What could be causing left-sided pain while walking in an adult with a history of recurring left-sided headaches originating from the nasal region?

Left-Sided Pain While Walking with History of Nasal-Origin Headaches

This presentation requires urgent evaluation for cerebral venous thrombosis (CVT), as the combination of progressive left-sided symptoms with a history of recurring headaches originating from the nasal region raises concern for sinus thrombosis, particularly lateral or cavernous sinus involvement. 1

Immediate Diagnostic Priorities

Obtain MRI brain with contrast and MR venography (MRV) immediately to evaluate for:

• Cerebral venous sinus thrombosis 1, 2
• Signs of increased intracranial pressure 2
• Venous infarction or hemorrhage 1

Why CVT Must Be Excluded First

• CVT presents with progressive symptoms in 56% of cases (subacute onset >48 hours to 30 days), with median delay from symptom onset to diagnosis of 7 days 1
• Headache occurs in nearly 90% of CVT patients and is typically diffuse, progressing over days to weeks 1
• Lateral sinus thrombosis specifically causes pain in the ear or mastoid region and headache, often related to middle ear infection 1
• The nasal origin of headaches suggests possible extension from sinonasal infection, which increases CVT risk 1
• Bilateral or unilateral motor signs can occur with CVT, and symptoms may worsen with activity due to increased venous pressure 1

Critical Imaging Approach

• MRV with contrast is superior for evaluating sigmoid venous sinuses, which are often degraded by artifact on noncontrast MRV 1
• If MRI/MRV unavailable, CT head with CT venography (CTV) is acceptable 2
• D-dimer has high sensitivity for CVT identification, though methodological limitations exist in studies 1

Red Flags Present in This Case

• Progressive, lateralized pain aggravated by activity (walking) suggests increased intracranial venous pressure 1, 2
• History of recurring headaches from nasal region raises concern for sinonasal pathology with potential intracranial extension 1
• Pain worsening with exertion is a recognized red flag requiring neuroimaging 3, 4, 5

Alternative Diagnoses to Consider After CVT Excluded

If MRV Shows Venous Obstruction Without Thrombosis

• Pseudotumor cerebri (idiopathic intracranial hypertension) can show venous outflow obstruction on MRV in 52% of cases 1
• Look for MRI findings: empty sella, dilated optic nerve sheaths, flattening of posterior globes, tortuous optic nerves 2
• Venous obstruction may be reversible after lumbar puncture, suggesting it's secondary to increased intracranial pressure itself 1

If Imaging Normal

• Migraine with exertional trigger 1
• Tension-type headache (though less likely with unilateral presentation) 6
• Primary stabbing headache (though typically lasts only 1-3 seconds, not sustained during walking) 6

Management Algorithm

1. Immediate: Order MRI brain with contrast + MRV (or CT/CTV if MRI unavailable) 1, 2
2. If CVT confirmed: Urgent neurology/neurosurgery consultation for anticoagulation consideration 1
3. If increased ICP without mass: Lumbar puncture with opening pressure (contraindicated if mass effect present) 2
4. If sinonasal pathology identified: ENT consultation for source control 1

Critical Pitfalls to Avoid

• Do not attribute symptoms to "sinus headache" without imaging—62% of pediatric migraineurs have cranial autonomic symptoms mimicking sinusitis 1
• Do not delay imaging based on normal neurologic examination—CVT can present without focal findings 1
• Do not assume benign primary headache with new exertional component—this mandates secondary headache evaluation 3, 4, 5
• Avoid medication overuse (>2 times per week) which can cause medication-overuse headache 1