What is the cause of paresthesia (pins and needles sensation) in the head and face radiating to the back, accompanied by lightheadedness?

Paresthesia of Head, Face, and Back with Lightheadedness: Differential Diagnosis

The combination of pins and needles sensation in the head and face radiating to the back with lightheadedness most likely represents migraine with aura, vestibular migraine, or a central nervous system disorder requiring urgent evaluation to exclude vertebrobasilar insufficiency or stroke.

Primary Diagnostic Considerations

Migraine with Aura

• Sensory aura presenting as "pins and needles" is a positive aura symptom recognized by the International Classification of Headache Disorders 1
• Sensory symptoms typically spread gradually over ≥5 minutes, last 5-60 minutes, and may be unilateral 1
• The aura is accompanied or followed within 60 minutes by headache in classic presentations 1
• Migraine-associated dizziness accounts for 14% of adult vertigo cases and can present without headache, making it critical to consider even without classic migraine symptoms 2

Vestibular Migraine

• Vestibular symptoms of moderate to severe intensity lasting 5 minutes to 72 hours, combined with migraine features, define this condition 1
• Lightheadedness and spatial disorientation are characteristic vestibular symptoms 1
• At least 5 episodes are required for diagnosis, with migraine features present in ≥50% of episodes 1

Critical Red Flags Requiring Urgent Evaluation

Vertebrobasilar Insufficiency

• Isolated transient vertigo and paresthesias may precede vertebrobasilar stroke by weeks or months 1
• Attacks typically last <30 minutes without hearing loss 1
• The presence of additional neurological signs (dysarthria, dysmetria, dysphagia, sensory/motor loss) suggests central causes like stroke 3
• Gaze-evoked nystagmus that does not fatigue distinguishes central from peripheral causes 1

Central Nervous System Pathology

• Differentiation between peripheral vestibular causes and CNS causes is a key clinical challenge 1
• Brainstem lesions (infarction, vascular malformations, tumors, multiple sclerosis) can affect facial nerve nuclei and present with paresthesias 1
• Intracranial hypotension can cause postural symptoms with nausea, neck pain, tinnitus, and photophobia 1

Algorithmic Diagnostic Approach

Step 1: Characterize the Paresthesia Pattern

• Determine if symptoms spread gradually (≥5 minutes) suggesting migraine aura 1
• Assess for unilateral vs. bilateral distribution 1
• Document duration: 5-60 minutes typical for migraine aura 1
• Identify triggers: position changes, head rotation, or spontaneous onset 1

Step 2: Evaluate Lightheadedness Characteristics

• Daily occurrence without episodic pattern makes typical vestibular disorders (BPPV, Menière's disease) unlikely 2
• Positional lightheadedness triggered by head position changes suggests BPPV, though this typically presents as true vertigo 3
• Constant lightheadedness unaffected by position suggests non-vestibular causes 3
• Lightheadedness is closely related to changes in cerebral blood flow velocity, particularly during hypocapnia 4

Step 3: Identify Associated Symptoms

• Absence of hearing loss or tinnitus excludes Menière's disease and most otologic causes 2
• Presence of headache, photophobia, or phonophobia supports migraine 1
• Dyspnea suggests cardiovascular, anxiety, or systemic causes 2
• Gait disturbance unrelated to positional changes requires further evaluation 3

Step 4: Perform Targeted Physical Examination

• Evaluate for nystagmus: gaze-evoked suggests central pathology 1
• Assess postural stability and neurological signs 1
• Dix-Hallpike maneuver if positional vertigo suspected 3
• Orthostatic blood pressure testing to exclude postural hypotension 1, 5

Common Pitfalls to Avoid

Misattribution to Benign Causes

• BPPV does not cause constant severe dizziness unaffected by position or movement, and does not affect hearing or cause fainting 3
• Cervical vertigo may produce similar symptoms but is triggered by head rotation relative to the body in upright posture, not position changes relative to gravity 1
• Anxiety or panic disorder commonly presents with chronic nonspecific dizziness, but neurological causes must be excluded first 2

Delayed Recognition of Serious Pathology

• Failure to recognize vertebrobasilar insufficiency can result in missed stroke prevention opportunities 1
• Persistent or progressive symptoms warrant neuroimaging even without classic stroke features 1
• Atypical symptoms (subjective hearing loss, gait disturbance, non-positional vertigo, persistent nausea/vomiting) may indicate underlying vestibular or CNS disorder 3

Imaging Considerations

When Imaging is Indicated

• MRI brain with and without contrast is the study of choice when CNS pathology is suspected 1
• Neurological symptoms (dysarthria, dysmetria, dysphagia, sensory/motor loss) mandate urgent imaging 3
• The diagnostic yield of imaging in nonspecific dizziness without vertigo, ataxia, or neurologic deficits is extremely low (<1% for CT, 4% for MRI) 2

When Imaging May Be Deferred

• Classic migraine with aura pattern without red flags 1
• Typical vestibular migraine meeting diagnostic criteria 1
• Anxiety/panic disorder with daily pattern and associated dyspnea after excluding serious pathology 2

Management Based on Diagnosis

If Migraine with Aura or Vestibular Migraine

• Migraine prophylaxis and trigger avoidance are recommended 2
• Consider triptans for acute episodes if headache component present 1

If Cervicogenic Dizziness Confirmed

• Manual therapy combined with vestibular rehabilitation exercises is most effective 2

If Anxiety/Panic Disorder

• Cognitive behavioral therapy and appropriate anxiolytic management 2

If Vertebrobasilar Insufficiency

• Urgent vascular neurology consultation for stroke prevention strategies 1