When a Sinus Headache Is Really a Migraine

Gary E Cordingley, MD, PhD
Do you have recurring sinus headaches that are bad enough to put you
in bed or even just slow you down? Then it's likely that your sinuses are
not to blame. Instead, you probably have migraine.
The concept of sinus headaches runs so deep in the public mind that many people with pain in the fronts of
their heads (and even some people with pain in the backs of their heads) automatically assume that it is
caused by their sinuses. Moreover, their diagnosis seems confirmed when any of the following occurs:

*  The headache is caused by a change in weather.
*  The headache includes nasal congestion or sinus pressure.
*   A "sinus" medication helps resolve the headache.

Yet most headache experts feel that sinus headaches are way over-diagnosed as a cause of recurring head
pain. In fact, the author attended a conference of headache experts at which one seasoned physician stood up
and said, "Everything I know about sinus headaches I learned from television!" So what gives?

The speaker's point was that we have all been brain-washed by years of pharmaceutical advertising to
associate pain in the front of the head with sinus disease. Do you remember all those little triangles pasted
around someone's nose, eyes and forehead in advertisements for Dristan(R) sinus pills? These pictures
appeared for years in not just the media, but in buses and subways, as well. The company's marketing
department did their job well.

Certainly, an acutely infected sinus can cause substantial pain. But in the far more typical circumstance of mere
congestion of the nasal passageways and sinuses, usually there is either no pain or just mild discomfort. So if
that's the case, what accounts for more significant pains in the front of the head? The most frequent causes
are migraine and tension-type headaches. And when the pain is bad enough to interfere with or even prevent
usual activities, migraine is the most common culprit.

An internationally agreed-upon system for diagnosing the most common form of migraine includes the following:

*  Untreated or unsuccessfully treated attacks last for 4-72 hours each.
*  Attacks have at least two of the four following features:
1. present on just one side of the head
2. pulsating quality
3. moderate to severe intensity
4. the pain is aggravated by exertion
*  Attacks also have at least one of the two following features:
1. the pain is worsened by light and noise
2. there is nausea or vomiting

If that system seems too complicated, then here are a couple of screening questions you can substitute. Do
you suffer from recurrent, disabling headaches? When you have your usual headache, would you like to lie
down? A "yes" answer to either question makes migraine likely (and sinus headaches unlikely).

Researchers at the Headache Care Center of Springfield, Missouri, screened 2991 clinic patients for
individuals who believed they had sinus headaches and who had never previously been diagnosed as having
migraine. The researchers excluded people with signs of infection. Using the system of diagnosis we already
discussed, 80% had definite migraine and another 8% had probable migraine.

So what about those three items that seemed to confirm that a headache was due to sinuses? It turns out that
a change of weather can trigger a migraine, probably via a drop or rise in barometric pressure. It also turns out
that nasal congestion or pressure in the sinuses can be the
effect of a migraine attack rather than its cause.
Finally, it is always chancy to diagnose a condition based on what treatment works for it, because a single
treatment might help more than one condition. In the case of sinus pills there are usually multiple ingredients,
one of which is a painkiller. For example, in the various Dristan(R) formulations, aspirin, acetaminophen or
ibuprofen is present. Sometimes caffeine is also included in the pills which can resolve migraine headaches,

The confusion between sinus and migraine headaches has an ironic component. While the drug companies
used to work hard to convince people they had sinus headaches, now that some decent migraine medicines
are available, the drug companies that sell them are just as intent on persuading people they have migraines.

I guess it should go without saying that you shouldn't let the marketing department of a drug company diagnose
your headaches.

(C) 2005 by Gary Cordingley