Are You Treating Your Sinus Headache All Wrong?
Sinus infections aren’t very fun. Runny nose, sneezing, tiredness, the whole nine yards. But you know what’s a real headache? Headaches. Sinus headaches are headaches associated with sinus inflammation, usually from an infection or allergies. Weirdly, in study[1] after study[2] after study[3], only a tiny percent of patients who report “sinus headaches” actually have headaches caused by sinus inflammation or infections! What’s going on? What are sinuses anyway?!
Sinuses (technically the paranasal sinuses) are, in essence,eight hollow areas in your face - four on each side. These holes are covered with cells and contain a bunch of air, but their exact purpose is debated[4]. Possible purposes include:
- Making our voices sound nice
- Warming and moistening the air we breathe
- Insulating important organs from warm or cold air
- Generating important chemicals
- Acting as a “crumple zone” in case we get punched in the face
Regardless of what the sinuses are supposed to do, one thing they seem pretty good at is getting infected and inflamed. In most cases of infection, a virus starts causing problems in one of the sinuses. Allergies and other infections in the body can also cause inflammation in the sinuses. Sinuses usually get air through little passages called ostia, but infections and inflammation can block these, making the sinuses a warm, wet space with little air[5] - just like the shared showers in my college dorm. Also, just like those showers, it’s the perfect place for breeding bacteria.
Now that we know what sinuses are, what are sinus headaches? Simply put, these are headaches associated with sinus inflammation. These range in time from days to years. Unfortunately, the definition of sinus headache is vague and ill-defined. In fact, it’s so ill-defined that the third edition of the International Classification of Headache Disorders (ICHD-3) got rid of the term “sinus headache” altogether in 2018[6]. Typically, people think of sinus headaches as any headache affecting the front of the face around the sinuses. This makes intuitive sense. Unfortunately, this symptomatic idea of a sinus headache rarely points to the correct cause of the pain. Sinus headaches are classified as secondary headaches, meaning they are caused by a separate underlying condition. These occur in numbers much smaller than most people think. So what’s causing these headaches?
Migraines! There are several possible explanations, as neurologist Steven Toenjes, MD, explains on the MedEvidence Podcast “migraine can hurt in the region of our sinuses and the vast majority of what is even diagnosed by physicians as a sinus headache is migraine. The statistics are 85% of what a physician diagnoses as a sinus headache is migraine.[7]” Other diagnoses include tension headaches, cluster headaches, and other types of headaches [ 8, 9, 10]. Facial pain above the sinuses by itself proves to be an inadequate sign that the sinuses are causing the pain. Drainage from the nose may indicate a closer look is needed. Cases of “sinus headache” should be investigated as though they are migraines, not just headaches due to sinus infection, inflammation, and/or congestion[10].
The reason this is important, of course, is because of treatment. If your doctor thinks your headache is caused by a bacterial infection, they may prescribe an antibiotic. This is generally safe but can negatively affect your microbiome and may not relieve the headaches! Multiple studies [1, 3, 11] have found that prescribing triptans (sumatriptan, eletriptan) for “sinus headache” can provide relief where anti-inflammatory, decongestant, and antibacterial medications do not. In some cases, patients had previously undergone surgery for sinus issues but found relief for the headaches through antimigraine medications.[3] Good diagnoses are critical to finding adequate relief; some patients have gone for years assuming their headaches are sinus-oriented instead of migraines. These studies show the importance of evidence-based medicine and randomized clinical trials!
Creative Director Benton Lowey-Ball, BS, BFA
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[1] Eross, E., Dodick, D., & Eross, M. (2007). The sinus, allergy and migraine study (SAMS) CME. Headache: The Journal of Head and Face Pain, 47(2), 213-224. https://headachejournal.onlinelibrary.wiley.com/doi/full/10.1111/j.1526-4610.2006.00688.x
[2] Foroughipour, M., Sharifian, S. M. R., Shoeibi, A., Ebdali Barabad, N., & Bakhshaee, M. (2011). Causes of headache in patients with a primary diagnosis of sinus headache. European archives of oto-rhino-laryngology, 268, 1593-1596. https://link.springer.com/article/10.1007/s00405-011-1643-6
[3] Daudia, A. T., & Jones, N. S. (2002). Facial migraine in a rhinological setting. Clinical Otolaryngology & Allied Sciences, 27(6), 521-525. https://onlinelibrary.wiley.com/doi/full/10.1046/j.1365-2273.2002.00628.x
[4] Cappello, Z. J., Minutello, K., & Dublin, A. B. (2023). Anatomy, head and neck, nose paranasal sinuses. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK499826/
[5] Ceriani, C. E., & Silberstein, S. D. (2021). Headache and rhinosinusitis: A review. Cephalalgia, 41(4), 453-463. https://journals.sagepub.com/doi/full/10.1177/0333102420959790
[6] International Headache Society. (2018). 11.5 Headache attributed to disorder of the nose or paranasal sinuses. IHS Classification ICHD-3. https://ichd-3.org/11-headache-or-facial-pain-attributed-to-disorder-of-the-cranium-neck-eyes-ears-nose-sinuses-teeth-mouth-or-other-facial-or-cervical-structure/11-5-headache-attributed-to-disorder-of-the-nose-or-paranasal-sinuses/
[7] Koren, M.J. & Toenjes, S. (Hosts). (2024). Two docs talk: Migraines. [Podcast Episode]. In MedEvidence! Truth Behind the Data. MedEvidence. https://medevidence.com/two-docs-talk-migraines
[8] Schreiber, C. P., Hutchinson, S., Webster, C. J., Ames, M., Richardson, M. S., & Powers, C. (2004). Prevalence of migraine in patients with a history of self-reported or physician-diagnosed sinus headache. Archives of internal medicine, 164(16), 1769-1772. https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/217302
[9] Straburzyński, M., Gryglas-Dworak, A., Nowaczewska, M., Brożek-Mądry, E., & Martelletti, P. (2021). Etiology of ‘sinus headache’—moving the focus from rhinology to neurology. A systematic review. Brain Sciences, 11(1), 79.https://www.mdpi.com/2076-3425/11/1/79
[10] Patel, Z. M., Kennedy, D. W., Setzen, M., Poetker, D. M., & DelGaudio, J. M. (2013, March). “Sinus headache”: rhinogenic headache or migraine? An evidence‐based guide to diagnosis and treatment. In International forum of allergy & rhinology (Vol. 3, No. 3, pp. 221-230). https://onlinelibrary.wiley.com/doi/abs/10.1002/alr.21095
[11] Ishkanian, G., Blumenthal, H., Webster, C. J., Richardson, M. S., & Ames, M. (2007). Efficacy of sumatriptan tablets in migraineurs self-described or physician-diagnosed as having sinus headache: a randomized, double-blind, placebo-controlled study. Clinical therapeutics, 29(1), 99-109. https://www.clinicaltherapeutics.com/article/S0149-2918(07)00026-4/abstract
