A 69-year-old woman with new persistent right temporal headache and high ESR was diagnosed with temporal arteritis in primary care. She was started on steroids, but developed a right 6th nerve palsy with continuing headache and raised inflammatory markers. Investigation revealed a sphenoid sinus abscess with intracranial extension and extensive cerebral venous sinus thrombosis. The abscess was drained endoscopically and she was treated with antibiotics and anticoagulation. Over the course of two months she made a complete recovery.