What could cause headache with dizziness and paresthesia (pins and needles sensation) in the head, face, and radiating to the back?

Differential Diagnosis: Headache with Dizziness and Paresthesias

The combination of headache, dizziness, and pins-and-needles sensations radiating from the head and face to the back most likely represents migraine with sensory aura, though vertebrobasilar insufficiency and spontaneous intracranial hypotension must be urgently excluded based on specific clinical features. 1

Primary Diagnostic Algorithm

Step 1: Assess Temporal Pattern of Paresthesias

Migraine with sensory aura is the leading diagnosis if the pins-and-needles sensation spreads gradually over ≥5 minutes, lasts 5-60 minutes, and may be unilateral. 1 The International Classification of Headache Disorders specifically recognizes this "pins and needles" presentation as a positive aura symptom. 1

• If symptoms spread gradually (≥5 minutes): Strongly suggests migraine aura 1
• If symptoms are sudden onset: Consider vertebrobasilar stroke or other vascular causes 1
• If symptoms are positional (worse upright, better lying down): Consider spontaneous intracranial hypotension 2

Step 2: Characterize the Dizziness Component

Vestibular migraine accounts for 14% of adult vertigo cases and commonly presents with lightheadedness and spatial disorientation lasting 5 minutes to 72 hours. 1 Critically, this can occur without headache. 1

• Lightheadedness without true spinning: Favors migraine-associated dizziness or anxiety 1, 3
• True vertigo (spinning sensation): Consider peripheral vestibular causes or posterior circulation stroke 3
• Dizziness duration 5 minutes to 72 hours with migraine features: Diagnostic of vestibular migraine 1

Step 3: Identify Red Flags Requiring Urgent Evaluation

Isolated transient vertigo and paresthesias may precede vertebrobasilar stroke by weeks or months, making urgent vascular assessment critical. 1

Red flags mandating immediate imaging and neurology consultation: 1

• Dysarthria (slurred speech)
• Dysmetria (coordination problems)
• Dysphagia (swallowing difficulty)
• Sensory or motor loss beyond paresthesias
• Gaze-evoked nystagmus that does not fatigue

Step 4: Assess for Intracranial Hypotension

If headache is orthostatic (absent/mild when lying, develops within 2 hours of standing, improves >50% within 2 hours of lying flat), spontaneous intracranial hypotension is the diagnosis. 2 This condition is highly underdiagnosed. 2

Associated symptoms supporting this diagnosis: 2

• Nausea and vomiting
• Neck pain
• Tinnitus and hearing changes
• Photophobia

Risk factors include: 2

• Connective tissue disorders
• Joint hypermobility
• Spinal osteophytes or disc herniation
• History of bariatric surgery

Imaging Strategy

MRI brain with and without contrast is the study of choice when CNS pathology is suspected, particularly with any neurological symptoms beyond isolated dizziness. 1

Critical caveat: The diagnostic yield of imaging in nonspecific dizziness without vertigo, ataxia, or neurologic deficits is extremely low (<1% for CT, 4% for MRI). 1, 3 However, the presence of paresthesias radiating from head to face to back constitutes a neurological symptom that elevates concern and warrants imaging. 1

For suspected intracranial hypotension with orthostatic headache: CT myelography or digital subtraction myelography is required to identify CSF leaks. 2

Management Based on Diagnosis

If Migraine with Aura or Vestibular Migraine:

• Migraine prophylaxis and trigger avoidance are recommended. 1
• Triptans for acute episodes if headache component is present. 1

If Vertebrobasilar Insufficiency:

• Urgent vascular neurology consultation for stroke prevention strategies is necessary. 1

If Spontaneous Intracranial Hypotension:

• Patients unable to care for themselves require emergency admission; those able to self-care need referral within 2-4 weeks. 2
• Epidural blood patching by skilled practitioners is the definitive treatment. 2
• Referral to specialist neuroscience center with CT/digital subtraction myelography capability and multidisciplinary team is required if first-line treatments fail. 2

If Anxiety/Panic Disorder (with chronic nonspecific dizziness and dyspnea):

• Cognitive behavioral therapy and appropriate anxiolytic management are recommended. 3

Common Pitfalls to Avoid

Do not dismiss paresthesias as "just anxiety" without excluding migraine aura and vascular causes. The gradual spread over ≥5 minutes is pathognomonic for migraine aura. 1

Do not assume all orthostatic symptoms are from orthostatic hypotension or POTS. Spontaneous intracranial hypotension has a specific orthostatic pattern (absent on waking, onset within 2 hours upright, >50% improvement within 2 hours lying flat) that distinguishes it. 2

Do not overlook that vestibular migraine can occur without headache. 1 The absence of headache does not exclude migraine-associated dizziness.

Post-lumbar puncture complications can mimic spontaneous intracranial hypotension. Headache occurs in 18.8% of patients, dizziness in 1.3%, and back pain in 17.0% after lumbar puncture. 2 Always inquire about recent procedures.