Sinus headaches

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Written By Dr. Marcus Yu Bin Pai

MD, PhD. Physical Medicine & Rehabilitation Physician from São Paulo - Brazil. Pain Fellowship in University of São Paulo.

Sinus headaches are a common complaint among patients, who often believe their pain and discomfort stem from their sinuses. However, this is not always the case.

If a patient suspects they may have sinus migraine, it is essential to differentiate it from sinusitis to ensure appropriate treatment. One diagnostic approach involves obtaining a CT scan while the patient is symptomatic. This can help identify any structural abnormalities or inflammation in the sinuses[1]Hamilos DL. Chronic sinusitis. Journal of Allergy and Clinical Immunology. 2000 Aug 1;106(2):213-27..

This article will explore the potential causes of sinus headaches, including migraine, sinusitis, and rhinogenic headache, and provide a practical approach to managing patients with these conditions.

Sinus Migraine: A Complex Phenomenon

Sinus migraine is not currently recognized as an official headache diagnosis. Instead, it is considered a variant of a headache. The challenge arises when patients with non-traditional headache symptoms consult primary care physicians or otolaryngologists who may not be well-versed in this variant.

Consequently, these patients are at risk of being misdiagnosed, leading to inadequate treatment and management.

Why Does This Connection Matter?

Rhinosinusitis affects approximately 15% of the population each year, leading to significant disability and financial burden on the healthcare system. It is one of the most common reasons for prescribing antibiotics, with over 80% of patients receiving them. This has led to growing concerns about antibiotic resistance and adverse effects on the human microbiome[2]Rosenfeld RM, Andes D, Neil B, Cheung D, Eisenberg S, Ganiats TG, Gelzer A, Hamilos D, Haydon RC, Hudgins PA, Jones S. Clinical practice guideline: adult sinusitis. Otolaryngology–Head and Neck … Continue reading.

The American Academy of Otolaryngology has developed clinical guidelines for diagnosing and managing rhinosinusitis. These guidelines rely on the presence of facial pain or pressure, nasal congestion, and nasal discharge to diagnose the condition. However, sinus migraine can mimic these symptoms, resulting in misdiagnosis and inappropriate treatment with antibiotics.

Prevalence of Sinus Migraine

The exact prevalence of sinus migraine remains to be determined. However, small clinical studies suggest that 60-80% of patients with symptoms resembling neurologically-based rhinosinusitis may respond to migraine medications.

This indicates that a significant portion of patients diagnosed with rhinosinusitis may actually have sinus migraine.

Causes of Sinus Headaches

Sinus headache symptoms can include facial pain, pressure in the maxillary, frontal, and ethmoid sinus regions, nasal congestion, and nasal drainage[3]American Academy of Pediatrics. Clinical practice guideline: management of sinusitis. Pediatrics. 2001 Sep;108(3):798-808..

The differential diagnosis for sinus headaches can include primary headache disorders (such as migraine, cluster, and tension headaches), dental issues, temporomandibular disorders, rhinogenic or contact point headaches, acute or chronic sinusitis, allergic or non-allergic rhinitis, and the presence of a mass or neoplasm.

Clinical Presentation of Sinus Migraine

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Patients with sinus migraine frequently report pain and pressure across their forehead and behind their eyes. Approximately 60% of them also complain of dental pain or cheek pain. Additionally, they may experience sensations of air pressure, with symptoms typically affecting both sides of the face (bilateral presentation).

Sinus migraine symptoms can also include nasal congestion, runny nose, and clear or slightly cloudy secretions. These symptoms arise from the involvement of the autonomic nervous system, which controls the size of blood vessels and secretory cells within the nose. As a result, patients with sinus migraine often present with sinus-like symptoms that can be easily mistaken for sinus infections or other sinus-related issues.

International Headache Society Definitions

The International Headache Society (IHS) has established criteria for diagnosing sinus headaches, migraines, and rhino genic headaches. These criteria are essential for research and studies, but when it comes to individual patients, it’s crucial to consider their unique symptoms and experiences.

Diagnostic Dilemmas

Differentiating between sinus headaches and other conditions can be challenging. Both sinusitis and migraine have relatively high incidences, and patients with these conditions can have overlapping symptoms.

Autonomic symptoms, such as nasal congestion, drainage, and tearing, can further complicate the diagnosis.

Migraines as a Primary Cause

In many cases, patients who believe they have sinus headaches may actually be experiencing migraines. One study found that 97% of patients with self-diagnosed sinus headaches did not have a sinus source for their pain. Instead, 75% to 90% of these patients met the criteria for migraine or possible migraine.

Understanding the Connection Between Migraines and Sinusitis

Migraines are typically characterized by severe, throbbing headaches, while sinusitis involves inflammation of the sinuses, often accompanied by facial pain, pressure, and nasal discharge. Some researchers have observed that certain migraine patients experience sinus-related symptoms, leading to the proposal of a condition called “sinus migraine,” which is essentially a migraine variant that mimics the presentation of sinusitis.

In sinus migraine, spontaneous firings of special sensory organs in the nervous system create illusions of sinus symptoms. This phenomenon is also observed in vestibular migraine, where malfunctioning nerves responsible for balance lead to dizziness.

The sensory organs involved in sinus migraine are likely different from those in traditional migraines. For instance, they might be mechanical receptors that measure pressure. Consequently, sinus migraine patients may experience pressure in their ears or sinuses, rather than pain.

Pathophysiology of Sinus Migraine: An Evolving Understanding

The exact pathophysiology of sinus migraine remains to be elucidated, but it is thought to share commonalities with other types of migraines, such as ocular migraines. Ocular migraines can lead to visual disturbances, while sinus migraines may cause sensory hallucinations in the form of sinus headache symptoms.

One possible explanation for the development of sinus migraine symptoms lies in the dysregulation of the autonomic nervous system. This system controls various involuntary functions in the body, such as blood vessel dilation and constriction and the secretion of fluids from glands. In the case of sinus migraine, the autonomic system may become overactive, causing the blood vessels in the nose to swell and leading to the production of excessive nasal secretions.

Another potential contributing factor to the pathophysiology of sinus migraine is the activation of the trigeminal nerve, which plays a key role in the sensation of pain and pressure in the face. The activation of this nerve may lead to increased sensitivity and pain perception in the sinus regions, resulting in the clinical presentation of sinus migraine.

Practical Approach to Management

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In the absence of clinical practice guidelines for sinus headaches, the following practical approach can be useful:

  1. Sinusitis with a headache: Focus on diagnosing and treating the sinusitis, but also consider the possibility of an underlying migraine or other condition.
  2. Suspected migraines with a history of sinusitis: Work to convince the patient that migraines might be a possibility, especially if they have no known history of migraines.
  3. Rhino genic headache: If the patient’s symptoms do not match migraine or sinusitis criteria, consider the possibility of a rhino genic headache. Be cautious in this approach, but patients who receive successful treatment are often very appreciative.

Headaches are a common complaint among patients, often attributed to sinusitis, migraines, or rynogenic sources. In this article, we will discuss the various causes of headaches, diagnostic approaches, and potential treatment options, using two case presentations as examples.

Misdiagnosis and Antibiotic Overuse

Rhinosinusitis is a significant burden on the healthcare system, with an estimated 15% of the population affected each year. It is also a common cause of antibiotic prescriptions. However, the American Academy of Otolaryngology has developed clinical guidelines to prevent the overuse of antibiotics, recommending that patients first wait a week to see if symptoms resolve spontaneously before using antibiotics.

Unfortunately, many patients with sinus migraine are misdiagnosed and prescribed antibiotics, which can contribute to antibiotic resistance and other negative consequences. The similarities in presentation between sinus migraine and bacterial infections make it difficult for clinicians and patients to differentiate between the two.

Differentiating Between Sinusitis, Migraines, and Rynogenic Headaches

Diagnosing Sinus Migraine

To diagnose sinus migraine, a CT scan of the sinuses can help rule out bacterial infections. However, the scan may also reveal findings that do not correlate with a patient’s symptoms. In such cases, the doctor may ask about a history of migraine headaches, as many patients with sinus migraine have had migraines in the past.

Additionally, other symptoms can hint at a neurological cause for sinus symptoms. These may include light or noise sensitivity, ear pressure or discomfort, and a history of fibromyalgia, sleep disorders, gastrointestinal issues, or dizziness.

1. Sinusitis

Sinusitis is characterized by inflammation of the sinuses, causing headaches and facial pain. Diagnosis can be confirmed through nasal endoscopy or CT scans. However, these tests should only be performed on patients with recurrent sinusitis and inconclusive clinical findings.

2. Migraines

Migraines are a type of headache caused by changes in the brain and surrounding blood vessels. Symptoms include nausea, photophobia, and impaired function. Patients with migraine-like symptoms and negative imaging for sinusitis should be considered for a trial of migraine medication, such as Imitrex.

3. Rynogenic Headaches

Rynogenic headaches are headaches or facial pain caused or exacerbated by issues within the nasal cavity. Patients may experience nasal congestion and septal spurs. While these symptoms may contribute to headaches, the primary cause is often migraine-related.

Diagnostic Algorithm

When evaluating a patient with headache and sinus-related symptoms, follow these steps:

  1. Screen for migraine symptoms
  2. Consider other trigeminal nerve sources (e.g., dental or jaw issues)
  3. Perform imaging or nasal endoscopy if necessary
  4. Attempt a trial of migraine medication (e.g., Imitrex)
  5. If migraine medication is unsuccessful, consider allergy, dental, or neurology evaluations

In addition to imaging, healthcare providers may consider the patient’s medical history, symptoms, and response to previous treatments. For instance, if a patient has a history of migraines or if their sinus-like symptoms respond to migraine-specific treatments, this may support a diagnosis of sinus migraine.

Treatment Options

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Once a sinus migraine diagnosis is confirmed, treatment options may include migraine-specific medications, such as triptans, nonsteroidal anti-inflammatory drugs (NSAIDs), or preventative medications like beta-blockers, calcium channel blockers, or antiepileptic drugs. Additionally, addressing potential migraine triggers and implementing lifestyle changes, such as stress management, regular sleep patterns, and hydration, can help manage symptoms.

  1. Topical antihistamines: May be helpful for patients with sinus-related headaches and sensitivities to odors.
  2. Afrin: Use for a limited trial to see if it improves headaches.
  3. Lidocaine: In-office administration may help determine if nasal issues are contributing to headaches.
  4. Surgical options: Proceed with caution, considering surgery only after exhausting other diagnostic and treatment options.

Clinical Implications and Future Directions

The identification and management of sinus migraine remain challenging due to its complex presentation and the lack of a standardized diagnostic criteria. By raising awareness and improving our understanding of this migraine variant, healthcare providers can better identify and manage sinus migraine in patients experiencing these symptoms.

Future research should focus on elucidating the underlying pathophysiology of sinus migraine, as well as establishing clear diagnostic criteria and effective treatment options. This will not only improve the clinical care for patients suffering from sinus migraine but also contribute to a more comprehensive understanding of the migraine spectrum as a whole.


Sinus headaches can be a complex and challenging issue for both patients and healthcare providers. By understanding the potential causes of sinus headaches and using a practical approach to diagnosis and management, providers can help their patients find relief and improve their quality of life.

The pathophysiology of sinus migraine involves spontaneous firings of sensory organs in the nervous system, which can create illusions. For example, patients with vestibular migraine experience dizziness due to malfunctioning nerves responsible for maintaining balance. Similarly, sinus migraine may result from the dysfunction of pressure-sensitive receptors in the sinus mucosa, which can cause pressure sensations in the ears or sinuses instead of pain.

Because sinus migraine is often a chronic form of migraine, patients may respond well to the same preventive medications used for chronic headaches. As with traditional migraine treatment, the choice of preventive medication depends on the individual patient.

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MD, PhD. Physical Medicine & Rehabilitation Physician from São Paulo - Brazil. Pain Fellowship in University of São Paulo.


1Hamilos DL. Chronic sinusitis. Journal of Allergy and Clinical Immunology. 2000 Aug 1;106(2):213-27.
2Rosenfeld RM, Andes D, Neil B, Cheung D, Eisenberg S, Ganiats TG, Gelzer A, Hamilos D, Haydon RC, Hudgins PA, Jones S. Clinical practice guideline: adult sinusitis. Otolaryngology–Head and Neck Surgery. 2007 Sep;137(3_suppl):S1-31.
3American Academy of Pediatrics. Clinical practice guideline: management of sinusitis. Pediatrics. 2001 Sep;108(3):798-808.

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