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Paccioni granulations are normal anatomical structures that correspond to very enlarged arachnoid villi.1 They are involved in the filtration of CSF from the subarachnoid space to the venous system. Hypertropic Paccioni granulations (hPgs), usually secondary to high CSF pressure, can be symptomatic and responsible for lytic skull lesions or dural destruction.2 3 More exceptionally, the development of hPgs within the venous lumen makes their distinction from other pathological intravascular processes complicated. We report a case of unusual headache in a migrainous patient in whom hPgs in venous sinuses first led to an erroneous diagnosis of venous thrombophlebitis. This finding emphasises the importance of MRI as a mode of distinguishing between hPgs and dural venous thrombosis and suggests a possible link between hPgs and headache.