Workup for Pulsatile Tinnitus with Migraines and Exercise-Induced Headaches
Order CT angiography (CTA) of the head and neck with contrast as your first-line imaging study, as this patient's presentation—particularly the combination of pulsatile tinnitus, migraines, and exercise-induced headaches—raises significant concern for idiopathic intracranial hypertension (IIH), which is the second most common cause of pulsatile tinnitus and can lead to permanent vision loss if missed. 1
Immediate Clinical Assessment
Before ordering imaging, perform these specific evaluations:
Determine if the tinnitus is truly pulsatile (synchronous with heartbeat) versus other rhythmic sounds, as this distinction fundamentally changes diagnostic urgency—pulsatile tinnitus has an identifiable structural or vascular cause in over 70% of cases 1
Assess for objective versus subjective tinnitus by listening with a stethoscope over the periauricular area, mastoid, orbit, and neck; objective tinnitus strongly suggests vascular pathology requiring immediate workup 1
Check for unilateral versus bilateral presentation, as unilateral pulsatile tinnitus has higher likelihood of identifiable structural or vascular cause 1
Perform jugular/carotid compression test during auscultation—relief of pulsatile tinnitus upon compression suggests venous etiology (sigmoid sinus abnormalities, jugular bulb variants) or arterial dissection 1
Conduct fundoscopic examination to evaluate for papilledema, which would indicate elevated intracranial pressure and make IIH diagnosis more likely 1
Document any focal neurological deficits, as these would shift the evaluation toward stroke, hemorrhage, or mass lesions 1
Perform otoscopic examination to identify vascular retrotympanic masses (paragangliomas appear as pulsatile red masses behind the tympanic membrane) 1
Why This Patient Profile is High-Risk
The combination of pulsatile tinnitus, migraines, and exercise-induced headaches in this patient creates a clinical picture highly suggestive of IIH, particularly if the patient is a young, overweight woman 1. IIH is the second most common cause of pulsatile tinnitus and is associated with sigmoid sinus wall abnormalities 1. Missing this diagnosis can result in permanent vision loss, making urgent evaluation critical 1.
First-Line Imaging Strategy
Order CTA head and neck with contrast using a mixed arterial-venous phase (20-25 seconds post-contrast) to capture both arterial and venous pathology in a single acquisition 1. This approach is superior because:
CTA evaluates for life-threatening vascular causes including dural arteriovenous fistulas (8% of cases, can cause hemorrhagic or ischemic stroke), arterial dissection (potentially life-threatening), atherosclerotic carotid disease (17.5% of cases), and arteriovenous malformations 1
CTA assesses venous sinus anatomy for sigmoid sinus diverticulum or dehiscence (commonly associated with intracranial hypertension), jugular bulb abnormalities, and aberrant venous anatomy 1
CTA source images can be reconstructed to create dedicated temporal bone CT images without additional radiation exposure, providing evaluation for bony causes like superior semicircular canal dehiscence 1
Alternative First-Line Option
If clinical suspicion strongly favors bony or middle ear pathology (e.g., visible retrotympanic mass on otoscopy), order high-resolution CT temporal bone (non-contrast) instead, as this is preferred for paragangliomas (16% of cases), glomus tumors, jugular bulb abnormalities, superior semicircular canal dehiscence, and aberrant vascular anatomy 1.
Concurrent Audiologic Testing
Order comprehensive audiologic examination within 4 weeks, including pure tone audiometry, speech audiometry, and acoustic reflex testing 1. This is essential because:
- Asymmetric hearing loss changes the imaging algorithm and raises concern for retrocochlear pathology 1
- Audiometry documents baseline hearing status for future comparison 2
- The American Academy of Otolaryngology recommends this for any unilateral or persistent tinnitus 1
Second-Line Imaging if Initial Studies are Negative
If CTA is negative but clinical suspicion remains high (particularly for IIH given the migraine and exercise-induced headache history), proceed to MRI brain with contrast and MR venography (MRV) to further evaluate for:
- Venous sinus abnormalities not visible on CTA 1
- Cerebellopontine angle lesions or acoustic neuroma 1
- Subtle vascular malformations 1
Life-Threatening Causes You Cannot Miss
The following diagnoses require urgent identification as they can cause catastrophic outcomes:
Dural arteriovenous fistulas (8% of cases)—can lead to hemorrhagic or ischemic stroke if untreated; may present with isolated pulsatile tinnitus before catastrophic hemorrhage 1
Arterial dissection—potentially life-threatening condition requiring urgent identification 1
Arteriovenous malformations—carry 2-3% annual hemorrhage risk with 10-30% mortality from first hemorrhage 1
Idiopathic intracranial hypertension—can cause permanent vision loss if missed, particularly in young overweight women with headaches 1
Common Pitfalls to Avoid
Do not dismiss pulsatile tinnitus as benign without imaging—this is a common pitfall, as pulsatile tinnitus almost always requires imaging evaluation due to identifiable causes in >70% of cases 1
Do not perform inadequate otoscopic examination—this can lead to delayed diagnosis and inappropriate imaging selection, particularly for vascular retrotympanic masses (paragangliomas) 1
Do not overlook intracranial hypertension in young, overweight women with headaches, as this can lead to vision loss 1
Do not order MRV alone—it is insufficient for evaluating pulsatile tinnitus; CT temporal bone or CTA head and neck should be performed as the initial study 1
Do not use standard tinnitus protocols if asymmetric hearing loss or neurologic deficits are present—these require different ACR criteria 1
If Symptoms are Truly Transient
If the pulsatile tinnitus episodes last only minutes and are self-limited without other symptoms, observation with close monitoring may be appropriate 3. However, given this patient's migraines and exercise-induced headaches, proceed with imaging regardless, as these associated symptoms elevate concern for IIH 1. Red flags requiring urgent evaluation include: