Head Pressure and Pulsatile Tinnitus in Long COVID and POTS

A Guide for GPs

Dr Graham Exelby May 2025

Overview:

Head pressure and pulsatile tinnitus are distressing but under-recognized symptoms in patients with Long COVID, POTS, and related disorders. These symptoms may reflect intracranial venous congestion, impaired cerebrospinal fluid (CSF) drainage, or brainstem hypoperfusion. While often dismissed as anxiety-related, they frequently indicate underlying mechanical or vascular dysfunction.

Mechanistic Insights:

1. Intracranial Venous Congestion:

• Venous flow from the brain is primarily through the IJVs when supine, and vertebral veins when erect.   Obstruction in these can result in venous backpressure (and sometimes retrograde flow)

• Impaired outflow through internal jugular veins (IJVs).   May be due to thoracic outlet syndrome, vertebral rotation, or anatomical narrowing at C1–C2, usually associated with neck trauma or EDS.  Seen on SPECTRAL CT at C1 +/- base of neck

• Leads to increased intracranial pressure sensations (“head pressure”), particularly in the occipital or crown region and frontal region, with pressure behind the eye (s) and visual changes

• Nutcracker syndrome causes increased pressure in the valveless vertebral plexus

• Traditional ICH diagnoses are made when lying

• When there is both IJV obstruction, plus vertebral vein obstruction, head pressure occurs with standing.  This can be immediate or slowly progressive, and the whole hydraulic system including the CSF Canalicular System needs to be assessed.

2. Pulsatile Tinnitus:

• Rhythmic whooshing sound in one or both ears, synchronous with the heartbeat.

• Often associated with venous reflux or dural sinus turbulence.

• May indicate jugular outflow/ IJV obstruction obstruction or aberrant arachnoid granulations

  
  

3. Brainstem Hypoperfusion

• Seen in upright neuroimaging -SPECT easiest access

• Characteristic of CFS (with PEM)

• May present with head pressure, tinnitus, brain fog, and coat-hanger pain

  
  

4. Glymphatic and CSF Impairment:

• COVID affects glymphatic function increasing risk of ICH

• CSF drainage through arachnoid granulations or canalicular pathways may be impaired

• Lymphatic obstruction common in neck over the IJVs and back of neck.  Fascial changes may be noted -Covid and mast cell dysfunction

  
  

Key Clinical Clues:

• Symptoms vary, can be worse upright, improve lying down, opposite or both

• Associated with facial flushing, visual snow, or head/neck tightness.

• Frequently coexists with orthostatic intolerance, MCAS, and mast cell symptoms.

• Consider especially in young females with EDS, Long COVID, or POTS symptoms.

  
  

First-Line Management:

• Validate symptom: not psychogenic, but often vascular or neuroinflammatory.

• Postural education: avoid forward flexion and prolonged upright strain.

• Hydration, compression garments, head-of-bed elevation may be appropriate

• Trial of antihistamines (H1/H2), LDN for glial-mast cell dampening.

Further Evaluation:

• MRI brain venography (+/- arteriography)

• Retinal vascular check with suitable optometrist

• Evaluate for thoracic outlet or jugular outflow obstruction , and best with Spectral head/neck + chest + abdo/pelvis to look for the known compression areas.

Further Management:

• Once mechanical/hydraulic drivers identified, arrange for assessment by appropriate therapist

• Refer to vascular surgeon if severe ATOS or severe Nutcracker Syndrome