FAQ Episode 77: Is your headache pain sinus, a migraine or both?

Frequently Asked Questions about Natural Migraine Relief

Even when you’re accurately diagnosed, it can be hard enough to find the migraine relief regimen that works best for you. But getting to the right diagnosis can also be a difficult journey. Today we’ll discuss what is probably the most common mis-diagnosis made before migraine is properly identified.

A study that demonstrates this challenge evaluated almost 3,000 people, none of whom were diagnosed with or being treated for migraine prior to the study.¹ Study participants reported at least six “sinus headaches” in the six months prior to the start of the study. Researchers found that 88% of the participants had migraine and not sinus headache. Other studies also confirm this version of mis-diagnosis to be in the 80-90% range for “the diagnosis was sinus before it was migraine.”

How to tell the difference?

Headache pain from a sinus condition is a real condition, but it differs from migraine headaches in several ways:

Sinus related head pain:

• usually due to inflammation in the sinuses that is often caused by an infection. You likely just had or have a viral cold. Or you could have a secondary bacterial infection as a complication.

• often has associated thick, colored nasal mucus. You may also have a fever.

• you usually need to blow your nose to clear drainage and/or pain. Your sense of smell is often decreased.

• pain is generally mild to moderate, continuous, and may vary with a sense of local pressure. It is centered over the sinus area and affects both sides fairly equally.

• you usually can function, as pain is not specifically better or worse with routine activities.

• often may show objective findings of sinus congestion, obstruction or blockage on CT scan or nasal endoscopy.

• if your only symptom from among those listed above is sinus area pain, your headache is probably more than just a sinus problem and a migraine should be suspected.

Typically, with a migraine headache:

• you do not have a cold.

• nasal drainage is clear, and is more likely to occur with or after the headache, not before.

• your sense of smell is not affected, in fact it may he heightened.

• pain is typically throbbing or pulsating, and worse on one side. We should keep in mind that this is not always the case. Migraine-related facial pain can occur on both sides of the face, just as sinus blockage might involve one side more than the other. I’ve seen many cases where previous nasal injury caused sinus outflow obstruction that was mostly one sided.

• your acute headache symptoms tend to get worse with physical activity.

• you are more likely to have associated symptoms of light sensitivity and nausea. These symptoms are not typically sinus related.

• the pain is often debilitating, impairing the ability to work or participate in regular activities.

• you have family members with similar headaches. Somewhere between 50-75% of those with migraine also have a close family member with migraine.

We should keep in mind that since migraine and sinusitis are both common, you could:

• have sinus inflammation or infection that triggers an acute migraine attack

• have both a true sinusitis and a migraine at the same time. This would most likely not be an ongoing “coincidence.”

• mistake a successful course of therapy for a sinus headache diagnosis as an exclusion of migraine treatment. A common strategy for acute sinusitis is to give both an antibiotic and a dose of steroids. If the facial pain and pressure gets better, we doctors might confirm that our treatment cleared the sinusitis and ignore the role that steroids played in reducing a migraine provoking amount of inflammation. If steroids made your headache better, I suggest that its more likely the diagnosis is migraine, not a sinus problem.

• have an early migraine headache, but thinking it is sinus related, could fail to take preventive measures to interrupt its progression.

Action considerations:

1. If you have headaches previously diagnosed and treated as primarily sinus, consider the above information and recheck with your primary care physician or a neurologist to consider the possibility of a migraine diagnosis.

2. If you have sinusitis that provokes a migraine, you may benefit from:

   -having testing or treatment for allergens that are provoking congestion.

   -investigating the potential role of home or workplace air quality contaminants. Using saline nasal lavage to clear cumulative particulate dust and debris from the nasal passages can be very helpful. I find the Navage device makes this easy to do.

   -getting evaluated for structural alterations like septal deviations, injury or chronic inflammation of the nasal turbinates, obstruction of the sinus outflow tracts, or not uncommonly all three, especially if you have experienced past nasal trauma. This was true for me, and finally getting it treated was life changing. A CT or nasal endoscopy can be helpful to better define these issues. Current techniques in endoscopic sinus surgery can correct many of the underlying structural factors that promote chronic sinusitis.

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   Understanding the difference between sinus related pain and migraine headaches can help guide you to your most accurate diagnosis, as well as, to more accurately identify sinus problems that may be root cause factors amplifying your primary headache disorder.

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1. Prevalence of migraine in patients with a history of self-reported or physician-diagnosed "sinus" headache. Curtis P Schreiber, et. al. Arch Intern Med 2004 Sep 13;164(16):1769-72. doi: 10.1001/archinte.164.16.1769.