"Sinus Headache" or Migraine



"Sinus Headache" or Migraine
Susan Hutchinson, MD

Key Points:

  • Migraine is commonly misdiagnosed as sinus headache.
  • Self-diagnosed sinus headache is nearly always migraine (~90% of the time).
  • Migraine is commonly associated with forehead and facial pressure over the sinuses, nasal congestion and runny nose.
  • In the absence of fever, pus from your nose, alteration in smell or foul smelling breath you likely have a migraine headache.
  • Your diagnosis needs health practitioner confirmation for accuracy and best treatment.

Sinus Headache is a common complaint in the general population. But just what is sinus headache? Common symptoms include facial pain and pressure, nasal and sinus congestion, and headache.  Numerous over the counter medications are marketed for these symptoms and reinforce the belief that this condition is common. However, sinus headache is not as common as you and others may think. How do we know that?

A very large population-based study, entitled American Migraine Study II, showed that many people who were diagnosed with migraine thought they had "sinus" headache. Significantly, there were almost 30,000 study participants; only about 50% who were diagnosed with migraine knew they had migraine before the study. The most common misdiagnosis was "sinus" headache.

"True" sinus headache, more properly called rhinosinusitis, is rare and secondary to typically a viral sinus infection characterized by thick, discolored nasal discharge, possibly decreased smell or no smell, facial pain or pressure and commonly fever. Any pain should resolve after completion of an appropriate course of antibiotics. If pain continues despite antibiotics, then your diagnosis should be reconsidered.

What is "sinus headache"? It is migraine with sinus symptoms. A very large study involving almost 3000 patients was very important in evaluating the frequent complaint of "sinus headache". In this study, the participants had at least 6 "sinus headaches' in the 6 months prior to entrance into the study. They had never been diagnosed with migraine and had never been treated with a migraine-specific medication. What were the results? Eighty-eight percent of the participants were found to be having migraine headache and not sinus headache. Strict criteria from the International Classification of Headache Disorders were used to tell the difference between headache types. In addition to their common symptoms of facial pain and pressure and nasal and sinus congestion, sufferers often had the following symptoms we associate with migraine:

  1. Nausea
  2. Sensitivity to light and/or noise
  3. Moderate to severe headache
  4. Pulsing/throbbing pain
  5. Headache worsened by activity

In this study, the almost 3000 patients with the complaint of "sinus headache" were taking lots of over the counter and prescription decongestants, antihistamines, nasal sprays, analgesics, and anti-inflammatory  medications. However, there was a lot of patient dissatisfaction with their results. The dissatisfaction makes sense since many actually had migraine producing the sinus complaints.

Research studies show how common sinus symptoms occur with migraine. Specifically, in one study, 45% of migraine patients had at least one symptom of either nasal congestion or watery eyes. Significantly, if the congestion is part of the migraine, it would be expected to resolve with the specific migraine treatment.

So, how do you know if your headache is migraine and not sinus? Ask yourself the following questions:

  1. In the last 3 months, how disabling are your headaches; do they interfere with your ability to function? (Are you missing work; school; family activities?)
  2. Are your headaches ever associated with nausea?
  3. Are your headaches ever associated with sensitivity to light?

There is the ID Migraine Questionnaire developed by Dr. Richard Lipton of Albert Einstein College of Medicine. If two of the above three criteria are present, migraine is likely 93% of the time. If all 3 are present a migraine diagnosis is 98% likely.

Take-Home Point: Go beyond the nasal and sinus congestion; the facial pain and pressure and look for a headache associated with inability to function normally at work, school, home or social functions; nausea; sensitivity to light and triggers such as weather change; menses; and stress (all common provokers for migraine). Significantly, it is commonly thought that weather change often causes "sinus headache" when weather change is a common trigger for migraine.

If you feel that your sinus headaches could be migraine, ask your provider if a migraine specific medication could be right for you. If so, try the migraine specific medication for your next 3 "sinus headaches". Look for the headache and associated symptoms to improve better than all the previous treatments you were taking. In some cases, a work-up may be done such as a CT scan of your sinuses to rule out a secondary cause such as sinus disease or simply to reassure you that the diagnosis is migraine and not a sinus problem.

In summary, most "sinus headache" is migraine with sinus symptoms. Knowing this can help with getting the right diagnosis and treatment. Ultimately, this can help free you from the recurring burden of failed headache treatment and disability!

By Susan Hutchinson, MD, Director, Orange County Migraine & Headache Center, Irvine, CA.


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