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Review| Volume 80, ISSUE 7, P908-916, July 2005

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

  • Author Footnotes
    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.
    Roger K. Cady
    Correspondence
    Address reprint requests and correspondence to Roger K. Cady, MD, Headache Care Center, Primary Care Network, Inc, 3805 S Kansas Expressway, Springfield, MO 65807
    Footnotes
    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.
    Affiliations
    Headache Care Center, Primary Care Network, Inc, Springfield, Mo
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  • David W. Dodick
    Affiliations
    Department of Neurology, Mayo Clinic College of Medicine, Scottsdale, Ariz
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  • Howard L. Levine
    Affiliations
    Cleveland Nasal-Sinus & Sleep Center, Cleveland, Ohio
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  • Curtis P. Schreiber
    Affiliations
    Headache Care Center, Primary Care Network, Inc, Springfield, Mo
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  • Eric J. Eross
    Affiliations
    Department of Neurology, Mayo Clinic College of Medicine, Scottsdale, Ariz
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  • Michael Setzen
    Affiliations
    NYU School of Medicine, Senior Clinical Attending Surgeon in Otolaryngology, North Shore University Hospital, Manhasset, NY
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  • Harvey J. Blumenthal
    Affiliations
    Neurological Associates of Tulsa, Tulsa, Okla
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  • William R. Lumry
    Affiliations
    Allergy & Immunology, University of Texas, Southwestern Medical School, Dallas
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  • Author Footnotes
    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.
    Gary D. Berman
    Footnotes
    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.
    Affiliations
    Allergy and Asthma Specialists, University of Minnesota, Minneapolis
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  • Paul L. Durham
    Affiliations
    Department of Biology, Southwest Missouri State University, Springfield
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  • Author Footnotes
    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.
      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.
      AAO-HNS (American Academy of Otolaryngology-Head and Neck Surgery), CT (computed tomography), IHS (International Headache Society), MRI (magnetic resonance imaging), NSAIDs (nonsteroidal anti-inflammatory agents), OTC (over the counter)
      Sinus headache is a common but nonspecific diagnosis attributed to headaches associated with facial pain and pressure. Headache specialists consider sinus headache to be relatively rare, even when there is demonstrable noninfectious sinus inflammation.
      • Bryan CS
      Sinusitis: more than a headache [editorial].
      • Schor DI
      Headache and facial pain-the role of the paranasal sinuses: a literature review.
      • Cady RK
      • Schreiber CP
      Sinus headache or migraine? considerations in making a differential diagnosis.
      This suggests that other types of headache are being misdiagnosed as sinus headache in many patients and, by extension, that patients are not receiving appropriate treatment. Otolaryngologists and allergists who frequently evaluate patients with headache and rhinogenic symptoms acknowledge that sinus headache is often migraine but consider many additional pathologic disorders in the differential diagnosis of a patient who experiences recurrent episodes of headache.
      Both the International Headache Society (IHS) and the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) 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 from multiple disciplines that suggest sinus headache (headache of rhinogenic origin) and migraine are frequently confused with one another.

      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-HNS
      • Lanza DC
      • Kennedy DW
      Adult rhinosinusitis defined.
      and the IHS criteria, originally published in 1988
      • Headache Classification Committee of the International Headache Society
      Classification and diagnostic criteria for headache disorders, cranial neuralgias and facial pain.
      but revised recently.
      • Headache Classification Subcommittee of the International Headache Society
      The International Classification of Headache Disorders: 2nd edition.
      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 reviews to incorporate feedback and new information to facilitate the development of more precise definitions. They also recognize that the criteria must be practical and compatible with clinical reality, although they maintain that a definitive diagnosis of rhinosinusitis should rest on diagnostic nasal endoscopy or computed tomography (CT) of the paranasal sinuses. The group acknowledges that most symptomatic patients will be treated by primary care physicians who generally lack the equipment and training necessary to perform these tests and thus accepts that a routine diagnosis of rhinosinusitis can generally be made by thorough history and physical examination (including anterior rhinoscopy and oropharyngeal neck examination). The AAO-HNS criteria include a series of major and minor clinical symptoms and signs (Table 1). A diagnosis of rhinosinusitis requires at least 2 major factors or at least 1 major and 2 minor factors. Although facial pain or pressure is a major factor, this symptom on its own is insufficient for a diagnosis of rhinosinusitis. In addition, headache is considered a minor factor.
      TABLE 1Factors Associated With the Diagnosis of Rhinosinusitis According to American Academy of Otolaryngology–Head and Neck Surgery Criteria
      • Lanza DC
      • Kennedy DW
      Adult rhinosinusitis defined.
      Major factorsMinor factors
      Purulence in nasal cavityHeadache
      Facial pain, pressure, congestion, and fullnessFever (all nonacute)
      Halitosis
      Nasal obstruction, blockage, discharge, and purulenceFatigue
      Dental pain
      Fever (acute rhinosinusitis only)Cough
      Hyposmia and anosmiaEar pain and fullness
      The original IHS classification system included the term acute sinus headache but did not acknowledge chronic sinusitis as a cause of headache or facial pain. A diagnosis of acute sinus headache was to be made on the basis of 5 criteria: (1) purulent discharge of the nasal passage; (2) pathologic findings on x-ray examination, CT, magnetic resonance imaging (MRI) or transillumination; (3) simultaneous onset of headache and sinusitis; (4) headache location (in relationship to specific sinus structures); and (5) disappearance of headache after treatment of acute sinusitis. Examinations by x-ray and transillumination are now obsolete because of CT and nasal endoscopy. The evidence for the importance of headache location in relationship to sinus disease is now considered doubtful, and the circular reasoning of the fifth criterion has been criticized.
      • Blumenthal HJ
      Headaches and sinus disease.
      The revised IHS classification system relates headache to sinus disease under the classification “headache attributed to rhinosinusitis,” with 4 diagnostic criteria (Table 2). The reliance on location by the original classification has been dropped, and the examinations required for clinical evidence have been updated. The IHS still considers that chronic sinusitis is “not validated as a cause of headache or facial pain unless relapsing into an acute stage” and deems other conditions that are often considered to induce headache, such as deviation of the nasal septum, hypertrophy of turbinates, atrophy of sinus membranes, and mucosal contact, “not sufficiently validated as causes of headache.” Mucosal contact is, however, defined in the appendix under “mucosal contact point headache” as a cause of headache for which “evidence is limited.” To be included in IHS criteria, further research needs to validate this diagnosis.
      TABLE 2International Headache Society Diagnostic Criteria for Headache Attributed to Rhinosinusitis
      • Headache Classification Subcommittee of the International Headache Society
      The International Classification of Headache Disorders: 2nd edition.
      CategoryCriterion
      AFrontal headache accompanied by pain in 1 or more regions of the face, ears, or teeth and fulfilling criteria C and D
      BClinical,
      Clinical evidence may include purulence in the nasal cavity, nasal obstruction, hyposmia, anosmia, and/or fever.
      nasal endoscopic, computed tomography, and/or magnetic resonance imaging and/or laboratory evidence of acute or acute-on-chronic rhinosinusitis
      CHeadache and facial pain develop simultaneously with onset of acute exacerbation of rhinosinusitis
      DHeadache and/or facial pain resolves within 7 days after remission or successful treatment of acute or acute-on-chronic rhinosinusitis
      * Clinical evidence may include purulence in the nasal cavity, nasal obstruction, hyposmia, anosmia, and/or fever.
      The new IHS recommendations also point out that it is easy to confuse migraine and tension-type headache with headache attributed to sinusitis because of similarity in the location of the headache. The IHS committee identified a group of patients who had all the features of migraine without aura (classification 1.1, Table 3) and, additionally, concomitant clinical features, such as facial pain, nasal congestion, and headache triggered by weather changes, but who did not have purulent nasal discharge or any of the other features diagnostic of acute rhinosinusitis. The IHS consensus is that most of the cases diagnosed as “sinus headache” fulfill the criteria for migraine without aura, with headache either accompanied by prominent autonomic symptoms in the nose or triggered by nasal changes. Despite new data that show that nasal symptoms frequently accompany migraine,
      • Cady RK
      • Schreiber CP
      Sinus headache or migraine? considerations in making a differential diagnosis.
      • Couch JR
      Sinus headache: a neurologist's viewpoint.
      • Barbanti P
      • Fabbrini G
      • Pesare M
      • Vanacore N
      • Cerbo R
      Unilateral cranial autonomic symptoms in migraine.
      nasal symptoms are not included in the IHS diagnostic criteria for migraine (Table 3).
      TABLE 3International Headache Society Diagnostic Criteria for Migraine Without Aura
      • Headache Classification Subcommittee of the International Headache Society
      The International Classification of Headache Disorders: 2nd edition.
      CategoryCriterion
      AAt least 5 attacks fulfilling criteria B-D
      BHeadache attacks lasting 4-72 h (untreated or treated successfully)
      CHeadache has at least 2 of the following characteristics
       Unilateral location
       Pulsating quality
       Moderate or severe pain intensity
       Aggravation by or causing avoidance of routine physical activity (eg, walking or climbing stairs)
      DDuring headache at least 1 of the following
       Nausea and/or vomiting
       Photophobia and phonophobia
      ENot attributed to another disorder
      Using the AAO-HNS classification system, the otolaryngologist investigates headache as one of several symptoms and signs to diagnose a pathophysiologic condition; the neurologist or headache specialist searches for a pathophysiologic condition to explain a symptom. Although the AAO-HNS and IHS systems have limitations, a consideration of the diagnostic criteria they encompass reveals useful signs and symptoms that will help in the differentiation of rhinogenic headache and migraine. The characteristics of the patient's head or facial pain and pressure; the location, severity, frequency, and duration of the pain or pressure; any association with nausea, vomiting, or photophobia; the presence or absence of nasal symptoms (particularly purulent discharge); and the temporal relationship between the headache and nasal symptoms are all important factors that can guide diagnosis and patient management. Diagnostic nasal endoscopy and CT may be required in certain patients to confirm rhinosinusitis or reveal anatomical abnormalities. The index of suspicion should be higher in patients with allergic rhinitis, guiding the physician (primary or allergist) to perform CT because patients with migraine can have concomitant rhinosinusitis and vice versa, thus creating a confusing clinical picture.

      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.
      • Lipton RB
      • Diamond S
      • Reed M
      • Diamond ML
      • Stewart WF
      Migraine diagnosis and treatment: results from the American Migraine Study II.
      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 sinus headache from a physician.
      • Diamond ML
      The role of concomitant headache types and non-headache co-morbidities in the underdiagnosis of migraine.
      Although some of these patients may have had coexisting sinus headache and migraine, misdiagnosis of migraine as sinus headache is probably common. In addition, sinus headache is often self-diagnosed incorrectly by patients.
      • Lipton RB
      • Stewart WF
      • Liberman JN
      Self-awareness of migraine: interpreting the labels that headache sufferers apply to their headaches.
      An original small pilot study was conducted of 47 patients with self-diagnosed sinus headache who underwent a complete medical and neurologic evaluation of their headache.
      • Cady RK
      • Schreiber CP
      Sinus headache or migraine? considerations in making a differential diagnosis.
      This study concluded that 90% of these patients experienced headaches that fulfilled the IHS criteria for migraine. Subsequent treatment of a “sinus” headache that met IHS criteria for migraine demonstrated significant response to a migraine-specific medication (sumatriptan). The authors concluded that self-diagnosed “sinus” headache is often migraine and that nasal symptoms frequently accompany migraine attacks.
      Recent studies have attempted to characterize more accurately the nature of sinus headaches as self-reported by patients or diagnosed by a physician. In a prospective, open-label, observational study performed in 452 sites (mainly primary care physicians’ offices), 2991 patients with self-described or physician-diagnosed sinus headache were assigned a headache diagnosis using IHS diagnostic criteria (migraine without aura, migraine with aura, migrainous, episodic tension type, or other).
      • Schreiber CP
      • Hutchinson S
      • Webster CJ
      • Ames M
      • Richardson MS
      • Powers C
      Prevalence of migraine in patients with a history of self-reported or physician-diagnosed “sinus” headache.
      Patients were aged 18 to 65 years and had to have had at least 6 attacks in the preceding 6 months. Patients with a prior diagnosis of migraine, prior use of a triptan medication, an abnormal sinus x-ray examination result in the preceding 6 months, and fever or purulent discharge with their typical sinus headache were excluded from the study. The study patients were 75% female, with a mean age of 39.8 years, and reported an average of 3 sinus headaches per month. Although a large proportion of the patients reported sinus symptoms such as sinus pressure (84%), sinus pain (82%), or nasal congestion (63%), large proportions of patients also reported IHS migraine symptoms such as moderate to severe pain (97%), pulsatility (89%), photophobia (79%), and phonophobia (67%); 28% reported aura, and 24% reported vomiting (Figure 1). An IHS diagnosis of migraine with or without aura was given to 80% of the patients, and another 8% met IHS criteria for migrainous headache (now called probable migraine in the 2004 IHS criteria); 8% fulfilled the criteria for episodic tension-type headache, and the remaining 4% were categorized as “other.” Among those diagnosed as having migraine (with or without aura) during the study, the use of pain medication was more frequent than the use of decongestants and antihistamines; more than 70% of these patients had treated their sinus headache with nonnarcotic analgesics or nonsteroidal anti-inflammatory agents (NSAIDs, over the counter [OTC] or prescribed), whereas 57% had used decongestants and 48% antihistamines. These patients also exhibited high scores on measures of headache-related disability.
      Figure thumbnail gr1
      FIGURE 1Typical “sinus” symptoms (gray bars) and International Headache Society migraine symptoms (black bars) reported by patients with self-described or physician-diagnosed sinus headache. Adapted from Arch Intern Med,
      • Schreiber CP
      • Hutchinson S
      • Webster CJ
      • Ames M
      • Richardson MS
      • Powers C
      Prevalence of migraine in patients with a history of self-reported or physician-diagnosed “sinus” headache.
      with permission. Copyright 2004 American Medical Association. All rights reserved.
      The Sinus, Allergy and Migraine Study investigated, from a neurologic perspective, 100 consecutive patients older than 18 years who believed they had sinus headache and responded to a newspaper advertisement; there were no exclusion criteria.
      • Eross EJ
      • Dodick DW
      • Eross MD
      The Sinus, Allergy and Migraine Study (SAMS) [abstract].
      After a detailed history and examination, patients were given headache diagnoses according to IHS criteria. Sixty-three percent were diagnosed as having migraine, 23% with probable migraine, 3% with headache secondary to rhinosinusitis, 1% with hemicrania continua, and 1% with cluster headache; in the remaining 9%, headaches could not be classified under IHS criteria (Figure 2). Among those diagnosed as having migraine, reasons patients gave for assuming they had sinus headache included location of pain over the sinuses (98%), pain triggered by changes in the weather (83%), pain associated with rhinorrhea (73%), and the suggestion of this diagnosis by a previous physician (78%); factors cited as triggering sinus headaches included seasonal variation (73%) and exposure to “allergens” (62%). Of these patients, 76% reported pain in the distribution of the second division of the trigeminal nerve (unilateral or bilateral), and 62% experienced bilateral forehead and maxillary pain with their headaches. Of the patients diagnosed as having migraine, 75% reported cranial autonomic symptoms during headaches, with half experiencing more than 1 such symptom; the most common features included nasal congestion (56%), eyelid edema (37%), rhinorrhea (25%), conjunctival injection (22%), and lacrimation (19%) (Figure 3). The study investigators suggested that the misdiagnosis of sinus headache for migraine in these patients was a result of triggers (weather changes) and symptoms (nasal congestion, rhinorrhea) that were thought to be typical of sinus disorders and pain overlying the paranasal sinuses-“guilt by provocation, location, and association.”
      Figure thumbnail gr2
      FIGURE 2International Headache Society diagnoses given to individuals with self-diagnosed sinus headache.
      • Eross EJ
      • Dodick DW
      • Eross MD
      The Sinus, Allergy and Migraine Study (SAMS) [abstract].
      Figure thumbnail gr3
      FIGURE 3Cranial autonomic features associated with migraine mistaken as sinus headache.
      • Eross EJ
      • Dodick DW
      • Eross MD
      The Sinus, Allergy and Migraine Study (SAMS) [abstract].
      These studies indicate that most individuals who believe, either because of self-diagnosis or physician diagnosis, that they have sinus headaches actually have headaches that fulfill criteria for migraine or probable migraine according to IHS criteria. Migraine is also the most common diagnosis (58%) in patients with headache who are referred for sinus evaluation and are found to show no evidence of rhinosinusitis on CT of the sinuses or endoscopic examination.
      • Perry BF
      • Login IS
      • Kountakis SE
      Nonrhinologic headache in a tertiary rhinology practice.

      Illustrative Case

      A 34-year-old man seeks treatment for a long-standing history of “sinus headaches.” He reports that his headaches occur with a frequency of 2 to 3 per month, each lasting approximately 48 hours. They are worse in the spring and fall, when his “allergies are bad.” His headaches begin with a feeling of pressure around his eyes accompanied by nasal congestion. The pain intensifies and localizes into the periorbital area and will throb if he is active or bends forward. He experiences nausea when the pain is severe and also reports sensitivity to light and sound and a clear nasal discharge. This patient has tried multiple sinus medications in the past and has been prescribed antibiotics on several occasions, which usually work within a day or two. He has missed work on 2 occasions in the past 3 months. Approximately a year ago, he also underwent CT of his sinuses that showed mucosal thickening in one of his sinuses. Physical examination results are normal.

      Discussion

      This case illustrates the complexity of evaluating the patient with self- or physician-diagnosed sinus headache. The location of the pain, its association with allergy season, the apparent response to antibiotics and sinus medication, and a CT scan that shows mucosal thickening all support the patient's belief that sinus problems are the cause of his headaches. However, this individual's headaches meet IHS criteria for migraine. He reports bilateral pain of moderate to severe intensity aggravated by activity (bending) and associated with nausea, photophobia, and phonophobia. The headaches often last 1 to 2 days, and he experiences substantial headache-related disability with many headaches, as witnessed by his absenteeism from work. In addition, little evidence exists to support a diagnosis of sinusitis. The only evidence includes the established pattern of recurrent headache, the lack of signs and symptoms associated with infection, and the rapid response to antibiotics in the past. The natural resolution of his migraine headache over 1 to 2 days was likely misinterpreted as a response to antibiotics. The mucosal thickening noted on CT does not support a diagnosis of sinusitis.

      Final Diagnosis

      This patient's final diagnosis is migraine without aura.

      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.
      • Clerico DM
      Sinus headaches reconsidered: referred cephalgia of rhinologic origin masquerading as refractory primary headaches.
      • Clerico DM
      Pneumatized superior turbinate as a cause of referred migraine headache.
      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 possibility that a patient's headache may be associated with nasal or sinus conditions.
      Patients who consult otolaryngologists and allergists because of headaches tend to be in 3 groups: those with self- or physician-diagnosed sinus headache, those with nasal complaints such as discharge or congestion associated with headache, and those whose headaches are unresponsive to other forms of therapy. Many of these patients experience facial pain rather than headache. A thorough history should elicit the characteristics of the patient's head pain or pressure (location; duration; precipitating factors such as position, irritants, allergy, or weather; relieving factors; and associated nasal symptoms) that will guide diagnosis. The patient should be asked about associated nasal symptoms, such as nasal obstruction, congestion, and decreased sense of smell and taste. The possibility that the patient has migraine should be investigated. An otolaryngologic examination, including palpation of the sinuses to reveal tenderness, nasal endoscopy, or CT, should disclose evidence of sinusitis or congenital or acquired nasal abnormalities that might lead to rhinogenic headache.
      • Blumenthal HJ
      Headaches and sinus disease.
      • Clerico DM
      Sinus headaches reconsidered: referred cephalgia of rhinologic origin masquerading as refractory primary headaches.
      Many symptoms may not be useful in differentiating sinus headache from migraine. However, clinical otolaryngologic experience and limited studies suggest that sinus-related pain has some features that distinguish it from primary headache disorders, which might prompt a neurologist to consider nasal or sinus symptoms as a cause of or contributory factor in a patient's headaches.
      • Tarabichi M
      Characteristics of sinus-related pain.
      Sinusrelated pain or headache tends to be described by patients as pressurelike and dull, usually bilateral and periorbital (though it can be unilateral with deviated septum, middle or inferior turbinate hypertrophy, or unilateral sinus disease), and worse in the morning with improvement as the day progresses, indicating nasal, sinus, and turbinate congestion from overnight recumbent position. This latter characteristic, however, may also be encountered in patients with medication overuse headache who are undergoing withdrawal from pain medication during the night and therefore experiencing pain in the morning, which improves after medication has been taken. Sinus-related pain is associated with nasal obstruction or congestion, lasts for days at a time, and is not usually associated with nausea, vomiting, or visual disturbances. No evident correlation exists between the severity of pain and the extent or location of mucosal disease or between the site of disease revealed by imaging and the site of pain.
      • Tarabichi M
      Characteristics of sinus-related pain.
      Although the IHS does not consider nasal anatomical abnormality to be a validated cause of headache, clinical otolaryngologic experience indicates that anatomical abnormalities such as septal deviation or concha bullosa (enlargement of the middle turbinate) can cause rhinogenic headache de novo or secondarily lead to bouts of acute sinusitis.
      • Blumenthal HJ
      Headaches and sinus disease.
      Criteria for contact point headache have been proposed,
      • Blumenthal HJ
      Headaches and sinus disease.
      • Tosun F
      • Gerek M
      • Ozkaptan Y
      Nasal surgery for contact point headaches.
      but limited information is available on the clinical features that should alert a clinician to consider this diagnosis.
      • Blumenthal HJ
      Headaches and sinus disease.
      A diagnosis of contact point headache in a patient with a history of chronic headache unresponsive to medical therapy can be made only when other obvious causes of headache have been ruled out by neurologic, otolaryngologic, ophthalmic, and dental examinations and when there is endoscopic or CT evidence of contact points
      • Blumenthal HJ
      Headaches and sinus disease.
      ; the diagnosis can be confirmed by the rapid (within 5 minutes) relief of pain after application of topical anesthesia to the contact points (using placebo or other controls).
      • Blumenthal HJ
      Headaches and sinus disease.
      • Clerico DM
      Pneumatized superior turbinate as a cause of referred migraine headache.
      • Tosun F
      • Gerek M
      • Ozkaptan Y
      Nasal surgery for contact point headaches.
      Use of a topical decongestant and anesthetic spray at the onset of headache and maintenance of a headache diary may also provide valuable evidence of a rhinogenic contact point headache.

      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.
      • Diamond ML
      The role of concomitant headache types and non-headache co-morbidities in the underdiagnosis of migraine.
      The physician diagnoses of headaches reported by these individuals were generally consistent with their most frequent headache type; it is likely that patients emphasize their most frequent headaches when relaying their symptoms to health care practitioners and that physicians preferentially diagnose the headache type patients report to occur most frequently.
      • Diamond ML
      The role of concomitant headache types and non-headache co-morbidities in the underdiagnosis of migraine.
      The various phenotypes of migraine possibly reflect the bidirectional sensory traffic that occurs along branches of the trigeminal (sensory) and facial (parasympathetic) nerves. These fibers ultimately synapse or communicate with the trigeminal nucleus caudalis and innervate a variety of cranial structures (dura, cerebral blood vessels, nasal and sinus mucosa, lacrimal gland). The result is the expression of a variety of symptoms (head pain, sinus and nasal mucosal edema, lacrimation, neck pain) that may occur in various combinations together.
      Cephalic pain is mediated by sensory traffic along the trigeminal pathway. Neurons in the trigeminocervical complex are the major relay neurons for nociceptive afferent input from the pain-sensitive cephalic structures, including the meninges, dural blood vessels, cervical structures, temporomandibular joints, and the gingival, nasal, and sinus mucosa. Afferent traffic from any of these structures that results in activation of nociceptive specific neurons within the trigeminocervical complex may refer pain to the somatic distribution of the trigeminal and upper cervical nerves.
      • Bartsch T
      • Goadsby PJ
      The trigeminocervical complex and migraine: current concepts and synthesis.
      Although the genesis of a migraine attack is still debated, the pain is likely a result of sensitization of peripheral trigeminal afferents and central sensitization of trigeminovascular neurons.
      • Burstein R
      • Jakubowski M
      Analgesic triptan action in an animal model of intracranial pain: a race against the development of central sensitization.
      Activation of peripheral trigeminal pathways results in release of calcitonin gene-related peptide, a marker of trigeminal activation, during migraine attacks.
      • Goadsby PJ
      • Edvinsson L
      • Ekman R
      Vasoactive peptide release in the extracerebral circulation of humans during migraine headache.
      Migraine attacks are often accompanied by symptoms that reflect activation of cranial parasympathetic pathways, including conjunctival injection, lacrimation, nasal congestion, and rhinorrhea. Elevated levels of vasoactive intestinal polypeptide (a marker for parasympathetic activation) are found in the jugular venous blood of patients with migraine during attacks.
      • Goadsby PJ
      • Lipton RB
      A review of paroxysmal hemicranias, SUNCT syndrome and other short-lasting headaches with autonomic feature, including new cases.
      Recent evidence also suggests that increased parasympathetic tone contributes to the activation of perivascular trigeminal nociceptors. Activation of these nociceptors contributes significantly to the pain intensity and initiation of central sensitization, and maintenance of this central sensitization is for the most part independent of the incoming impulses from the activated nociceptors.
      • Yarnitsky D
      • Goor-Aryeh I
      • Bajwa ZH
      • et al.
      2003 Wolff Award: possible parasympathetic contributions to peripheral and central sensitization during migraine.
      The cranial parasympathetic innervation of intracranial structures arises from neurons located in the superior salivatory nucleus. The efferent fibers from this central nucleus exit the brainstem via the seventh cranial nerve, traverse the geniculate ganglion, and synapse in the sphenopalatine, otic, and carotid miniganglia. Parasympathetic vasomotor efferents then travel via the ethmoidal nerve to innervate the cerebral blood vessels. Secretomotor efferents from this pathway innervate both the lacrimal and the nasal mucosal glands, thus providing the anatomical basis for the cranial autonomic symptoms (lacrimation, nasal congestion, rhinorrhea) seen in patients with migraine and other primary headache disorders such as cluster headache.
      These anatomical and physiologic features explain why migraine attacks are associated with pain referred to the region overlying the paranasal sinuses in the face and may be accompanied by cranial autonomic symptoms. This undoubtedly explains why migraine is often mistaken for headache of rhinogenic or sinus origin. It also explains why inflammation and activation of trigeminal or parasympathetic afferents that innervate the nasal or sinus mucosa may lead to headache or serve as a trigger for migraine attacks in susceptible individuals.

      Illustrative Case

      A 31-year-old female smoker with a 2-day history of pressure and pain below the right eye seeks medical treatment. She states that she has had a cold for several weeks that seems to have resolved just 2 days ago. This patient has noted a foul green drainage from her nose and was told by her husband that her breath was “terrible.” The pain is described as a deep pressure that she feels in her face and teeth, and her symptoms are worse when she lies down. She thinks she may have had a fever yesterday but did not take her temperature. The nasal discharge makes her cough and feel a little nauseated. She might be slightly sensitive to light but denies sensitivity to sound. The patient took an OTC cold preparation 2 hours ago but had no response. She is congested to the point that she cannot smell things very well. Examination reveals an afebrile patient with a purulent greenish discharge from the right nostril, but findings otherwise are normal.

      Discussion

      The patient describes her headache as pressure in the face that is worse when she is supine. She also experiences a purulent nasal discharge and halitosis. There may be an associated fever, but since she just took an OTC cold product that contained acetaminophen this cannot be evaluated adequately. Examination reveals a purulent nasal discharge. Thus, her symptoms meet diagnostic criteria established by the AAO-HNS. Evidence of a primary headache disorder in this case is clearly lacking. This is a new headache as opposed to a pattern of recurrent headaches. Although clinicians may be called on to evaluate patients with their first migraine, it is far more common that they will evaluate patients with a pattern of headache activity. This patient describes nausea and photophobia associated with the facial pressure, but these symptoms are not prominent. Furthermore, the headache worsens when she is supine, which is not a characteristic of migraine. Finally, the discharge is purulent, which is far more characteristic of sinusitis than migraine, in which the discharge, if present, is clear.

      Final Diagnosis

      The final diagnosis is acute sinusitis.

      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.
      • Tosun F
      • Gerek M
      • Ozkaptan Y
      Nasal surgery for contact point headaches.
      • Clerico DM
      • Evan K
      • Montgomery L
      • Lanza DC
      • Grabo D
      Endoscopic sinonasal surgery in the management of primary headaches.
      • Parsons DS
      • Batra PS
      Functional endoscopic sinus surgical outcomes for contact point headaches.
      • Strong EB
      • Senders CW
      Surgery for severe rhinosinusitis.
      Allergists see many patients with headaches, and both allergists and headache specialists have observed that patients with allergies may reduce the frequency of headaches by better managing their allergies. Theoretically, this could be related to reducing one trigger for the patient's migraine (ie, allergies) or by decreasing mucosal inflammation, which can cause a dull headache. Patients with typical itchy eyes, itchy nose, and nasal congestion may benefit from an allergy evaluation.
      Before surgical management, the nonotolaryngologist might consider medical management of some nasal and sinus problems. For facial pressure and pain caused by inferior and/or middle nasal turbinate congestion, treatment would include use of a nasal corticosteroid spray or a systemic decongestant. A trial of at least 1 month of daily use is needed to determine the effectiveness of the corticosteroid spray on turbinate congestion. For the patient with infectious sinusitis manifested by symptoms of discolored nasal drainage, nasal obstruction, facial pressure, and opacification of sinuses or mucosal thickening on CT, antibiotics are of value as recommended by the Sinus and Allergy Health Partnership.
      • Sinus and Allergy Health Partnership
      Antimicrobial treatment guidelines for acute bacterial rhinosinusitis: executive summary.
      The choices might be amoxicillin-clavulanate, fluoroquinolones, telithromycin, or cefdinir. In most instances antibiotic use should be maintained for 10 days. If the condition is chronic, continuing antibiotics for 3 weeks is warranted.
      Because many patients who present to otolaryngologists and allergists with sinus headache will be diagnosed as having migraine, the issue becomes what management efforts should be undertaken by these specialty groups. Referral to a neurologist or a primary care physician may delay treatment for several months. Consequently, it is reasonable in many instances for otolaryngologists to initiate a trial of short-term migraine-specific therapy in patients with infrequent attacks (=1 per week).
      Nonspecific medications, such as ibuprofen, used in appropriate dosages may be helpful for some patients. Since most patients who consult a physician because of problematic recurrent headaches often will have tried several OTC analgesics including NSAIDs, migraine-specific drugs should be considered. According to the US Headache Consortium, the triptans, a class of selective serotonin 1B/ 1D receptor agonists, are the drugs of choice for short-term treatment of migraine
      • Silberstein SD
      Practice parameter: evidence-based guidelines for migraine headache (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology [published correction appears in Neurology. 2000;56:142].
      • Bigal ME
      • Bordini CA
      • Antoniazzi AL
      • Speciali JG
      The triptan formulations: a critical evaluation.
      in patients with moderate or severe attacks, especially those who have not responded to nonspecific drugs.
      • Silberstein SD
      Practice parameter: evidence-based guidelines for migraine headache (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology [published correction appears in Neurology. 2000;56:142].
      The mechanisms of action of the triptans are believed to be cranial vasoconstriction, peripheral trigeminal inhibition, and prevention of central sensitization.
      • Burstein R
      • Jakubowski M
      Analgesic triptan action in an animal model of intracranial pain: a race against the development of central sensitization.
      • Goadsby PJ
      The pharmacology of headache.
      Triptans have well-established efficacy, especially if they are taken while pain is mild, before central sensitization occurs.
      • Cady RK
      • Sheftell F
      • Lipton RB
      • et al.
      Effect of early intervention with sumatriptan on migraine pain: retrospective analyses of data from three clinical trials.
      • Burstein R
      • Collins B
      • Jakubowski M
      Defeating migraine pain with triptans: a race against the development of cutaneous allodynia.
      In addition to relieving pain, triptans relieve the migraine-associated symptoms of nausea, phonophobia, and photophobia. Clinical trials and postmarketing surveillance studies in a large number of patients have confirmed that the triptans are also safe and well tolerated.
      • Diener HC
      • Limmroth V
      Advances in pharmacological treatment of migraine.
      • Diener HC
      Pharmacological approaches to migraine.
      • Nappi G
      • Sandrini G
      • Sances G
      Tolerability of the triptans: clinical implications.
      Adverse events are usually mild and rarely necessitate discontinuation.
      • Nappi G
      • Sandrini G
      • Sances G
      Tolerability of the triptans: clinical implications.
      Transient and usually mild chest symptoms (pressure, heaviness, tingling) are reported by 1% to 7% of patients in clinical trials but are generally nonserious and are not explained by coronary ischemia. The incidence of serious cardiovascular events with triptans in both clinical trials and clinical practice appears to be extremely low, and the American Headache Society Triptan Cardiovascular Safety Expert Panel concluded that the cardiovascular risk-benefit profile of triptans favors their use in the absence of contraindications.
      • Dodick D
      • Lipton RB
      • Martin V
      • Triptan Cardiovascular Safety Expert Panel
      • et al.
      Consensus statement: cardiovascular safety profile of triptans (5-HT1B/1D agonists) in the acute treatment of migraine.
      However, triptans are contraindicated in patients with cardiovascular disease.
      • Welch KM
      • Mathew NT
      • Stone P
      • Rosamond W
      • Saiers J
      • Gutterman D
      Tolerability of sumatriptan: clinical trials and post-marketing experience [published correction appears in Cephalalgia. 2001;21:164-165].
      Seven triptans (almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, and zolmitriptan) are currently available, each with demonstrated efficacy in migraine. The triptans differ in pharmacokinetic and pharmacodynamic profiles, but clinically all triptans are efficacious and generally well tolerated. Almotriptan, eletriptan, rizatriptan, sumatriptan, and zolmitriptan have a more rapid onset of action (30 minutes) than naratriptan or frovatriptan and are generally chosen as first-line treatment in newly diagnosed migraine. Despite their slower onset of action and lower response rates, naratriptan and frovatriptan have a longer elimination half-life and are often used for menstrually associated migraine attacks. Almotriptan and naratriptan have tolerability profiles similar to those of placebo.
      • Pascual J
      Almotriptan: pharmacological differences and clinical results.
      • Dahlof CG
      • Dodick D
      • Dowson AJ
      • Pascual J
      How does almotriptan compare with other triptans? a review of data from placebo-controlled clinical trials.
      • Ashcroft DM
      • Millson D
      Naratriptan for the treatment of acute migraine: meta-analysis of randomised controlled trials.
      Advising patients to take any of the triptans while pain is mild but destined to become more severe appears to substantially improve efficacy while reducing headache recurrence, the need to redose, and the consumption of rescue analgesics.
      • Klapper J
      • Lucas C
      • Rosjo O
      • Charlesworth B
      • ZODIAC Study Group
      Benefits of treating highly disabled migraine patients with zolmitriptan while pain is mild.
      • Mathew NT
      Early intervention with almotriptan improves sustained pain-free response in acute migraine.
      Advising against the use of any short-term treatment medication (including OTC and symptomatic sinus medications) for more than 2 to 3 days per week is recommended. The frequent use of immediate relief medications can lead to medication-overuse (rebound) headache. An excellent general guideline to suggest to patients with headache is that they be medically reevaluated if short-term medications are consistently required more than 2 days per week.

      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 purulent nasal discharge is likely rhinogenic in origin.
      • 5.
        Expectations regarding therapeutic intervention should be defined for the patient and evaluated by a timely follow-up visit.
      • 6.
        Patients with evidence of infection should have complete evaluation to rule out otolaryngologic conditions. The preferred standard is nasal endoscopy; however, because of the high number of false-positive results, MRI and CT can be substituted.
      • 7.
        Referral to a headache specialist should be considered for new-onset headache, frequent (>1 per week) headache, headache with associated neurologic symptoms or signs, or headache that does not respond adequately to conventional therapy.
      • 8.
        Patients with migraine with no evidence of infection should be given a trial of migraine-specific medication and scheduled for a follow-up evaluation.
      • 9.
        Patients with noninfectious rhinogenic symptoms with headache as a minor symptom should be prescribed nasal corticosteroids and/or selective antihistamines.

      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 and initiate appropriate therapy based on an accurate diagnosis.
      The IHS and AAO-HNS diagnostic criteria relating to migraine and rhinosinusitis are useful but not yet ideal. A cooperative alliance is needed between the 2 societies when the criteria are revised to promote improved recognition, diagnosis, and treatment and to reduce unnecessary diagnostic interventions, antibiotic use, and surgery.
      A differential diagnosis of migraine and rhinogenic headache is necessary if a patient is to receive appropriate treatment. Migraine requires treatment directed at preventing or terminating trigeminal sensitization, whereas sinus conditions require treatment directed against microbial or allergic inflammation or anatomical abnormalities. Sinus features may obscure the diagnosis of migraine, and sole reliance on the IHS diagnostic criteria for migraine may result in misdiagnosis of migraine with nasal symptoms as sinus headache. Otolaryngologists, allergists, and primary care physicians need to consider a diagnosis of migraine and should be confident in prescribing short-term medications such as triptans to treat patients whose conditions have been diagnosed; equally, neurologists need to consider the possibility that a patient's headaches are of rhinogenic origin. To best facilitate diagnosis and treatment, specialists in all 3 fields (allergy, neurology, and otolaryngology) need to be proactive in their questioning to elicit as much information as possible from patients about the characteristics of their headache and associated features.

      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.

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