A 29-year-old woman presents for evaluation. She reports that she has had frequent headaches over the past 12 months that include pressure pain on her forehead, under her eyes, and over her cheeks. She usually has nasal congestion as well. She has not had any fevers or purulent nasal discharge. What is the most likely diagnosis?
A. Cluster headaches.
B. Migraine headaches.
C. Sinus headaches.
D. Tension headaches.
Myth: Recurrent sinus headaches are common.
Most physicians and patients would diagnose this case as sinus headache, but it is actually a common variant of migraine headache. Sinus headaches are rare, and when they do occur, they are almost always in the setting of acute sinusitis. Recurring headaches are rarely due to sinus problems.
In regard to sinus headache, the International Headache Society (IHS) classification states that chronic sinusitis is not a cause of headache and facial pain unless it relapses into an acute sinusitis ( Expert Rev. Neurother. 2009;9:439-44 ). The recurrent nature of the headaches in this patient suggests a primary headache disorder, with migraine being the most likely.
In a study of 2,991 patients with self-diagnosed or physician-diagnosed “sinus headaches,” 88% of the patients met IHS criteria for migraine ( Arch. Intern. Med. 2004;164:1769-72 ). In this study, most of the patients had symptoms suggesting sinus problems, with the most common symptoms being sinus pressure (84%), sinus pain (82%), and nasal congestion (63%).
The likely cause for these symptoms in migraine patients is vasodilation of the nasal mucosa that can be part of the migraine event ( Expert Rev. Neurother. 2009;9:439-44 ).
In the Sinus, Allergy and Migraine Study, 100 patients who believed they had sinus headaches were recruited. All of the patients received a detailed history and physical exam, and all received a headache diagnosis based on IHS criteria ( Headache 2007;47:213-24 ).
Final diagnoses were as follows: Migraine with or without aura, 52%; probable migraine, 23%; chronic migraine with medication overuse headache, 11%; nonclassifiable headache, 9%. A total of 76% of migraine patients reported pain in the distribution of the second division of the trigeminal nerve, and 62% experienced bilateral forehead and maxillary pain with their headaches.
It is interesting that both these studies showed the same thing: More than 85% of patients who think they have sinus headache actually meet criteria for migraine headache.
Two other articles also give strong evidence that patients with recurrent “sinus” headaches have causes other than sinus disease as the cause.
Dr. Mustafa Kaymakci and his colleagues studied 98 patients who had headaches diagnosed as “sinus” headaches ( J. Int. Med. Res. 2013;41:218-23 ). All patients received a detailed history and physical, nasal endoscopy, and sinus CT scans. All patients who did not have findings that could be considered the cause of the headaches were diagnosed according to IHS criteria.
A total of 61 (62%) were diagnosed with migraine headache, 26 (27%) diagnosed with tension-type headache, and 11 (11%) had cluster headache. Seventy-seven percent of these patients had previously received at least one treatment for sinusitis.
Another study, by Dr. Mohsen Foroughipour and his colleagues, gave similar results ( Eur. Arch. Otorhinolaryngol. 2011;268:1593-6 ). In this study, 58 patients with “sinus” headache were evaluated, with final diagnosis of migraine in 40 patients (69%), tension-type headache in 16 patients (27%), and chronic sinusitis with recurrent acute episodes in 2 patients (3%). Recurrent antibiotic therapy was given to 73% of the tension-type headache patients and 66% of the migraine patients.
In a study by Dr. Elina Kari and her colleagues, patients who had a history of “sinus headaches” were treated as though all these headaches were migraines ( Laryngoscope 2008;118:2235-9 ). Fifty-four patients were enrolled, and 38 patients completed the study. All patients had nasal endoscopy and sinus CT scans that were negative. They were then given migraine-directed treatment to use for their headaches.
The majority of the patients who dropped out of the study did so because they did not believe their headaches could be due to migraines, and they did not want to take the migraine medications.
Of the 38 patient who completed the study, 31 patients (82%) had a significant reduction of headache pain with triptan use, and 35 patients (92%) had a significant response to migraine-directed therapy.
These studies show us that recurrent “sinus headaches” are unlikely to be due to sinus disease. More likely, they represent migraine headache or, less likely, tension headache or cluster headache. Evaluation should include categorizing the headache by clinical features (IHS criteria) to make a diagnosis, followed by a trial of appropriate treatment for headache type. In patients who don’t meet criteria for a specific headache type, a trial of migraine-directed therapy is reasonable.
Dr. Paauw is a professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington Medical School. He is the Rathmann Family Foundation Chair in Patient-Centered Clinical Education. Contact Dr. Paauw at dpaauw@uw.edu.
