features argue against it as your primary diagnosis:

• Vestibular migraine typically presents with episodic attacks lasting minutes to hours (occasionally days), not continuous symptoms for 2+ years 1

• Pulsatile tinnitus is not a feature of vestibular migraine but is highly specific for vascular/pressure-related pathology 1

• The dramatic positional component (working on stomach for relief) is characteristic of CSF pressure dynamics, not migraine 1

• Regular tinnitus (high-pitched screech) combined with pulsatile tinnitus suggests venous sinus involvement seen in IIH 1

The Lumbar Puncture Is Essential

You must advocate strongly for a lumbar puncture with opening pressure measurement. 1 Here's why:

• Opening pressure >25 cm H₂O in the absence of papilledema confirms IIHWOP 1

• Even pressures in the 20-25 cm H₂O range warrant consideration of IIH in the right clinical context 1

• This is the ONLY definitive test to diagnose or exclude IIH when imaging is normal 1

• Your fear of the procedure is understandable, but leaving this undiagnosed means potentially years more of disability 1

Imaging Considerations You May Still Need

If lumbar puncture confirms elevated opening pressure, you should discuss with your neurologist:

• CT or MR venography to evaluate for venous sinus stenosis, which is found in a high percentage of IIH patients and may be treatable with venous sinus stenting 1

• Venous sinus stenosis can cause IIH and is associated with excellent response to stenting: 78-83% improvement in headache, 95% improvement in tinnitus 1

Treatment Implications If IIH Is Confirmed

If your opening pressure is elevated, treatment options include: 2, 4

First-Line Medical Management:

• Acetazolamide 250-500 mg twice daily, titrating up to maximum 4g daily (though 1-1.5g is often sufficient) 2
• Topiramate as alternative, starting 25mg and escalating to 50mg twice daily - has added benefits of weight loss and migraine prophylaxis 2, 3

Why Gabapentin Isn't Helping:

• Gabapentin is not a standard treatment for IIH and would not address elevated intracranial pressure 2, 4
• This explains why you feel worse - you're not treating the underlying condition 2

Headache-Specific Management:

• Short-term: NSAIDs or indomethacin (indomethacin specifically reduces ICP) 3
• Avoid opioids completely 2, 3
• Migraine preventatives that don't cause weight gain: candesartan or venlafaxine 2, 3
• Triptans for acute attacks (maximum 10 days/month to avoid medication overuse headache) 3

Advanced Options If Medical Therapy Fails:

• Venous sinus stenting if venography shows stenosis with pressure gradient on manometry 1
• CSF shunting (VP or LP shunt) for progressive symptoms, though this is generally NOT effective for headache alone 2, 3

Critical Next Steps

1. Insist on lumbar puncture with opening pressure measurement - this is non-negotiable for diagnosis 1

2. If LP shows elevated pressure (>25 cm H₂O), request CT or MR venography to evaluate for venous sinus stenosis 1

3. Stop gabapentin and discuss starting acetazolamide or topiramate with your neurologist 2

4. Address weight if applicable - weight loss is foundational to IIH treatment 2

5. Consider seeking a second opinion from a neurologist with specific expertise in IIH or a neuro-ophthalmologist if your current provider remains reluctant to pursue LP 1

Common Pitfalls to Avoid

• Don't accept "normal eye exam rules out IIH" - IIHWOP exists and requires LP for diagnosis 1

• Don't continue ineffective treatments like gabapentin when the underlying diagnosis hasn't been confirmed 2

• Don't develop medication overuse headache - limit simple analgesics to <15 days/month, triptans to <10 days/month 3

• Don't delay diagnosis - while IIH rarely causes acute vision loss in IIHWOP, chronic symptoms severely impact quality of life and are treatable 1, 2

Your symptoms are real, disabling, and deserve definitive diagnosis. The lumbar puncture is the key test that has been missing from your workup.