Dear Editor,We read the article titled “Facial palsy as an atypical presenting sign of cortical venous sinus thrombosis” by Akkayasamy et al.[1] Authors have mentioned a delay in the diagnosis of cerebral venous sinus thrombosis (CVST) in a migraine facial palsy (MFP) patient. We would like to highlight few points regarding the difficulty in diagnosing CVST in a migraine patient.Migraine headache and CVST induced headache may be similar. Both disorders are known to cause facial nerve palsy. Lack of definite clinical criteria for diagnosing CVST and increased prevalence of primary headache (migraine, tension type, chronic daily headache) are factors responsible for the difficulty in selecting patients for neuroimaging.[2] Probably the absence of papilloedema and headache red flag features[3] during initial emergency evaluation would have deferred the diagnosis of CVST in Akkayasamy’s MFP patient. The presence of periorbital swelling and redness of eye due to cranial autonomic features of migraine would have supported a differential diagnosis of glaucoma prompting ophthalmological consultation. Papilloedema would have developed in the midst of multidisciplinary evaluation (emergency care physician, ophthalmologist, and neurologist). Periorbital swelling, redness of eye, lacrimation, and nasal block/running are features of migraine-related autonomic disturbance.[4]The authors[1] have mentioned resolving papilloedema at the end of follow-up period (6 months). CVST patients with procoagulant factors may require anticoagulant therapy for a longer duration; hence, Kumaravelu et al.[5] recommend procoagulant workup (without anticoagulants for at least 14 days) 6 months after the onset of CVST. CVST patients may have multiple prothrombotic disorders.[5] To conclude, CVST in a migraine patient is difficult to diagnose in the absence of red flag features. Financial constraints may delay neuroimaging evaluation.