Sinus Headache

The International Classification of Headache Disorders (ICHD) 3-Beta states: “The term “sinus headache” is outmoded because it has been applied both to primary headaches and headache supposedly attributed to various conditions involving nasal or sinus structures.”

Primary headaches are Migraine and Tension Type Headache.  This whole area of frontal migraine and rhinosinusitis is difficult to read and clinically to sort out, so I’m going to include the official statements from ICHD 3-Beta:

Description:

1. Migraine and 2. Tension-type headache can be mistaken for 11.5.1 Headache attributed to acute rhinosinusitis because of similarity in location of the headache and, in the case of migraine, because of the commonly accompanying nasal autonomic symptoms. The presence or absence of purulent nasal discharge and/or other features diagnostic of acute rhinosinusitis help to differentiate these conditions. However, an episode of 1. Migraine may be triggered or exacerbated by nasal or sinus pathology.

Pain due to pathology in the nasal mucosa or related structures is usually perceived as frontal or facial, but may be referred more posteriorly. Simply finding pathological changes on imaging of acute rhinosinusitis, correlating with the patient’s pain description, is not enough to secure the diagnosis of 11.5.1 Headache attributed to acute rhinosinusitis. Treatment response to local anaesthesia is compelling evidence, but may also not be pathognomonic.

11.5.1 Headache attributed to acute rhinosinusitis

Description:
Headache caused by acute rhinosinusitis and associated with other symptoms and/or clinical signs of this disorder.

Diagnostic criteria:
A. Any headache fulfilling criterion C
B. Clinical, nasal endoscopic and/or imaging evidence of acute rhinosinusitis
C. Evidence of causation demonstrated by at least two of the following:

1. headache has developed in temporal relation to the onset of the rhinosinusitis
2. either or both of the following:

a) headache has significantly worsened in parallel with worsening of the rhinosinusitis
b) headache has significantly improved or resolved in parallel with improvement in or resolution of the rhinosinusitis

3. headache is exacerbated by pressure applied over the paranasal sinuses
4. in the case of a unilateral rhinosinusitis, headache is localized ipsilateral to it

D. Not better accounted for by another ICHD-3 diagnosis.

Comments:
1. Migraine and 2. Tension-type headache can be mistaken for 11.5.1 Headache attributed to acute rhinosinusitis because of similarity in location of the headache and, in the case of migraine, because of the commonly accompanying nasal autonomic symptoms. The presence or absence of purulent nasal discharge and/or other features diagnostic of acute rhinosinusitis help to differentiate these conditions. However, an episode of 1. Migraine may be triggered or exacerbated by nasal or sinus pathology.

Pain due to pathology in the nasal mucosa or related structures is usually perceived as frontal or facial, but may be referred more posteriorly. Simply finding pathological changes on imaging of acute rhinosinusitis, correlating with the patient’s pain description, is not enough to secure the diagnosis of 11.5.1 Headache attributed to acute rhinosinusitis. Treatment response to local anaesthesia is compelling evidence, but may also not be pathognomonic.

11.5.2 Headache attributed to chronic or recurring rhinosinusitis

Description:
Headache caused by a chronic infectious or inflammatory disorder of the paranasal sinuses and associated with other symptoms and/or clinical signs of the disorder.

Diagnostic criteria:
A. Any headache fulfilling criterion C
B. Clinical, nasal endoscopic and/or imaging evidence of current or past infection or other inflammatory process within the paranasal sinuses
C. Evidence of causation demonstrated by at least two of the following:

1. headache has developed in temporal relation to the onset of chronic rhinosinusitis
2. headache waxes and wanes in parallel with the degree of sinus congestion, drainage and other symptoms of chronic rhinosinusitis
3. headache is exacerbated by pressure applied over the paranasal sinuses
4. in the case of a unilateral rhinosinusitis, headache is localized ipsilateral to it

D. Not better accounted for by another ICHD-3 diagnosis.

Comment:
It has been controversial whether or not chronic sinus pathology can produce persistent headache. Recent studies seem to support such causation.

Clinical evidence of rhinosinusitis may include purulence (pus) in the nasal cavity, nasal obstruction, hyposnia/anosmia and/or fever.  Chronic sinusitis is generally not validated as a cause of headache or facial pain unless relapsing into an acute stage.  Migraine and tension-type headache are often confused with headache committed to rhinosinusitis because of similarity location of the headache.  A group of patients can be identified who have of all the features of migraine without aura and additionally, concomitant clinical features such as facial pain, nasal congestion and headache triggered by weather changes.  None of these patients have purulent nasal discharge or other features diagnostic of acute rhinosinusitis.  Therefore, is necessary to differentiate headache attributed to rhinosinusitis from so-called "sinus headaches", a commonly made but nonspecific diagnosis.  Most such cases fulfill the criteria for migraine without aura with headache either accompanied by prominent autonomic symptoms in the nose or triggered by nasal changes.

If you don’t have the above listed symptoms and clinical findings, then you don’t have acute rhinosinusitis.  Patients with what they call “sinus headache” usually localize the pain to behind the eyes, the forehead, or the cheeks.  The American Academy of Neurology has said that most patients with what they call “sinus headache” have a diagnosis of migraine made by a neurologist.  Many of these patients have no purulent nasal discharge which is a cardinal requirement of true nasal sinusitis, an infection in the sinus areas.

The myth about sinus headache has been taught to the American public since the 1950s by erroneous advertising such as Tylenol sinus ads on TV.  This misconception doesn’t exist in Europe where no one has heard of “sinus headache.”.  It is a marketing idea made up in America to sell pseudoephedrine type drugs to the unwary consumer.  It is common to have more than one type of migraine headache.  Many persons accurately name their worst, often one-sided headaches as migraines, but they are not aware that their milder, front of the head “sinus headache” may be migraine too.

Dr. David Dodick, head of the section of headache at the Mayo Clinic published in 2007 an article where he studied 100 patients with a self-diagnosis of “sinus headache.”  He found 97of the 100 patients had a diagnosis of either migraine or medication overuse headache.

Clinical tip-during the migraine process the cranial arteries dilate, a process called vasodilation.  With a frontal migraine in the sinus areas, the arteries in the nasal turbinates, the vascular tissue in the depth of the nose, dilate and the patient notices nasal congestion which is a migraine symptom.  Sinus headache TV ads would say nasal congestion is due to a “sinus” problem.

Patients with acute rhinosinusitis should have green or yellow frontal nasal discharge as evidence of infection, not a clear watery discharge like with allergic rhinitis.

Pseudoephedrine causes vasoconstriction of nasal turbinate arteries and is therefore is a “weak” migraine drug, like caffeine.  Yes, pseudoephedrine is a mildly effective over the counter drug for acute migraine.  Today there are over 200 pseudoephedrine drugs in the U.S.  The “sinus headache” myth is driven by big pharma to sell pseudoephedrine drugs.  Pseudoephedrine is also spelled “Sudafed.”  Pseudoephedrine has been banned for importation to the U.S. by the FDA. 

Ten years ago in Dallas there was an article in the Dallas Morning News about a man who went into Eckerd’s drug store, now CVS, and bought $5000 worth of pseudoephedrine which he took home and in his home chemistry lab made methamphetamine which he then sold to school children in Garland, Texas.  He was caught by the cops and put in jail.  The Wall Street Journal had an article about a man who made a “meth lab” in the men’s room of a New York airport.

Methamphetamine addiction is a big problem in America and methamphetamine comes from pseudoephedrine.   When I got my medical license to practice medicine in Texas in 1970 pseudoephedrine was doctor’s prescription only but then it went over the counter.  Now in Texas someone who buys pseudoephedrine at the drug store has to register their driver’s license, while in Oklahoma it is illegal, and Utah has it as prescription only.

How about this statement?  The phrase “sinus headache” is made and marketed by a mafia driven drug industry in the United States to sell--pseudoephedrine.