What could be the cause of a headache with lightheadedness and paresthesia (pins and needles sensation) on the face, head, and radiating to the back?

Differential Diagnosis: Migraine with Aura Most Likely

The combination of headache, lightheadedness, and paresthesias (pins and needles) affecting the face, head, and radiating to the back most strongly suggests migraine with aura, though spontaneous intracranial hypotension and other secondary causes must be excluded based on specific clinical features.

Primary Consideration: Migraine with Aura

Classic Presentation

• Sensory aura occurs in approximately 31% of migraine with aura patients and characteristically presents as unilateral paresthesias (pins and needles) that spread gradually in the face or arm 1
• The International Classification of Headache Disorders defines migraine with aura as requiring at least 2 attacks with fully reversible sensory symptoms that spread gradually over ≥5 minutes, last 5-60 minutes, and are accompanied by or followed by headache within 60 minutes 1, 2
• Pins and needles sensations are specifically recognized as positive symptoms of aura 1
• Lightheadedness can occur as part of the migraine attack spectrum, particularly during the headache phase 1

Diagnostic Criteria to Confirm

• At least 2 attacks with these characteristics are required for definitive diagnosis 1, 2
• The sensory symptoms should be fully reversible 1
• Headache typically follows the aura within 60 minutes, though it can occur simultaneously 1, 2

Critical Secondary Causes to Exclude First

Spontaneous Intracranial Hypotension (SIH)

• Must be considered if the headache has orthostatic features: absent or mild (1-3/10) on waking, onset within 2 hours of becoming upright, and >50% improvement within 2 hours of lying flat 1
• Associated symptoms can include neck stiffness and paresthesias 1
• This is a dangerous diagnosis to miss as it can lead to subdural hematoma 1
• If orthostatic pattern is present, urgent neurological referral within 48 hours to 1 month depending on severity 1

Red Flag Features Requiring Immediate Investigation

• Thunderclap onset (maximum intensity within seconds to minutes) suggests subarachnoid hemorrhage 3
• New onset after age 50 suggests temporal arteritis or other secondary causes 3
• Progressive worsening over time suggests space-occupying lesion 3
• Focal neurological deficits beyond typical aura patterns 3, 4
• Fever, neck stiffness, or altered consciousness suggest meningitis or subarachnoid hemorrhage 3

Alternative Primary Headache Diagnosis

Vestibular Migraine

• Can present with lightheadedness/dizziness as the predominant vestibular symptom lasting 5 minutes to 72 hours 1
• Requires at least 5 episodes with vestibular symptoms of moderate-to-severe intensity 1
• Must have current or previous history of migraine with or without aura 1
• At least 50% of episodes must have migraine features (unilateral pulsating headache, photophobia/phonophobia, or visual aura) 1

Diagnostic Approach Algorithm

Step 1: Rule Out Red Flags

• Obtain detailed history focusing on: onset pattern (sudden vs gradual), temporal profile (first/worst vs recurrent), positional component, and associated neurological symptoms 3, 4
• Perform complete neurological examination looking for focal deficits, neck stiffness, altered consciousness 3, 4
• If any red flags present: obtain neuroimaging (MRI preferred, CT if acute hemorrhage suspected) and consider lumbar puncture if subarachnoid hemorrhage suspected with negative CT 3

Step 2: Assess for Orthostatic Pattern

• Specifically ask about headache severity on waking vs after being upright for 2 hours 1
• Document improvement with lying flat (>50% reduction within 2 hours is significant) 1
• If orthostatic pattern confirmed, refer to neurology for SIH workup 1

Step 3: Apply Migraine with Aura Criteria

• Document number of similar attacks (need ≥2 for definitive diagnosis) 1, 2
• Confirm sensory symptoms spread gradually over ≥5 minutes 1, 2
• Verify individual symptoms last 5-60 minutes 1, 2
• Establish temporal relationship between aura and headache (within 60 minutes) 1, 2

Step 4: Consider Vestibular Migraine if Lightheadedness Predominates

• If dizziness/lightheadedness is the primary complaint rather than paresthesias, apply vestibular migraine criteria 1
• Requires ≥5 episodes with moderate-to-severe vestibular symptoms 1
• Must document migraine features in ≥50% of episodes 1

Common Pitfalls to Avoid

Atypical Aura Features Requiring Investigation

• Aura lasting >60 minutes suggests possible transient ischemic attack, stroke, or structural lesion rather than typical migraine 3, 5
• Motor weakness as part of aura requires exclusion of hemiplegic migraine vs stroke 1, 5
• Structural lesions like vascular malformations can mimic migraine with aura, making neuroimaging necessary when presentation is atypical 5

Distinguishing Migraine from Serious Pathology

• Migraine aura symptoms develop gradually over ≥5 minutes, whereas vascular events (stroke/TIA) typically have sudden onset 1, 2
• Migraine aura is fully reversible; persistent deficits suggest structural pathology 1, 5
• First-ever episode of aura-like symptoms, especially after age 50, warrants neuroimaging to exclude secondary causes 3, 4

When Neuroimaging is Indicated

• Any red flag features present 3, 4
• Atypical aura (prolonged duration, motor symptoms, incomplete resolution) 3, 5
• New onset headache with focal neurological symptoms in patient >50 years 3
• Progressive or changing headache pattern 3, 4
• MRI is preferred over CT due to higher resolution, except when acute hemorrhage suspected 3

Treatment Implications Once Diagnosis Established

If Migraine with Aura Confirmed

• First-line acute treatment: NSAIDs (ibuprofen, diclofenac, or aspirin) 1
• Second-line: triptans (can combine with NSAIDs for better efficacy) 1
• Consider preventive therapy if attacks are frequent or disabling 1

If Vestibular Migraine Confirmed

• Same acute and preventive treatments as standard migraine 1
• Patient education about vestibular triggers 1