The following article is a Thomas Jefferson Headache Center headache rounds presentation. A 37-year-old woman, who reports a history of chronic sinusitis, developed sudden onset headache 1 1/2 years prior to her initial presentation at the Jefferson Headache Center. At that time she noted acute severe pressure-like pain bilaterally in her neck, which radiated to her forehead above her eyebrows. She denied fever, rashes, or nasal discharge at the time. The pain was much more intense than her usual “sinus headaches” and associated with a positional component, occurring only upon standing, reaching a peak intensity of 10/10 that would only last seconds and remaining as a dull milder continuous frontal pain for up to 12 hours. She had nausea and vomiting but no photophobia, phonophobia, or osmophobia. There was no rhinorrhea, conjuctival injection, or eye tearing. The pain was alleviated upon lying down. After several emergency department visits, a head computed tomography was performed revealing chronic sinus disease that led her to sinus surgery with no improvement of symptoms. For several months, she was unsuccessfully treated with preventive therapy including topiramate, duloxetine, gabapentin, onabotulinumtoxin A, and abortive therapy including triptans, nonsteroidal anti-inflammatory drugs, barbiturates, and muscle relaxants. Acupuncture and occipital nerve blocks provided limited relief. The patient denied a prior medical and family history of migraines. Since the onset of symptoms, the patient continued to have intermittent explosive frontal headaches that would be triggered by standing and improved upon lying down. As time elapsed, she also noticed suboccipital pain and neck discomfort worsened by Valsalva maneuvers such as straining and coughing. She also reported bilateral upper extremity paresthesias along with subjective weakness.