Diagnosing and treating sinus headaches

Sinus headaches can be defined as pain over the sinus region of the face, especially the maxillary area and the periorbital region. The pain can vary and might even be pulsatile in nature.

There is a common belief among patients, and some clinicians, that sinusitis is present and causing a headache whenever there is pain over the sinuses. And, applying pressure over the sinuses may induce discomfort in patients with a sinus headache. So, facial pain and pressure is typically thought of as one of the classic signs of sinus headaches, however, it is only one of the major criteria.

The major criteria for sinus headaches are the following:

• Purulence in the nasal cavity
• Facial pain, pressure, congestion, or fullness
• Nasal obstruction, blockage, or discharge
• Hyposmia and anosmia
• Fever
• Ear pain and fullness

There are also five minor criteria for a sinus headache:

• Headache
• Fatigue
• Halitosis
• Cough
• Dental pain

The most likely locations for sinusitis to develop are within the maxillary and ethmoid sinuses. Sphenoid sinusitis has slightly different symptoms, is more difficult to diagnose, and is more significant in terms of morbidity.

There is usually some abnormality on computer tomography (CT) demonstrating mucosal thickening, clouding, sclerosis, and perhaps air fluid levels in the ethmoid sinuses. However, note that CT is not specific for bacterial sinusitis.

If a bacterial infection is identified, the usual treatment is a 10–14 day course of broad-spectrum oral antibiotics. Oral decongestants and / or nasal decongestant sprays are also used to reduce nasal tissue swelling. The sprays should only be used for a few days to reduce rebound edema and swelling. Surgical drainage may be necessary for refractory cases.

Some primary headache syndromes have rhinorrhea-like symptoms. The complaint of nasal congestion as well as the patient noting improvement with sinus medication, often leads to an incorrect diagnosis of sinus headache. For example, over half of patients who have migraine also have nasal symptomatology. Unless the clinician assesses the patient for findings associated with migraine, such as nausea, photophobia, phonophobia, laterality, throbbing pain, and aggravation with activity, the diagnosis of sinus headache may be erroneously made when migraine is actually present. In fact, the American Migraine Study II demonstrated that 42% of patients with all the criteria for migraine had been previously diagnosed with sinus headache.¹