Diagnosing 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.

Clinical criteria for diagnosing sinus headaches

Two major criteria or one major criterion plus two minor criteria are needed to support a diagnosis of sinus headache.

The major criteria for sinus headaches include:

  • 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.

Treatment for sinus infections

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 oedema and swelling. Surgical drainage may be necessary for refractory cases.

Treatment of true bacterial sinusitis

Potential for misdiagnosis

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.

The American Migraine Study II demonstrated that 42% of patients with all the criteria for migraine had been previously diagnosed with sinus headache.

So, in order to accurately diagnose your patient, remember to differentiate migraine and sinus headaches by applying the criteria of the International Headache Society International Classification of Headache Disorders.

This is an edited excerpt from the Medmastery course Headache Masterclass by Robert Coni, DO, EdS, FAAN. Acknowledgement and attribution to Medmastery for providing course transcripts.


Neurology Library: Secondary headaches

Neurology Library

Robert Coni, DO, EdS, FAAN. Vascular neurologist and neurohospitalist and Neurology Subspecialty Coordinator at the Grand Strand Medical Center in South Carolina. Former neuroscience curriculum coordinator at St. Luke’s / Temple Medical School and fellow of the American Academy of Neurology. In my spare time, I like to play guitar and go fly fishing. | Medmastery | Linkedin |

BMBS (The University of Nottingham) BMedSci (The University of Nottingham). Emergency Medicine RMO at Sir Charles Gairdner Hospital Perth, WA. Interested in Medical Education and Emergency Medicine. Swimmer and frequent concert attendee.

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