A patient presents with headache and tinnitus, what is the best course of action for management and diagnosis?

Management of Headache with Tinnitus

Begin with a comprehensive audiologic examination within 4 weeks and perform a targeted history to differentiate between primary headache disorders and secondary causes, particularly focusing on whether the headache has orthostatic features or is associated with hearing loss. 1

Initial Diagnostic Approach

Critical History Elements

The combination of headache and tinnitus requires specific questioning to identify potentially serious underlying conditions:

• Determine headache characteristics: Ask specifically about orthostatic features (headache absent/mild upon waking, onset within 2 hours of becoming upright, >50% improvement within 2 hours of lying flat) which suggests spontaneous intracranial hypotension (SIH). 1

• Assess tinnitus laterality: Unilateral tinnitus with headache raises concern for vestibular schwannoma, stroke, or other structural pathology requiring urgent evaluation. 1

• Identify red flags: Thunderclap onset, focal neurological deficits, altered mental status, fever, or headache awakening from sleep mandate immediate neuroimaging. 1, 2, 3

• Distinguish migraine features: Headache provoked by movement (not posture), unilateral, pulsating, moderate-severe intensity with photophobia/phonophobia/nausea suggests migraine, though migraine typically presents with vertigo rather than hearing impairment and tinnitus. 1, 2

Physical Examination Priorities

Perform a targeted neurologic examination looking for focal deficits, papilledema, neck stiffness, and asymmetric hearing loss. 1, 3

• Check for orthostatic vital signs to evaluate for orthostatic hypotension or postural tachycardia syndrome (>30 bpm increase in heart rate). 1

• Examine for cervical pathology with reduced range of motion and myofascial tenderness if cervicogenic headache is suspected. 1

Mandatory Diagnostic Testing

Audiologic Evaluation

Obtain a prompt comprehensive audiologic examination (within 4 weeks) for any patient presenting with tinnitus and headache. 1

This is critical because:

• Tinnitus most often occurs with concomitant sensorineural hearing loss. 1
• Unilateral tinnitus with hearing loss may indicate vestibular schwannoma requiring urgent workup. 1
• The audiogram characterizes the nature of hearing loss (conductive, sensorineural, or mixed; unilateral or bilateral). 1

Neuroimaging Indications

Obtain imaging studies (MRI preferred over CT) if the patient has any of the following: 1

• Unilateral or pulsatile tinnitus
• Focal neurological abnormalities
• Asymmetric hearing loss on audiometry
• Thunderclap headache presentation
• Progressive worsening or new onset in older adults

Do not obtain routine imaging for bilateral non-pulsatile tinnitus with normal neurologic examination and symmetric hearing. 1

Management Based on Diagnosis

If Spontaneous Intracranial Hypotension is Suspected

• Refer to neurology within 2-4 weeks if patient can care for themselves; within 48 hours if they cannot but have help; emergency admission if unable to self-care without help. 1
• Consider epidural blood patch as first-line treatment (requires specialist referral). 1

If Primary Headache Disorder (Migraine) is Diagnosed

For acute treatment: 1

• First-line: NSAIDs (ibuprofen 400-600 mg, naproxen 500 mg, or diclofenac potassium) taken early when headache is still mild. 1
• Second-line: Triptans if NSAIDs provide inadequate relief, taken early in attack when headache is mild. 1
• Avoid opioids as they do not address underlying pathophysiology and risk medication overuse headache. 2

For preventive therapy if ≥2 headaches per week: 1

• Consider topiramate (only agent with proven efficacy in randomized controlled trials for chronic migraine). 1
• Alternative options include gabapentin, amitriptyline, or valproate. 1

Management of Tinnitus Component

Distinguish bothersome from non-bothersome tinnitus, as this guides treatment intensity. 1

For Persistent, Bothersome Tinnitus (≥6 months):

Provide education and counseling about management strategies to all patients. 1, 4

Recommend cognitive behavioral therapy (CBT) as the strongest evidence-based treatment for improving quality of life. 1, 4

If hearing loss is present on audiometry, recommend hearing aid evaluation even if hearing loss is mild or unilateral. 1, 4

May offer sound therapy for symptomatic relief. 1, 4

Treatments to Avoid:

Do not routinely prescribe: 1, 4

• Antidepressants, anticonvulsants, or anxiolytics for primary tinnitus treatment
• Ginkgo biloba, melatonin, zinc, or other dietary supplements (lack consistent evidence)
• Intratympanic medications
• Transcranial magnetic stimulation

Critical Pitfalls to Avoid

• Missing medication overuse headache: Patients using acute headache medications >2 days per week are at risk for rebound headaches requiring medication withdrawal. 1, 2

• Delaying audiologic evaluation: Waiting beyond 4 weeks may delay diagnosis of serious conditions like vestibular schwannoma. 1

• Overlooking psychiatric comorbidities: Patients with tinnitus and severe anxiety or depression have increased suicide risk and require prompt mental health referral. 1, 4

• Assuming bilateral tinnitus is benign: While less concerning than unilateral, 10-15% of bilateral tinnitus cases have identifiable underlying causes requiring long-term follow-up. 1, 4

Referral Criteria

Refer to neurology if: 1, 5

• Diagnosis remains uncertain after initial evaluation
• Headache with persistent aura or associated motor weakness
• Poor response to preventive strategies
• Suspected spontaneous intracranial hypotension

Refer to otolaryngology if: 1

• Unilateral or pulsatile tinnitus
• Asymmetric hearing loss on audiometry
• Abnormal otologic examination findings

Team approach involving otolaryngology, audiology, and mental health professionals optimizes outcomes for patients with persistent bothersome tinnitus. 4