Management of a 19-Year-Old Female with Unbearable Tinnitus and Headache

Top Differential Diagnosis: Idiopathic Intracranial Hypertension (IIH)

Step 1: Full History & Risk Factor Assessment

• Is the headache positional (worse lying down/morning)? → Raises ICP
• Is the tinnitus pulsatile (heartbeat-synchronous)? → Strongly suggests IIH
• Visual changes - transient blurring, "greying out," double vision?
• BMI / recent weight gain? IIH is strongly linked with obesity (94% cases)
• Medications: tetracyclines, isotretinoin (Accutane), oral contraceptives, vitamin A supplements, steroids (withdrawal), growth hormone?
• Recent infections (otitis media, mastoiditis)?
• Menstrual irregularity, thyroid symptoms, or Addison-like features?
• Trauma - even minor head injury?
• Oral contraceptive pill use (risk factor for cerebral venous sinus thrombosis)

Step 2: Clinical Examination

• Pulsatile/objective tinnitus → vascular cause (IIH, AV fistula, glomus tumor, sigmoid sinus dehiscence, carotid stenosis)
• Subjective non-pulsatile tinnitus → sensorineural, noise-induced, drug-induced, Meniere's

Step 3: Investigations (Parallel Workup)

Imaging (FIRST - before LP)

• MRI brain with gadolinium + MR Venography (MRV) - mandatory before LP
  • Rules out: intracranial mass, abscess, hydrocephalus
  • Rules out: cerebral venous sinus thrombosis (CVST) - a critical mimic of IIH in young women on OCP
  • IIH findings: empty sella, posterior globe flattening, tortuous optic nerves, transverse sinus stenosis

Blood Tests

• CBC (anaemia can cause raised ICP)
• Thyroid function (hypo/hyperthyroidism)
• Renal and liver function
• Electrolytes, calcium
• Vitamin A level (if supplement use suspected)
• Coagulation screen + thrombophilia screen (if CVST suspected)
• Blood cultures if fever present

Lumbar Puncture (after imaging clears the way)

• Opening pressure > 25 cm H₂O (250 mm H₂O) in adults confirms raised ICP
• Measure in lateral decubitus position with legs extended (sitting position overestimates)
• CSF composition must be normal in IIH (rule out meningitis, SAH)
• Therapeutic drainage of CSF provides temporary relief

Audiological Assessment

• Pure tone audiometry (IIH can cause fluctuating low-frequency SNHL)
• If pulsatile tinnitus: ABR (auditory brainstem response), electrocochleography

Step 4: IIH Diagnostic Criteria (Modified Dandy / Friedman 2013)

Step 5: Secondary Causes to Rule Out ("Secondary Pseudotumor Cerebri")

Step 6: Treatment of Confirmed IIH

Medical Management (first-line)

1. Weight loss - even 5-10% body weight reduces ICP significantly; cornerstone of long-term management
2. Acetazolamide (carbonic anhydrase inhibitor) - reduces CSF production
   • Start at 500 mg twice daily, titrate up
   • Up to 4 g/day used in IIHTT with efficacy
   • Side effects: paraesthesias, fatigue, GI upset, metabolic acidosis
3. Topiramate - alternative; also aids weight loss
4. Loop diuretics (furosemide) - adjunctive
5. Discontinue offending drugs (isotretinoin, tetracyclines, excess Vitamin A)

Symptomatic Relief

• Analgesia for acute headache: NSAIDs, triptans if migraine phenotype
• Therapeutic LP - provides temporary relief; can be repeated
• Antiemetics if nausea/vomiting present

Surgical Options (refractory/vision-threatening cases)

• Optic nerve sheath fenestration - primarily to protect vision
• CSF shunting (lumboperitoneal or ventriculoperitoneal shunt) - for refractory raised ICP and/or headache
• Venous sinus stenting - emerging option for patients with significant transverse sinus stenosis

For Tinnitus Specifically

• In IIH: tinnitus typically improves or resolves with treatment of raised ICP (acetazolamide + weight loss)
• Jugular venous compression test: in IIH-related pulsatile tinnitus, compression of the ipsilateral jugular vein eliminates the tinnitus - this can be used as a bedside diagnostic sign

Other Important Differentials Not to Miss

Summary Algorithm

19F with headache + tinnitus
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History: pulsatile tinnitus? visual Sx? medications? BMI? OCP use?
        ↓
Exam: fundoscopy (papilledema?), CN exam, BP, otoscopy, meningism
        ↓
MRI brain + MRV → rules out mass, CVST, hydrocephalus
        ↓
Bloods: CBC, TFT, electrolytes, coagulation, Vit A, thrombophilia
        ↓
If imaging clear → LP (lateral decubitus, legs extended)
 Opening pressure > 25 cm H₂O + normal CSF → IIH confirmed
        ↓
Treatment: weight loss + acetazolamide ± therapeutic LP
 Refer: ophthalmology (visual fields), neurology

Clinical note: In any young female presenting with this combination, always ask about isotretinoin, tetracycline, and OCP use - these are common drug causes in this demographic that are easily missed and easily reversed.