Could my symptoms of intense pressure, ear spasms, and difficulty walking be related to Idiopathic Intracranial Hypertension (IIH) or a vestibular disorder, given my history of chronic headaches and normal imaging studies, and current medication regimen including gabapentin?

Urgent Evaluation Required: Your Symptoms Warrant Immediate Medical Assessment

Your symptoms of intense pressure sensation, ear spasms, severe difficulty walking requiring you to drop to your knees, and the prolonged 30-45 minute duration are concerning and require urgent neurological evaluation, as these features are atypical for typical IIH presentations and raise concern for either acute IIH decompensation, vestibular crisis, or potentially spontaneous intracranial hypotension. 1, 2

Why This Requires Urgent Attention

Your symptom constellation is particularly concerning because:

• The severe postural instability requiring you to crawl is not a typical IIH symptom and suggests either acute vestibular dysfunction or central nervous system involvement 1
• The intense pressure sensation while lying prone could represent either elevated intracranial pressure or paradoxically, spontaneous intracranial hypotension (which can cause severe positional symptoms) 1, 2
• The 30-45 minute duration with ear "spasming" does not fit typical benign paroxysmal positional vertigo (BPPV), which causes brief episodes lasting seconds to minutes, not 30-45 minutes 1

Differential Diagnosis Framework

Most Likely Possibilities:

1. Acute Vestibular Disorder (Primary Consideration)

• Your symptoms of severe vertigo-like sensations, ear involvement, and profound imbalance lasting 30-45 minutes suggest vestibular pathology 1
• However, BPPV typically causes episodes lasting seconds to minutes, not 30-45 minutes 1
• Vestibular migraine can cause episodes lasting 5 minutes to 72 hours and may present with ear symptoms, but the severity requiring crawling is unusual 3
• The ear "spasming" sensation could represent tinnitus or aural fullness associated with vestibular dysfunction 1, 4

2. IIH-Related Complications

• While IIH classically presents with headache, papilledema, pulsatile tinnitus, and transient visual obscurations, atypical presentations can include vestibular dysfunction and hearing disturbances 2, 5, 4
• Your chronic headache history with normal imaging raises the possibility of IIH without papilledema, which occurs in patients with chronic daily headache 6
• The ear symptoms could represent pulsatile tinnitus (common in IIH) or vestibular dysfunction (an atypical IIH presentation) 2, 4

3. Spontaneous Intracranial Hypotension (Critical to Exclude)

• This is a dangerous mimic that presents with severe positional symptoms, including dizziness, nausea, and imbalance 1
• Symptoms are typically worse when upright and better when lying down, but can present with severe postural instability 1
• Can be associated with cerebral venous thrombosis in rare cases, which is life-threatening 1

Immediate Actions Required

Clinical Evaluation Needed:

Neurological Examination:

• Assessment for papilledema (fundoscopic exam) 1
• Cranial nerve testing, particularly VI nerve palsy (common in IIH), III, IV, VII, VIII nerve function 2, 4
• Cerebellar testing and gait assessment 1
• Assessment for nystagmus patterns (central vs. peripheral) 1

Vestibular Testing:

• Dix-Hallpike maneuver to evaluate for BPPV (though your prolonged duration makes this less likely) 1
• Supine roll test for horizontal canal BPPV 1
• Assessment of nystagmus characteristics: BPPV causes fatigable nystagmus that suppresses with gaze fixation, while central causes do not 1

Red Flags Present in Your Case:

• Severe postural instability requiring crawling suggests either severe vestibular dysfunction or central nervous system involvement 1
• Prolonged episode duration (30-45 minutes) is atypical for BPPV 1
• History of chronic headaches with these new severe symptoms requires investigation 1, 7

Imaging Considerations:

MRI Brain with and without contrast is indicated because: 7

• Your symptoms are atypical and prolonged 7
• Normal prior imaging does not exclude evolving pathology 1, 7
• MRI is superior for detecting central causes, inflammatory processes, and small infarcts 1, 7
• Can identify signs of IIH (empty sella, optic nerve sheath distension, transverse sinus stenosis) or intracranial hypotension (brain sagging, subdural collections) 1, 6

MRI venography should be considered to evaluate for cerebral venous thrombosis, which can complicate both IIH and spontaneous intracranial hypotension 1, 5

Lumbar Puncture Considerations:

Opening pressure measurement is diagnostic and potentially therapeutic: 1, 2, 8

• IIH diagnosis requires elevated opening pressure (>25 cm H2O) 1, 2
• The diagnostic lumbar puncture itself provides immediate symptomatic relief in IIH 8
• Low opening pressure would suggest spontaneous intracranial hypotension 1
• However, lumbar puncture should only be performed after imaging excludes mass lesion or other contraindications 1

Medication Review

Your gabapentin may be relevant:

• Gabapentin can cause dizziness and ataxia as side effects 1
• However, the acute severe nature of your symptoms makes medication side effect less likely as the sole explanation 1
• Do not stop medications without physician guidance 1

Common Pitfalls to Avoid

1. Assuming this is "just BPPV" because of positional symptoms—the 30-45 minute duration and severity requiring crawling are atypical 1

2. Dismissing symptoms as anxiety or panic disorder—while these can cause dizziness, the severe postural instability and ear symptoms suggest organic pathology 1

3. Delaying evaluation because prior imaging was normal—IIH can develop over time, and spontaneous intracranial hypotension can occur acutely 1, 6

4. Failing to consider spontaneous intracranial hypotension—this is a rare but potentially life-threatening condition that can present with severe positional symptoms and requires specific treatment 1

Follow-Up Strategy

If IIH is confirmed: 1

• Weight reduction program (critical for obese patients) 1, 8
• Acetazolamide starting at 250-500 mg twice daily, titrating up as tolerated 1
• Regular ophthalmologic monitoring for papilledema and visual field testing 1
• Headache management with migraine-specific therapies 1, 3

If vestibular disorder is confirmed: 1

• Canalith repositioning maneuvers (Epley maneuver) for BPPV 1
• Vestibular rehabilitation therapy 1
• Consideration of vestibular migraine prophylaxis if criteria met 3

If spontaneous intracranial hypotension is confirmed: 1

• Identification and treatment of CSF leak 1
• Epidural blood patch 1
• Possible surgical repair if conservative measures fail 1

Do not wait—seek urgent neurological evaluation today or go to the emergency department if symptoms recur with similar severity. 1, 7