for neurologist

[big stan]

Headache# 1 -  This headache is constant and never goes away.  It is a moderate to severe dull pressure deep behind my forehead and eyes.  It does not get worse with exercise. My forehead feels stiff, as if it is hard to raise my eyebrows. Again, I have had this headache for 4 years, when at the beginning it was not too bad, but in May of 2005 it quickly became much worse and I have had no relief since.  It has responded to no medications, including Elavil and Topamax.

Headache# 2 - This is a throbbing headache that always occurs when I first wake up, and usually lasts half the day.  It usually responds well to OTC's. It gets worse when I bend over forward.  However, even when this headache goes away, Headache type # 1 remains.

Dizziness and Blurred vision -I have dizziness episodes that last from hours to days at a time, and then goes away for days or possibly weeks at a time, but it always occurs again and again.  It begins when I lay down on my back or either side.  My vision blurs out (similar to needing glasses), and I then become very severely dizzy and sometimes nauseated. I also get dizzy when I bend over forward, or if I am standing up and turn my head to look up. This lasts until I sit or stand back up, and then immediately goes away in about 10 seconds.   My headache (type # 1) is usually worse during dizziness episodes.

[Joanna Fong, MD]

   Your symptoms are:  headache, dizziness (especially when bending over), blurry vision.  
CT/MRI--3.5 CM supra orbital mass, possibly intraossous meningioma.

Since I am not able to examine you nor review your MRI/CT, it is difficult to answer your questions with 100% certainty.

But, here are my thoughts:  

1)  If you were not a "headache" kind of person and this is a new onset headache, it deserves an imaging study.  You stated that your CT/MRI (which one?) showed supraorbital mass, possibly intraossous meningioma.  A mass in that region can cause double vision.

2)  Chronic nasal stuffiness or chronic respiratory infection suggests a diagnosis of sinusitis, although patients with migraine may also have nasal symptoms.

3)  The presence of nausea, vomiting, worsening of headache with changes in body position (particularly bending over), an abnormal neurologic examination, and/or a significant change in prior headache pattern suggest the headache was caused by a tumor.

4)  Blurring of vision on forward bending of the head, headaches upon waking early in the morning that improve with sitting up, and double vision or loss of coordination and balance should raise the suspicion of raised intracranial pressure.  This fits your symptoms the best.  Many conditions can cause high intracranial pressure:  Pseudotumor cerebri, brain tumor, hydrocephalus, etc.  CT/MRI would be able to see brain tumor or hydrocephalus (enlarged ventricles).  Description of pseudotumor cerebri is the following:

Pseudotumor cerebri:  Pseudotumor cerebri (PTC) is encountered most frequently in young, overweight women between the ages of 20 and 45. Headache is the most common presenting complaint, occurring in more than 90 percent of cases. Dizziness, nausea, and vomiting may also be encountered, but typically there are no alterations of consciousness or higher cognitive function. Tinnitus, or a "rushing" sound in the ears, is another frequent complaint. Visual symptoms are present in up to 70 percent of all patients with PTC, and include transient visual obscurations, general blurriness, and intermittent horizontal diplopia. These symptoms tend to worsen in association with Valsalva maneuvers (e.g. bearing down) and changes in posture. Reports of ocular pain, particularly with extreme eye movements, have also been noted.

Pseudotumor cerebri is a syndrome disorder defined clinically by four criteria: (1) elevated intracranial pressure as demonstrated by lumbar puncture; (2) normal cerebral anatomy, as demonstrated by neuroradiographic evaluation; (3) normal cerebrospinal fluid composition; and (4) signs and symptoms of increased intracranial pressure, including papilledema.

My suggestions:

1)  Go see a neurologist.  Do not delay as it can cause permanent eye damage.  
2)  Need to set up for lumbar puncture.  It is a quick, outpatient/in-office procedure.  It typically takes about 15 minutes to perform.  It is both diagnostic and therapeutic for PTC.  However, lumbar puncture should not be ordered until neuroimaging is found negative for space-occupying mass due to risk for herniation of brainstem through foramen magnum secondary to mass during lumbar puncture.  Bring your old CT/MRI films to the office.  
3)  Have a good fundoscopic examination (opthalmologist or neurologist) to see if there's any signs of increased intracranial pressure.
4)  Medical treatment of PTC:  the drug of choice for the initial management of PTC is oral acetazolamide (Diamox).
4)  If all above are negative, your headache can be benign:  tension headache, migraine headache, chronic daily headache, rebound headache.  A good neurologist can help you.

Good luck.

[Pikaboo]

Hi, I've had every test out there for the same headaches you are discribing.I've also been on different meds for this. The thing I'm taking now is called Midrin, its great.My headaches start normal and then I can't see,noices drive me crazy,head is tender,I go to bed with ice packs and meds.usually by the next day no headache,but ther is still the fuzzyness in the eyes and dizzyness is still there.My doctor was looking for a tumer, fonud nothing, told me they were migraine headache at the most severe. I've delt with these for  years. Midrin makes it better. Good Luck.

[CCFNeuroMD JT, MD]

I am happy to address the questions that you pose, although it is important that you recognize that my impression is based entirely on the information you have provided in your posting and is by no means a replacement for an office visit with a neurologist.  Diagnosis is contingent on detailed history and physical exam and as such, the following information should be considered solely for educational purposes.

I will first address “Headache #2,” as it is the most straightforward of the symptoms you have described.  A history of headache, present every morning yet responsive to OTC analgesics is highly suggestive of rebound headaches, sometimes referred to as medication overuse headaches.  Similar headaches can also be experienced from chronic daily caffeine intake.  You mentioned that you have tried Elavil (Amitriptyline) and Topamax (Topirimate) in the past which were ineffective in treating “Headache #1.”  While taking either of these drugs, did you happen to note an improvement in “Headache #2” symptoms?  Medications that have proven effective in treating classical rebound headaches include tricyclic antidepressants (such as Amitriptyline) and calcium channel blockers.  However, for these medications to be effective, it is imperative that you discontinue frequent use of OTC medications.  For symptomatic relief, Topirimate may be effective in alleviating symptoms whereas a tricyclic antidepressant or calcium channel blocker taken on a daily basis is used for primary prevention.

“Headache #1” poses a bit more of a challenge as it does not meet criteria for migraine proposed by the International Headache Society.  The constancy, quality, lack of association with activity, and location (non-lateralized) are symptoms that warrant assessment by a headache specialist.  The dizziness you describe, sometimes associated with nausea, may be related or unrelated to your headache symptoms.  It would be important to clarify whether “dizziness” refers to a room-spinning sensation (vertigo) or rather a lightheadedness. The positional component, time course, and sporadic episodes can be seen in conditions such as Benign Positional Vertigo and Migraine-Associated Vertigo, although these are clinical diagnoses and must be arrived at by a thorough neurologic exam.  If you have not done so already, it is likely in your best interest to make an appointment with a headache specialist for further evaluation.