headache, vertigo, blurred vision

[babyblue1]

I always have this moderate dull headache. Very disabling, and I am NOT a weak person. My forehead feels stiff and my nose feels swolen shut. I also frequently wake up in the morning with an intense THROBBING headache that lasts about half a day and responds well to 1-2 ADVIL (although the underlying dull pressure headache responds to NOTHING).

Every now and then I get in this "dizziness mode" for several hours or days at a time. My vision gets blurred like I need glasses and I become very severly dizzy AND THIS IS ONLY IN A HORIZONTAL POSTION, OR WHEN I BEND OVER FORWARD. Standing or sitting back up vertically and the dizziness/blurred vision is gone in 15 seconds. Even if I tilt my head back when standing the dizziness kicks in. Even if I lay very, very still for hours I'm still highly dizzy and blurry until I sit back up. Very disabling I must tell you the truth!

CT/MRI--3.5 CM supra orbital mass, possibly intraossous meningioma.  Otherwise NORMAL.
Eye exam--NORMAL
Video Caloric testing-NORMAL
Spinal tap--Refusal to administer upon my request.

HELP..PLEASE?  DESPERATE HERE!

[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.

[vega1318]

Have you ever been checked for a Chiari malformation?  They can usually see it on an MRI -- it is just a mild anomaly in the way your cerebellum looks but it could result in similar problems.