Clinical Consultation: Distinguishing sinus headache from migraine

This is a difficult question, because most "sinus headaches" are migraines.^1-3 In fact, there is no such thing as a sinus headache. The International Headache Society (IHS) defines a headache attributable to rhinosinusitis according to the criteria listed in Table 1.⁴ This requires a diagnosis of acute rhinosinusitis and a headache that occurs at the same time.

The otolaryngology literature has always included headache as a symptom of acute rhinosinusitis, but it has viewed it as a "minor factor" in the diagnosis; thus, by itself, headache does not support the diagnosis of rhinosinusitis.⁵ Signs such as congestion, purulent rhinorrhea, and anosmia are much more supportive of the diagnosis. Migraine headache has also been clearly defined by IHS criteria (Table 2).⁴

When patients complain of "sinus headache," what do they really have? A few excellent studies have addressed this. Eross and coworkers⁶ studied 100 patients who responded to a newspaper advertisement for the workup of sinus headache and found the vast majority met the criteria for migraine or probable migraine headache. Only 3% of these respondents had acute rhinosinusitis-related headaches.

In a multicenter prospective study, Schreiber and coworkers² found that 88% of 2991 patients complaining of sinus headache had migraine or probable migraine. Most of those with migraine had nasal symptoms, sinus pressure, and sinus pain.

The importance of these studies is that they suggest that sinus headache complaints are usually migraine and are seldom caused by bacterial rhinosinusitis. Also, this presentation of migraine is frequently accompanied by rhinorrhea (and other nasal symptoms) as well as by mid-facial discomfort, both of which can lead to an incorrect diagnosis. Even in otolaryngology offices, patients referred for sinus headache frequently have undiagnosed migraine.

Physicians who treat patients complaining of sinus headache should have a good working familiarity with the IHS criteria as well as a high index of suspicion for migraine. This will help minimize the overuse of inappropriate medications (such as antibiotics) and will allow more disease-specific therapies (such as triptan medications) when indicated.

References:

REFERENCES

1. Mehle ME, Schreiber CP. Sinus headache, migraine, and the otolaryngologist.

Otolaryngol Head Neck Surg.

2005;133:489-496.
2. Schreiber CP, Hutchinson S, Webster CJ, et al. Prevalence of migraine in patients with a history of self-reported or physician-diagnosed "sinus" headache.

Arch Intern Med.

2004;164:1769-1772.
3. Perry BF, Login IS, Kountakis SE. Nonrhinologic headache in a tertiary rhinology practice.

Otolaryngol Head Neck Surg

. 2004;130:449-452.
4. Headache Classification Subcommittee of the International Headache Society. The international classification of headache disorders, 2nd ed.

Cephalalgia

. 2004;24(suppl 1):9-160.
5. Lanza DC, Kennedy DW. Adult rhinosinusitis defined.

Otolaryngol Head Neck Surg.

1997;117:S1-S7.
6. Eross EJ et al. Poster presented at: The International Headache Congress. September 13-16, 2003; Rome.