Review
Sinus Headache: A Neurology, Otolaryngology, Allergy, and Primary Care Consensus on Diagnosis and Treatment

https://doi.org/10.4065/80.7.908Get rights and content

Sinus headache is a widely accepted clinical diagnosis, although many medical specialists consider it an uncommon cause of recurrent headaches. The inappropriate diagnosis of sinus headache can lead to unnecessary diagnostic studies, surgical interventions, and medical treatments. Both the International Headache Society and the American Academy of Otolaryngology-Head and Neck Surgery have attempted to define conditions that lead to headaches of rhinogenic origin but have done so from different perspectives and in isolation of each other. An interdisciplinary ad hoc committee convened to discuss the role of sinus disease as a cause of headache and to review recent epidemiological studies that suggest sinus headache (headache of rhinogenic origin) and migraine are frequently confused with one another. This committee reviewed available scientific evidence from multiple disciplines and concluded that considerable research and clinical study are required to further understand and delineate the role of nasal pathology and autonomic activation in migraine and headaches of rhinogenic origin. However, this group agreed that greater diagnostic and therapeutic attention needs to be given to patients with sinus headaches.

Section snippets

Differentiating Sinus Headache, Rhinosinusitis, and Migraine

There are 2 principal systems of classification and diagnostic criteria relating headaches and sinus disease: the working definitions for acute, subacute, and chronic rhinosinusitis recommended by the AAO-HNS4 and the IHS criteria, originally published in 19885 but revised recently.6 Both sets of criteria represent the consensus of expert opinion in each particular field rather than being founded on scientific evidence-based evaluations. The authors of the AAO-HNS criteria recommend periodic

When A Sinus Headache is Really A Migraine

Migraine is underdiagnosed in the United States. The American Migraine Study II, a population-based survey that involved more than 20,000 US households conducted in 1999 (following up the original study performed a decade earlier), indicated that only 48% of patients who met IHS criteria for migraine reported a physician diagnosis of migraine.10 Follow-up data from the American Migraine Study II suggest that 42% of patients with migraine as defined by IHS criteria had received a diagnosis of

When A Migraine is Really A Sinus Headache

Although most patients who present with sinus headache may not actually have rhinosinusitis-associated headache, some do, and it is possible for headache of rhinogenic origin to fulfill IHS migraine criteria.16, 17 Therefore, headaches must be diagnosed correctly so that patients can receive appropriate treatment. Just as otolaryngologists and allergists should consider the possibility that a patient with sinus headache has migraine, neurologists and headache specialists should consider the

Peripheral and Central Processing of Cranial Nociception

Patients with disabling primary headaches often report experiencing multiple unique clinical presentations of their headaches. Follow-up data from the American Migraine Study II showed that individuals who fulfilled IHS migraine criteria also reported experiencing other types of headache (tension, sinus, and cluster) in addition to migraine headaches.11 The physician diagnoses of headaches reported by these individuals were generally consistent with their most frequent headache type; it is

Treatment

Neurologists need to be alert to the possibility that a patient's headaches may be secondary to or triggered by structural rhinogenic causes; in particular, they need to be aware that nasal anatomical abnormalities can be a trigger factor and refer properly selected patients for otolaryngologic or allergy evaluation. If aggressive medical therapy fails, surgical approaches (eg, septoplasty, resection of the concha bullosa) may relieve contact point headaches in selected patients.19, 25, 26, 27

Guidelines

We recommend use of the following diagnostic and therapeutic guidelines in diagnosing headaches.

  • 1.

    A stable pattern of recurrent headaches that alter daily function with headache as the presenting symptom is most likely migraine.

  • 2.

    Recurrent self-limited headaches associated with rhinogenic symptoms are most likely migraine.

  • 3.

    Prominent rhinogenic symptoms with headache as one of several symptoms should be evaluated carefully for otolaryngologic conditions.

  • 4.

    Headache with associated fever and

Conclusion

Headache associated with rhinogenic symptoms is a diagnostic dilemma that physicians commonly confront. Diagnostic clarity is essential because primary headache disorders such as migraine and rhinosinusitis have specific treatments. Recent clinical studies suggest that patients who present with sinus headache frequently have migraine. However, important rhinogenic causes of headache exist. Physicians should carefully evaluate patients who present with headache described to be of sinus origin

Acknowledgments

We thank Sharon Schaier, PhD, for editorial assistance. Committee members were selected independently by Drs Cady and Dodick on the basis of the individual's research interests, publications, and professional activities. The materials reviewed were determined at the independent discretion of each group member.

REFERENCES (43)

  • HJ Blumenthal

    Headaches and sinus disease

    Headache

    (2001)
  • JR Couch

    Sinus headache: a neurologist's viewpoint

    Semin Neurol

    (1988)
  • P Barbanti et al.

    Unilateral cranial autonomic symptoms in migraine

    Cephalalgia

    (2002)
  • RB Lipton et al.

    Migraine diagnosis and treatment: results from the American Migraine Study II

    Headache

    (2001)
  • ML Diamond

    The role of concomitant headache types and non-headache co-morbidities in the underdiagnosis of migraine

    Neurology

    (2002)
  • RB Lipton et al.

    Self-awareness of migraine: interpreting the labels that headache sufferers apply to their headaches

    Neurology

    (2002)
  • CP Schreiber et al.

    Prevalence of migraine in patients with a history of self-reported or physician-diagnosed “sinus” headache

    Arch Intern Med

    (2004)
  • EJ Eross et al.

    The Sinus, Allergy and Migraine Study (SAMS) [abstract]

    Headache

    (2004)
  • DM Clerico

    Sinus headaches reconsidered: referred cephalgia of rhinologic origin masquerading as refractory primary headaches

    Headache

    (1995)
  • DM Clerico

    Pneumatized superior turbinate as a cause of referred migraine headache

    Laryngoscope

    (1996)
  • F Tosun et al.

    Nasal surgery for contact point headaches

    Headache

    (2000)
  • Cited by (78)

    • The Role of the Otolaryngologist in the Evaluation and Management of “Sinus Headache”

      2022, Otolaryngologic Clinics of North America
      Citation Excerpt :

      Therefore, a complete history and nasal endoscopy (preferably witnessed by the patient on a monitor) become essential to demonstrate the presence or absence of purulent nasal discharge, loss of sense of smell, and other features diagnostic of acute and chronic rhinosinusitis that will help to differentiate these conditions. It is also important to consider that the combination of different diagnostic modalities can provide more of the information necessary to elucidate each case.8 First published in 1997 and then revised in 2007 and 2015, a Rhinosinusitis Task Force (RTF) established by the American Academy of Otolaryngology–Head and Neck Surgery designated cardinal symptoms for the diagnosis of acute and chronic rhinosinusitis (Box 2).

    • Novel Devices for Sinus Headache

      2022, Otolaryngologic Clinics of North America
    • Rhinogenic and sinus headache – Literature review

      2021, American Journal of Otolaryngology - Head and Neck Medicine and Surgery
      Citation Excerpt :

      Paroxysmal hemicrania and hemicrania continua respond well to oral Indomethacin, which, in addition to being one of the diagnostic criteria, provides excellent relief for the patient. Indomethacin should be prescribed at a dose of 150 mg or higher, although maintenance doses should be lower [32,38]. Current treatment for trigeminal neuralgia consists of anticonvulsants, muscle relaxants, neuroleptic agents, and surgery (refractory) [44,45].

    • “Sinus” Headaches: Sinusitis Versus Migraine

      2018, Physician Assistant Clinics
    • Neurologic Symptom Complexes

      2018, Principles and Practice of Pediatric Infectious Diseases
    • Migraine: A look down the nose

      2017, Journal of Plastic, Reconstructive and Aesthetic Surgery
    View all citing articles on Scopus

    The multispecialty consensus meeting was supported by an unrestricted educational grant from Ortho-McNeil Pharmaceutical, Inc. Participants were provided airfare and paid a $1000 honorarium for their time and preparation. No reception or overnight accommodations were provided to attendees by the sponsor.

    This consensus report is based on the proceedings of an advisory board meeting on sinus headache, Dallas, Tex, December 8, 2003.

    1

    Dr Cady serves as an advisory board consultant and receives research grants from Ortho-McNeil and numerous other pharmaceutical companies. Dr Dodick serves as an advisory board consultant and receives research grants from Ortho-McNeil and many other pharmaceutical companies. Dr Levine serves as a consultant to several medical companies that specialize in pharmaceuticals and instrumentation for nasal and sinus disease. Dr Schreiber has received research grants from Ortho-McNeil and other pharmaceutical companies. Dr Eross has received honoraria for consultation and writing and research grants from Ortho-McNeil. Drs Setzen and Lumry have no conflicts of interest to disclose. Dr Blumenthal has received honoraria from Ortho-McNeil for speaking engagements.

    2

    Dr Berman has served on advisory boards for various pharmaceutical companies. Dr Durham has received funding for research from government, Ortho-McNeil and other pharmaceutical, and private companies.

    View full text