What is the cause of paresthesia in the face, head, and back accompanied by headache and slight dizziness?

Differential Diagnosis of Paresthesias in Face, Head, and Back with Headache and Dizziness

The combination of widespread paresthesias (face, head, and entire back) with headache and dizziness most likely represents vestibular migraine or migraine with aura, though serious central nervous system pathology including posterior circulation stroke, multiple sclerosis, or spontaneous intracranial hypotension must be excluded urgently. 1

Most Likely Diagnoses

Vestibular Migraine (Primary Consideration)

• Vestibular migraine is a common cause of dizziness that can present with widespread sensory symptoms including paresthesias, even without classic headache features. 1
• Migraine with aura characteristically produces unilateral, fully reversible sensory symptoms affecting the face and head, though bilateral presentations occur. 1
• The International Headache Society criteria require recurrent attacks with visual, sensory, or other central nervous system symptoms lasting minutes, typically followed by headache. 1
• Vestibular migraine often presents with associated migrainous features including photophobia, phonophobia, and visual aura alongside dizziness. 1
• Migraine-associated dizziness accounts for 14% of adult vertigo cases and can present without headache, making it a critical consideration even without classic migraine symptoms. 2

Anxiety/Panic Disorder

• Anxiety or panic disorder commonly presents with chronic nonspecific dizziness and paresthesias, particularly when symptoms occur daily without true vertigo. 2
• This diagnosis should be strongly considered given the widespread distribution of paresthesias and associated dizziness. 2

Cervicogenic Contribution

• Cervicogenic headache can present with dizziness, though it typically features unilateral headache starting posteriorly and advancing frontally, with reduced neck range of motion. 3
• The presence of cervical spine degenerative changes may contribute to symptoms, though cervicogenic dizziness alone does not explain widespread paresthesias. 2

Critical Exclusions Required

Posterior Circulation Stroke (URGENT)

• In patients presenting with acute persistent vertigo and dizziness, posterior circulation infarct involving the brainstem or cerebellum is the most worrisome diagnosis to exclude, with prevalence as high as 25% in those with acute vestibular syndrome. 1
• Critically, 75-80% of patients with posterior circulation stroke may have no focal neurologic deficits on initial examination. 1
• The HINTS examination (Head Impulse, Nystagmus, Test of Skew) performed by specially trained practitioners is more sensitive than early MRI for detecting infarct (100% versus 46%). 1
• Nystagmus findings suggesting central causes include downbeating nystagmus without torsional component, direction-changing nystagmus, and baseline nystagmus without provocative maneuvers. 4

Multiple Sclerosis

• Multiple sclerosis involving the brainstem or cerebellar peduncles accounts for approximately 4% of acute vestibular syndrome cases. 1
• Nearly all MS patients with vestibular symptoms have additional abnormal neurologic findings suggesting a central lesion. 1

Spontaneous Intracranial Hypotension

• Spontaneous intracranial hypotension can present with holocephalic headaches accompanied by dizziness and nausea, with characteristic smooth, diffuse dural and leptomeningeal enhancement on MRI. 1
• This diagnosis can precipitate life-threatening complications including cerebral venous thrombosis. 1

Bell's Palsy or Trigeminal Neuropathy

• Facial paresthesias can result from trigeminal sensory neuropathy caused by local, traumatic, iatrogenic, or systemic conditions. 5
• A thorough cranial nerve examination is essential, as approximately 30% of patients presenting with facial symptoms have underlying causes other than benign conditions. 1
• The clinician should document function of all cranial nerves and inquire about dizziness, dysphagia, or diplopia which suggest alternative diagnoses. 1

Diagnostic Approach

Immediate Clinical Assessment

• Perform HINTS examination if trained: assess head impulse test, nystagmus characteristics, and test of skew deviation to distinguish peripheral from central causes. 1
• Document all cranial nerve functions systematically to identify focal deficits. 1
• Assess for true vertigo (spinning sensation) versus nonspecific dizziness—absence of true vertigo makes peripheral vestibular causes unlikely. 2, 4
• Evaluate nystagmus characteristics including direction, duration, fatigability, and response to visual fixation. 4

Imaging Decisions

• If HINTS examination suggests central pathology, abnormal neurologic examination is present, or high vascular risk factors exist, obtain MRI brain without contrast urgently. 1
• MRI allows detailed evaluation with improved soft tissue resolution compared to CT and is superior for detecting posterior circulation infarcts. 1
• The diagnostic yield of imaging in nonspecific dizziness without vertigo, ataxia, or neurologic deficits is extremely low (<1% for CT, 4% for MRI), but serious pathology must be excluded first. 2
• CT head without contrast may be appropriate for rapid initial evaluation if MRI is unavailable, though sensitivity for acute infarct is limited. 1

Laboratory Testing

• Routine laboratory testing is not indicated in patients with new-onset symptoms when history and physical examination do not suggest an alternative cause. 1
• Consider targeted testing only when specific risk factors are identified (e.g., Lyme serology in endemic areas). 1

Management Based on Diagnosis

If Vestibular Migraine Confirmed

• Initiate migraine prophylaxis and implement trigger avoidance strategies. 2
• Consider triptans for acute episodes if headache is prominent. 1

If Anxiety/Panic Disorder Identified

• Cognitive behavioral therapy and appropriate anxiolytic management are recommended. 2

If Cervicogenic Component Present

• Manual therapy combined with vestibular rehabilitation exercises is the most effective treatment for cervicogenic dizziness. 2

If Medication-Related

• Adjust or discontinue offending agents including anticonvulsants, antihypertensives, and cardiovascular medications that can cause vertigo. 4

Critical Pitfalls to Avoid

• Do not assume benign etiology based solely on normal initial neurologic examination—posterior circulation strokes frequently present without focal deficits. 1
• Do not delay imaging in patients with acute persistent symptoms, high vascular risk, or concerning HINTS examination findings. 1
• Do not perform routine imaging in typical cases without red flags, as diagnostic yield is extremely low and may lead to false positives. 2
• Do not confuse nonspecific dizziness with true vertigo—the differential diagnosis and management differ substantially. 2, 4
• Do not dismiss widespread paresthesias as purely functional without excluding structural central nervous system pathology first. 1