Headaches associated with facial pain and pressure are commonly given the nonspecific term “sinus” headache. However, headache specialists consider sinus headache to be relatively rare. A pilot study of 47 subjects with self-diagnosed sinus headache who underwent a complete medical evaluation of their headache concluded that 90% of these subjects experienced headaches that fulfilled the criteria for migraine. Subsequent treatment of such “sinus” headaches demonstrated significant response to migraine-specific medications. The authors concluded that self-diagnosed “sinus” headache is often migraine and that nasal symptoms frequently accompany migraine attacks which helps confuse making this diagnosis.
The sinuses are air-filled cavities within the skull that are lined with the same tissues that line the nose. A “sinus” headache implies that there is ongoing, active inflammation or infection of the sinuses as the cause of facial pain, unlike the more common migraine headache which is felt to involve inflammation of various brain centers and has no direct affect on the sinus cavities themselves. With other types of headache being misdiagnosed as “sinus” headache, many patients do not receive appropriate treatment, often being placed on antibiotics and other medicines inappropriately. Otolaryngologists frequently evaluate patients complaining of headache and nasal symptoms recognize that “sinus headache” is often migraine and consider this as well as many other disorders in the diagnosis of a patient experiencing recurrent episodes of these symptoms.
Otolaryngologists try to arrive at a diagnosis for a patient’s headaches after taking a thorough history of their symptoms, performing a physical exam which usually includes the use of a nasal endoscope (a small telescope to examine the nose and sinus drainage pathways) and performing a sinus CT scan. Patients with true inflammatory or infectious causes of sinusitis will often have purulent material (yellow thick mucous) when their nose is examined where patients with migraines will not. CT scans are very detailed x-ray images of the sinuses that can show inflammation in patients with sinusitis even though there may be no real signs of this when the patient was examined. Patients with migraines, despite the severity of discomfort they may be having, will have little or no signs of inflammation on a sinus CT scan making it unlikely the nose or sinuses were a cause for their symptoms. At Albany ENT and Allergy Services we feel CT scans are so important in differentiating migraine from sinusitis, we have placed a CT scanner in our office to make obtaining this test very quick and easy as once the proper diagnosis is found, appropriate treatment can begin.
Since many patients presenting to otolaryngologists with sinus headache will ultimately be diagnosed with migraine, these specialists are capable of the initial management of migraine though patients are typically referred to their primary physician or a neurologist for the long term management of this condition. Nonspecific medications such as ibuprofen, used in appropriate dosages, may be helpful for some patients, however, since most already have tried several over-the-counter medicines, prescription migraine-specific drugs are often recommended. According to the US Headache Consortium, the triptans, a prescription class of medicines with limited side effects that work on the primary causes of migraine in the brain, are the drugs of choice for the acute treatment of migraine in patients with attacks that are moderate or severe, especially for those who have failed to respond to nonspecific agents. When headaches occur more than twice a week, the use of preventative headache medicines is typically considered.
In the more rare case where sinus headache is in fact due to severe inflammation or infection of one or more of the sinuses, antibiotics, oral steroids and potentially surgical treatment may be recommended. In cases involving patients with allergies and headaches, management of allergies may reduce the frequency of their headaches. This can be related to reducing one trigger for the patient's migraine (ie, allergies) or by decreasing mucosal inflammation, which can cause a dull headache. Patients with typical itchy eyes, itchy nose, and nasal congestion may benefit from an allergy evaluation and ultimately allergy treatment including immunotherapy (allergy shots or sub-lingual drops).
The most critical step in treating “sinus headache” is diagnosing the underlying condition, whether it be migraine, sinusitis or other related disorders. As discussed this requires a careful review of a patient’s symptoms, a physical exam by a qualified practitioner and often a sinus CT scan. Once this is done, proper treatment can be initiated which is typically very successful in improving the frequency and severity of symptoms. If you suffer from what you believe are “sinus” headaches, as always, discuss your condition with your doctor and if needed schedule a consultation with a specialist to help establish a correct diagnosis for your problem.
Various articles and text referenced for this newsletter were taken from the following publication:
An Otolaryngology, Neurology, Allergy, and Primary Care Consensus on Diagnosis and Treatment of Sinus Headache.
Otolaryngol Head Neck Surg March 2006 vol. 134 no. 3 516-523