I am experiencing a sensation of pressure in my head; what should I do?

Immediate Medical Evaluation Required for Head Pressure Sensation

You need urgent medical evaluation to determine whether your head pressure represents a serious condition requiring immediate intervention, particularly to rule out increased intracranial pressure, intracranial hypotension, or other secondary causes that could threaten your vision or neurological function.

Critical Red Flags Requiring Emergency Evaluation

Seek immediate emergency care if you experience any of these warning signs 1:

• Sudden onset or "worst headache of your life" 2
• Neurological symptoms: weakness, numbness, vision changes, difficulty speaking, confusion, or altered consciousness 3, 1
• Fever with neck stiffness suggesting possible infection 2
• Recent head trauma 3, 2
• Headache triggered by coughing, straining, or Valsalva maneuver 2
• Progressive worsening of symptoms over days to weeks 1
• Awakening from sleep due to headache 1

Urgent Evaluation Needed Within 24-48 Hours

Schedule prompt medical evaluation if you have 1, 2:

• Visual disturbances: blurred vision, double vision, or transient visual obscurations 1
• Papilledema (swelling of optic nerve, requires eye examination) 3, 1
• Pulsatile tinnitus (whooshing sound in ears) 1
• Positional changes: headache worse when lying down or standing up 3, 4
• Age over 50 years with new-onset headache 2, 5
• History of cancer or immunosuppression 2, 5

Diagnostic Approach Your Physician Will Follow

Initial Clinical Assessment

Your physician will evaluate specific characteristics 1, 2:

• Headache pattern: location (frontal, occipital, bilateral), quality (pressure, throbbing, tightness), duration, and frequency 3, 6
• Positional component: whether symptoms worsen when upright (suggesting low pressure) or when lying down (suggesting high pressure) 3, 4
• Associated symptoms: nausea, vomiting, visual changes, neck pain, or dizziness 3, 7
• Neurological examination: checking for papilledema, cranial nerve abnormalities, gait disturbances, abnormal reflexes, or altered sensation 3

Imaging Studies

If signs of increased intracranial pressure are present, MRI is the imaging modality of choice 3, 1:

• MRI brain and orbits with and without contrast is most appropriate for detecting signs of elevated intracranial pressure including empty sella, dilated optic sheaths, posterior globe flattening, and pachymeningeal enhancement 3, 1
• MR venography (MRV) should be included to evaluate for venous outflow obstruction commonly associated with pseudotumor cerebri 1
• Orbital imaging with coronal fat-saturated T2-weighted sequences to evaluate optic nerve sheath dilation 3, 1

If intracranial hypotension is suspected (headache worse when upright), MRI brain should include 3:

• Evaluation for venous sinus engorgement, pachymeningeal enhancement, brain sagging, and subdural collections 3
• Spine MRI may be needed to identify CSF leak source 3

Lumbar Puncture Considerations

If imaging suggests increased intracranial pressure, lumbar puncture with opening pressure measurement is diagnostic 1:

• Opening pressure >250 mm H₂O defines idiopathic intracranial hypertension requiring urgent intervention 1
• Opening pressure <60 mm H₂O suggests intracranial hypotension 7, 4
• CSF analysis rules out infection or other causes 2

Common Diagnoses Based on Presentation Patterns

Increased Intracranial Pressure (Pseudotumor Cerebri)

Typical presentation 3, 1, 7:

• Headache worse in morning, improves throughout day with upright posture 1
• Visual disturbances and papilledema 1, 7
• Predominantly affects overweight females of childbearing age 3, 1
• Pulsatile tinnitus common 1, 7

MRI findings 3, 1:

• Empty or partially empty sella (56% sensitivity, 100% specificity for posterior globe flattening) 1
• Dilated, tortuous optic nerve sheaths 3, 1
• Flattened posterior globes 3, 1

Intracranial Hypotension

Typical presentation 3, 4:

• Orthostatic headache: worse when upright, improves when lying down 3, 4
• May have neck pain, nausea, tinnitus, hearing changes 3
• Often follows minor trauma or occurs spontaneously 4

MRI findings 3:

• Pachymeningeal enhancement 3
• Brain sagging with midbrain descent 3
• Subdural collections 3

Primary Headache Disorders

If no red flags present and normal neurological examination 8, 5:

• Migraine: unilateral throbbing with nausea, photophobia, phonophobia 8, 5
• Tension-type headache: bilateral band-like pressure without migraine features 6, 5

Treatment Depends on Underlying Cause

For Increased Intracranial Pressure 1:

• Weight loss and acetazolamide for pseudotumor cerebri 1
• Surgical intervention if vision declining 1
• Serial lumbar punctures if pressure remains elevated 1

For Intracranial Hypotension 3, 4:

• Conservative management: bed rest, caffeine, hydration 4
• Epidural blood patch for persistent symptoms 3, 4
• Surgical repair for identified CSF leaks 3

For Primary Headaches 3, 5:

• Acute migraine: NSAIDs, triptans, or gepants 3, 5
• Tension-type: acetaminophen or ibuprofen 3, 6
• Preventive therapy if frequent or disabling 3, 5

Critical Pitfalls to Avoid

• Do not assume normal neurological examination excludes serious pathology if symptoms are progressive or concerning 1
• Do not delay imaging in patients with papilledema, as vision loss can be permanent 1
• Do not confuse post-lumbar puncture meningeal enhancement with pathology on MRI 3
• Recognize that CSF pressure can be normal in some patients with intracranial hypotension, especially with intermittent leaks 3, 4
• Nearly all children with brain tumors (94%) have abnormal neurological findings at diagnosis, emphasizing importance of thorough examination 3