What could be causing my symptoms of feeling heavy in the head, tingling in both lower legs, and sensations in my arms and back, and how should I proceed with diagnosis and treatment as an adult with no prior medical history?

Neurological Evaluation for Head Heaviness, Bilateral Leg Tingling, and Arm/Back Sensations

You need urgent neurological assessment to exclude serious secondary causes, particularly spontaneous intracranial hypotension, cervical myelopathy, or peripheral neuropathy, as your symptom constellation—head heaviness with bilateral lower extremity paresthesias—raises concern for spinal cord or nerve root pathology rather than a benign primary headache disorder. 1

Critical Red Flags Requiring Immediate Evaluation

Your symptom pattern warrants urgent investigation because:

• Bilateral lower leg tingling combined with head symptoms suggests possible spinal cord involvement or systemic neurological process rather than isolated headache 1, 2
• Sensations in multiple body regions (head, both legs, arms, back) indicate diffuse neurological involvement requiring imaging 3
• Head "heaviness" could represent orthostatic headache from spontaneous intracranial hypotension, especially if worse when upright and improved when lying flat 4, 1

Immediate Diagnostic Approach

History Elements to Clarify Urgently

• Positional component: Does head heaviness worsen within 2 hours of standing and improve >50% within 2 hours of lying flat? This pattern is diagnostic for spontaneous intracranial hypotension 4, 1
• Timing and progression: New-onset symptoms, worsening pattern, or abrupt onset all require neuroimaging 1, 2, 3
• Neurological symptoms: Any weakness, bowel/bladder dysfunction, or gait disturbance suggests myelopathy requiring emergency evaluation 4, 5
• Exacerbating factors: Symptoms triggered by Valsalva, cough, or exertion indicate increased intracranial pressure or structural lesion 1, 2, 3

Physical Examination Priorities

• Complete neurological examination including motor strength, sensory testing in dermatomal distribution, reflexes, and gait assessment 1, 3
• Assess for focal neurological deficits, particularly lower extremity weakness or sensory level suggesting spinal cord pathology 4, 5
• Evaluate for meningeal signs (neck stiffness, limited neck flexion) if any fever or altered consciousness present 4, 1

Recommended Imaging Strategy

First-Line Imaging

MRI brain with and without contrast PLUS whole spine MRI is the preferred initial study given your symptom distribution 4, 1:

• Brain MRI evaluates for intracranial hypotension signs (brain sagging, pachymeningeal enhancement, subdural collections) 4
• Spine MRI identifies spinal CSF leak, epidural fluid collections, cervical myelopathy, or nerve root compression 4, 5
• MRI provides superior resolution without radiation exposure for subacute presentations 1, 2

When CT is Appropriate

Non-contrast CT head is indicated only if:

• Acute trauma history exists 1, 2
• Abrupt thunderclap onset suggesting subarachnoid hemorrhage 1, 3
• MRI unavailable or contraindicated 1

CT has poor sensitivity for intracranial hypotension and spinal pathology, making it inadequate for your presentation 4, 2

Differential Diagnosis by Symptom Pattern

If Orthostatic Head Heaviness Predominates

• Spontaneous intracranial hypotension: Requires urgent neurology referral within 48 hours if able to self-care, or emergency admission if unable 4, 1
• Initial treatment with epidural blood patch may be needed before definitive leak localization 4
• Risk of long-term complications including superficial siderosis if untreated 4

If Bilateral Leg Symptoms Predominate

• Cervical or thoracic myelopathy: Compression at spinal cord level causing bilateral lower extremity symptoms 5
• Peripheral neuropathy: Symmetric distal paresthesias, though less likely to cause head symptoms 5
• Cauda equina syndrome: If any bowel/bladder symptoms present, requires emergency surgical evaluation 4, 5

If Multifocal Symptoms Without Clear Pattern

• Multiple sclerosis or demyelinating disease: Multifocal neurological symptoms in young adult 4
• Vitamin B12 deficiency: Can cause combined head symptoms and peripheral neuropathy 5
• Medication-induced: Review all medications, particularly gabapentin or pregabalin which cause dizziness and peripheral symptoms 6, 7

Urgent Referral Criteria

You require emergency department evaluation if any of the following present 1, 3:

• Inability to self-care or perform activities of daily living 4, 1
• Progressive lower extremity weakness 4, 5
• Bowel or bladder dysfunction (incontinence, retention, perineal numbness) 4
• Altered consciousness or confusion 4, 1
• Fever with neurological symptoms 4, 1

You require urgent neurology referral (within 48 hours) if 4, 1:

• Suspected spontaneous intracranial hypotension with orthostatic pattern 4
• Bilateral neurological symptoms without clear benign cause 1, 3
• Able to self-care but symptoms progressing 4

Common Pitfalls to Avoid

• Do not assume benign primary headache when bilateral lower extremity symptoms coexist—this combination suggests structural or systemic pathology 1, 3
• Do not delay imaging for "trial of therapy"—your symptom pattern requires anatomical diagnosis first 1, 2
• Do not obtain CT when MRI is needed—CT misses intracranial hypotension and most spinal pathology 4, 2
• Do not ignore positional component—orthostatic worsening is pathognomonic for CSF leak requiring specific treatment 4, 1

Initial Laboratory Testing

While awaiting imaging, obtain:

• Complete blood count to exclude infection or hematologic disorder 4
• Vitamin B12 level if peripheral neuropathy suspected 5
• ESR/CRP if age >50 years to exclude giant cell arteritis 1, 8
• TSH and free T4 if associated lightheadedness or cold intolerance 1