What are the differential diagnoses for a 30-year-old woman presenting with headache and tingling sensations in the lower abdomen and upper and lower limbs?

Differential Diagnoses for Headache with Tingling in Lower Abdomen and Limbs in a 30-Year-Old Woman

This presentation requires urgent evaluation to exclude life-threatening secondary causes, particularly given the atypical combination of headache with widespread paresthesias involving both abdomen and limbs, which is not characteristic of primary headache disorders. 1, 2

Life-Threatening Causes to Rule Out Immediately

The following conditions must be excluded first due to their potential for significant morbidity and mortality:

• Subarachnoid hemorrhage presenting as thunderclap headache ("worst headache of life") with associated neurological symptoms including altered sensations 2, 3, 4
• Stroke or transient ischemic attack with atypical aura manifesting as focal neurological symptoms including paresthesias 2, 3
• Brain tumor or space-occupying lesion causing progressive headache with neurological symptoms including sensory disturbances 2, 3
• Increased intracranial pressure presenting as headache that worsens with Valsalva maneuvers (coughing, sneezing, exercise) and may cause widespread neurological symptoms 2, 3
• Meningitis with headache, neck stiffness, fever, and altered mental status 2, 3
• Spontaneous intracranial hypotension presenting with orthostatic headache (absent or mild on waking, onset within 2 hours of upright posture, >50% improvement within 2 hours of lying flat) 1, 3

Red Flags Requiring Immediate Neuroimaging

Any of the following warrant urgent evaluation with neuroimaging: 2, 3, 4

• New-onset headache after age 50 years (though this patient is 30)
• Focal neurological symptoms or signs (the widespread tingling qualifies)
• Altered consciousness, memory, or personality
• Progressive worsening of headache over time
• Headache awakening patient from sleep
• Onset during exertion
• Witnessed loss of consciousness
• Neck stiffness or limited neck flexion
• Unexplained fever

Primary Headache Disorders (Less Likely Given Presentation)

Primary headache disorders are diagnoses of exclusion and do not typically present with widespread paresthesias: 1, 3

• Migraine with aura requires recurrent visual, sensory, speech, motor, or brainstem symptoms with gradual spread over ≥5 minutes, at least one unilateral symptom, and headache within 60 minutes of aura 3. However, the combination of lower abdominal and bilateral limb tingling is atypical for migraine aura 1
• Migraine without aura requires 4-72 hour duration, unilateral pulsating moderate-to-severe pain aggravated by activity, plus nausea/vomiting or photophobia and phonophobia 1, 3. The widespread paresthesias are not explained by this diagnosis
• Tension-type headache presents with bilateral, mild-to-moderate pressing/tightening pain without autonomic features or paresthesias 1, 3
• Cluster headache involves strictly unilateral severe headache lasting 15-180 minutes with ipsilateral autonomic symptoms, not widespread paresthesias 1, 5, 3

Uncommon but Important Differential: Abdominal Migraine

Abdominal migraine should be considered given the lower abdominal involvement: 6

• Traditionally pediatric but can occur in adults, particularly women of reproductive age
• Presents with periumbilical abdominal pain, nausea, vomiting, and may include headache
• Episodes are recurrent, lasting hours, with normal examination between attacks
• Often improves during pregnancy (relevant for 30-year-old woman)
• Diagnosis requires exclusion of celiac disease, inflammatory bowel disease, and other gastrointestinal pathology 6

Other Secondary Causes to Consider

Additional conditions that may present with headache and paresthesias: 1, 3

• Vasculitis affecting medium or small vessels can cause headache with neurological symptoms including paresthesias 1
• Hyperventilation syndrome associated with panic disorder or anxiety can cause perioral and limb paresthesias with lightheadedness, though typically not true headache 1
• Medication side effects from antihypertensives, cardiovascular medications, or anticonvulsants (carbamazepine, phenytoin) may produce dizziness and paresthesias 1
• Cervical spine pathology with cervicogenic headache may cause referred symptoms, though widespread abdominal and limb involvement is atypical 1

Diagnostic Approach

The following evaluation should be performed urgently: 2, 3, 7, 8, 4

1. Complete neurological examination including cranial nerves, motor/sensory function (particularly testing distribution of paresthesias), cerebellar testing, and assessment for meningismus 2, 3

2. Vital signs assessment including blood pressure, heart rate, temperature, and orthostatic vital signs to evaluate for spontaneous intracranial hypotension 1, 3

3. Non-contrast CT head if presenting within 6 hours of acute severe headache onset (sensitivity 95% on day 0 for subarachnoid hemorrhage) 2, 3

4. MRI brain with and without contrast is preferred for subacute presentations or when tumor, inflammatory process, or posterior fossa pathology is suspected, as it provides higher resolution without ionizing radiation 2, 3, 4

5. Lumbar puncture if CT is negative but subarachnoid hemorrhage remains suspected, or to evaluate for meningitis or spontaneous intracranial hypotension 2, 3, 4

6. Basic laboratory studies including complete blood count, comprehensive metabolic panel, ESR/CRP (if vasculitis suspected) 3, 4

Critical Pitfalls to Avoid

Common errors in evaluation that can lead to missed diagnoses: 2, 3, 8, 9

• Do not dismiss widespread paresthesias as benign without thorough evaluation, as this is not a typical feature of primary headaches and suggests secondary pathology 2, 3
• Do not rely solely on normal physical examination to exclude serious pathology; many secondary headaches present with minimal or no neurological deficits initially 9
• Do not attribute symptoms to migraine without meeting full diagnostic criteria and excluding secondary causes, particularly when the presentation is atypical 1, 3, 8
• Do not delay neuroimaging when red flags are present; the combination of headache with focal neurological symptoms (widespread paresthesias) warrants urgent imaging 2, 3, 4

Referral and Management

Given the atypical presentation with widespread neurological symptoms: 3

• Emergency admission is warranted if the patient cannot self-care, has any red flag features, or has progressive symptoms
• Urgent neurology referral within 48 hours if the patient can self-care with support but has concerning features
• Routine neurology referral within 2-4 weeks only if all secondary causes are excluded and symptoms are mild and stable