I'm experiencing persistent head pressure, pain around my forehead, high-pitched tinnitus, and headaches that sometimes move behind my eye or to the right side of my head, which started 18 days after caffeine (caffeine) withdrawal, what could be causing these symptoms?

Persistent Head Pressure and Tinnitus Following Caffeine Withdrawal

Your symptoms 18 days after caffeine cessation are most likely caffeine withdrawal headache that has evolved into medication overuse headache (MOH) from excessive analgesic use during the initial withdrawal period, though the absence of positional variation and presence of persistent tinnitus warrant urgent neuroimaging to exclude intracranial hypotension or elevated intracranial pressure.

Critical Diagnostic Considerations

Caffeine Withdrawal vs. Secondary Headache

• Typical caffeine withdrawal headaches resolve within 7-9 days, and your persistence beyond 18 days with continuous symptoms suggests either a secondary headache disorder or transformation to chronic daily headache 1
• The initial 7 days of "bad headaches" align with classic caffeine withdrawal, but the evolution to persistent 24-hour pressure requires investigation for alternative diagnoses 1

Red Flags Requiring Immediate Imaging

You need urgent MRI brain with contrast and MR venography based on the following concerning features:

• High-pitched tinnitus with head pressure can indicate either intracranial hypotension or elevated intracranial pressure—both require imaging 2
• Persistent daily symptoms beyond typical withdrawal timeline warrant exclusion of structural pathology 3
• Pain migrating behind the eye or to different head regions may suggest venous sinus abnormalities or CSF pressure disorders 2, 4

Intracranial Hypotension Evaluation

The ACR guidelines indicate that spontaneous intracranial hypotension (SIH) typically presents with:

• Orthostatic headache that worsens upright and improves lying down—you specifically note pressure is the SAME in both positions, which argues AGAINST classic SIH 2
• However, tinnitus occurs in 30-40% of intracranial hypotension cases and can be an early or isolated symptom 2
• Non-orthostatic presentations of SIH exist and should not be dismissed, particularly with persistent tinnitus 3

Elevated Intracranial Pressure Evaluation

Mildly elevated intracranial pressure presents with:

• Head fullness-pressure sensation as a dominant symptom 4
• Low-pitch pulsatile tinnitus is typical, though high-pitched tinnitus can occur 4, 5
• Absence of photophobia does not exclude elevated pressure 2
• Normal fundoscopic exam does not exclude early elevated pressure—papilledema develops later 2, 5

Immediate Diagnostic Algorithm

Step 1: Urgent Neuroimaging (Within 48-72 Hours)

Order the following studies:

• MRI brain and orbits with IV contrast to evaluate for pachymeningeal enhancement (SIH) or signs of elevated pressure (empty sella, optic nerve sheath dilation) 2, 3
• MR venography to exclude cerebral venous sinus thrombosis or stenosis, which can cause both pressure symptoms and tinnitus 2, 3, 4
• MRI complete spine if brain imaging suggests intracranial hypotension, to localize potential CSF leak 3

Step 2: Ophthalmologic Examination

• Dilated fundoscopic exam to assess for papilledema, though its absence does not exclude elevated intracranial pressure 2, 5
• Visual field testing if any concern for elevated pressure exists 2

Step 3: Lumbar Puncture with Opening Pressure

Only perform after neuroimaging excludes mass lesion or venous thrombosis:

• Opening pressure <6 cm H₂O confirms intracranial hypotension 2
• Opening pressure >20 cm H₂O (200 mm H₂O) confirms elevated intracranial pressure 2, 3
• Temporary symptom relief after LP strongly suggests pressure-related headache 4

Medication Overuse Headache Consideration

High Likelihood of MOH Development

If you used analgesics frequently during the initial 7-day withdrawal period:

• Taking acetaminophen, NSAIDs, or combination analgesics ≥15 days/month causes MOH 6
• MOH transforms episodic headache into chronic daily headache with constant, fluctuating intensity—matching your current pattern 6
• Tinnitus is NOT a typical MOH symptom, which is why imaging remains essential 6

MOH Management (If Imaging Normal)

• Abruptly stop all analgesics immediately—this is the only definitive treatment 6
• Expect worsening headache for 2-4 weeks before improvement—this is temporary and expected 6
• Start preventive medication on day 1 of analgesic withdrawal: topiramate 25-50 mg daily or amitriptyline 25 mg nightly 6
• Limit any future acute headache medication to ≤2 days per week to prevent recurrence 6, 7

Tinnitus-Specific Evaluation

Vascular vs. Non-Vascular Causes

• High-pitched tinnitus is typically non-pulsatile and less likely vascular, but pulsatile tinnitus requires vascular imaging 2, 8
• Tinnitus with head pressure suggests either intracranial pressure disorder or tensor tympani syndrome 9, 4
• Audiologic assessment with tympanometry should be performed if imaging is normal 2, 8

Critical Pitfalls to Avoid

Do Not Assume Simple Caffeine Withdrawal

• Caffeine withdrawal headaches should resolve by day 7-9—persistence to day 18 demands investigation 1
• The combination of persistent pressure + tinnitus + migratory pain is NOT typical caffeine withdrawal 1

Do Not Delay Imaging for "Conservative Management"

• Both intracranial hypotension and elevated pressure can cause permanent neurological damage if untreated 2, 3
• Venous sinus thrombosis can present with non-specific head pressure and is life-threatening 3

Do Not Resume Caffeine Without Diagnosis

• Caffeine can temporarily mask symptoms of intracranial hypotension through cerebral vasoconstriction, delaying diagnosis 7, 1
• If imaging confirms intracranial hypotension, caffeine 300-900 mg/day becomes therapeutic 7

Specific Next Steps for You

1. Contact your primary care physician or neurologist TODAY to request urgent MRI brain with contrast and MR venography 3
2. Document exact analgesic use during the past 18 days (type, frequency, total days used) to assess for MOH 6
3. Stop all analgesics immediately if you've been using them ≥10-15 days/month 6, 7
4. Maintain adequate hydration (2-3 liters daily) while awaiting imaging 7
5. Seek emergency care immediately if you develop visual changes, focal neurological symptoms, altered consciousness, or severe worsening of headache 3, 7

Expected Timeline

• Imaging should be completed within 48-72 hours given persistent symptoms and tinnitus 3
• If imaging is normal and MOH is diagnosed, expect 4-8 weeks for improvement after analgesic withdrawal 6
• If intracranial hypotension is confirmed, epidural blood patch provides relief within 24-48 hours in 70-90% of cases 3, 7