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

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

The combination of widespread paresthesia (head, face, entire back), headache, and dizziness requires urgent evaluation for serious neurological conditions including cerebral venous thrombosis, spontaneous intracranial hypotension, eosinophilic meningitis, or posterior circulation stroke—all of which can present with these symptoms and require immediate intervention to prevent permanent neurological damage or death. 1

Critical Red Flags Requiring Immediate Evaluation

This symptom constellation is not consistent with benign conditions like Bell's palsy or simple migraine, which present with focal unilateral facial symptoms rather than bilateral widespread paresthesia 1.

Life-Threatening Causes to Rule Out First:

Cerebral Venous Thrombosis (CVT):

• Presents with severe headache, paresthesias, dizziness, and can rapidly progress to hemorrhage and death within hours 1
• Requires immediate CT venography or MR venography 1
• Treatment with anticoagulation must be initiated urgently even in presence of hemorrhage per AHA/ASA guidelines 1

Spontaneous Intracranial Hypotension (SIH):

• Causes holocephalic headaches, dizziness, and can precipitate life-threatening CVT 1
• MRI shows diffuse dural and leptomeningeal enhancement 1
• Can present with non-orthostatic headaches, distinguishing it from typical orthostatic presentations 1

Eosinophilic Meningitis (Angiostrongylus, Neurocysticercosis):

• Presents with severe acute headache, meningism, paresthesias, and cranial nerve palsies 1
• Peripheral eosinophilia is marked; CSF shows eosinophilia in 20-50% of cases 1
• Consider in patients with travel history to Southeast Asia, Caribbean, Central/South America 1

Posterior Circulation Stroke:

• Vertebrobasilar TIAs cause dizziness with other posterior circulation symptoms 2
• Attacks typically last less than 1 hour 2
• Affects older adults with vascular risk factors 2

Diagnostic Approach Algorithm

Step 1: Immediate Neuroimaging

• MRI brain without and with contrast is the preferred initial study for widespread paresthesias with headache 1
• Add MR or CT venography to evaluate for CVT given the symptom constellation 1
• Look specifically for: dural enhancement (SIH), venous sinus thrombosis, hemorrhage, or posterior circulation infarction 1

Step 2: Assess Temporal Pattern

• Acute onset (hours to days): Consider CVT, stroke, eosinophilic meningitis—requires emergency evaluation 1, 2
• Subacute (days to weeks): Consider SIH, neurocysticercosis, schistosomiasis 1
• Daily chronic pattern: Less likely to be life-threatening; consider vestibular migraine, anxiety disorder 3

Step 3: Identify Associated Features

If accompanied by:

• Diplopia or cranial nerve deficits: Suggests cavernous sinus pathology, basilar meningitis, or brain stem lesion—requires MRI with dedicated cranial nerve sequences 1
• Meningismus or altered consciousness: Obtain lumbar puncture for CSF analysis including eosinophil count, serology 1
• Travel history to endemic areas: Check Lyme serology (if endemic area), Angiostrongylus serology, schistosomiasis serology 1
• Seizures or focal weakness: Indicates CVT with hemorrhagic transformation or stroke—requires immediate neurosurgical consultation 1

Step 4: Rule Out Specific Syndromes

Vestibular Migraine (if imaging negative):

• Requires history of migraine headaches (at least 5 prior attacks) 1
• Dizziness episodes last minutes to days 1
• Associated with photophobia, phonophobia, or visual aura 1
• However, vestibular migraine does NOT typically cause widespread bilateral paresthesias of head, face, and entire back 1

Cervicogenic Dizziness:

• Daily dizziness without true vertigo with cervical degenerative changes 3
• But does not explain widespread paresthesias 3
• Diagnostic yield of imaging in isolated nonspecific dizziness is extremely low (<1% for CT, 4% for MRI) 3

Critical Management Pitfalls

Do NOT dismiss as "anxiety" or "migraine" without imaging:

• The widespread distribution of paresthesias (bilateral head, face, entire back) is atypical for benign conditions 4
• Central nervous system-induced paresthesias are most commonly caused by ischemia, structural compression, infection, or inflammation 4
• Dizziness with headache has independent association with greater disability and may indicate serious pathology 5

Do NOT delay anticoagulation if CVT is confirmed:

• Anticoagulation should be continued even if hemorrhage develops, per AHA/ASA guidelines 1
• Delay in treatment can result in hemorrhage expansion and death within 24 hours 1

Do NOT perform lumbar puncture before imaging:

• Risk of herniation if mass lesion or increased intracranial pressure present 1
• Obtain MRI with venography first 1

When Imaging is Negative

If comprehensive neuroimaging including venography is negative and CSF analysis is normal:

• Consider peripheral neuropathy workup: B12, diabetes screening, monoclonal gammopathy 6
• Evaluate for panic disorder: episodes with choking, palpitations, tremor, heat, anxiety lasting minutes 2
• Check for medication-induced causes: review all current medications 3
• Consider vestibular migraine prophylaxis if migraine criteria met 3

The extensive distribution of paresthesias involving head, face, and entire back is highly unusual for benign conditions and mandates thorough exclusion of serious neurological pathology before attributing symptoms to functional or benign causes. 4