Key points
- •
Patients will believe pain or pressure over the sinus region is originating from the sinuses until you can prove otherwise, either by endoscopy or CT scan.
- •
Correct diagnosis can only come after completing a full history and physical, including nasal endoscopy, using imaging if indicated, and having a working knowledge of common headache diagnostic criteria.
- •
The most common primary headache syndrome that is mistakenly diagnosed as “sinus headache” is migraine.
- •
Although a neurologist is the best physician to evaluate and formulate a treatment strategy in patients with primary headache syndromes, there are a few straightforward initial treatment options that an otolaryngologist should be familiar with to try and alleviate the patient’s symptoms as soon as possible.
Introduction
According to a worldwide Nielsen survey performed in 2007, headache is the most common complaint that leads people around the world to seek medical care. Otolaryngologists see a large proportion of these patients, as people expect that if they have pain or pressure in their head and neck, that a head and neck doctor likely knows how to diagnose and treat the problem. Outside of primary care doctors and emergency room physicians, otolaryngologists, neurologists, and oral surgeons see the majority of these patients.
Patients with pain in or around their sinonasal region often blame the sinuses for this pain based on the logical rationale that if a structure lies directly below the surface of the face where the pain or pressure is located, it is likely caused by a problem with this structure. There are also those patients who mistakenly assume they have sinuses where the pain/pressure is located because they do not know what else would cause such a sensation. Some patients will point to their temple and say the pain is coming from “that sinus.” Patients are not the only ones guilty of this assumption. Many erroneous referrals for “sinus headache” are sent to otolaryngologists by primary care doctors and emergency room physicians. Although the mantra, “common things are common,” is generally a respectable guide for these physicians, distinguishing between multiple common disorders in this region has been a problem and is now the focus of cross-specialty efforts to educate whichever physicians may see these patients first.
There is good reason for confusion and misdiagnosis, because symptoms seen in multiple primary headache disorders as well as common rhinologic disorders overlap extensively. Otolaryngologists are often guilty of assuming all headaches not attributable to an ear, nose, and throat (ENT) disorder must be migraine. This review discusses the most common diagnoses that can masquerade as “sinus headache” or “rhinogenic headache”, including the trigeminal autonomic cephalalgias (TACs), which include cluster headache (CH) and paroxysmal hemicrania (PH), hemicrania continua (HC), trigeminal neuralgia (TN), and tension-type headache (TTH); temporomandibular joint dysfunction (TMD); giant cell arteritis (GCA), which is also known as temporal arteritis; medication overuse headache (MOH); and migraine. We will go through the diagnostic criteria for each and outline the evidence that will allow physicians to make better clinical diagnoses and point their patients toward better treatment options.
Introduction
According to a worldwide Nielsen survey performed in 2007, headache is the most common complaint that leads people around the world to seek medical care. Otolaryngologists see a large proportion of these patients, as people expect that if they have pain or pressure in their head and neck, that a head and neck doctor likely knows how to diagnose and treat the problem. Outside of primary care doctors and emergency room physicians, otolaryngologists, neurologists, and oral surgeons see the majority of these patients.
Patients with pain in or around their sinonasal region often blame the sinuses for this pain based on the logical rationale that if a structure lies directly below the surface of the face where the pain or pressure is located, it is likely caused by a problem with this structure. There are also those patients who mistakenly assume they have sinuses where the pain/pressure is located because they do not know what else would cause such a sensation. Some patients will point to their temple and say the pain is coming from “that sinus.” Patients are not the only ones guilty of this assumption. Many erroneous referrals for “sinus headache” are sent to otolaryngologists by primary care doctors and emergency room physicians. Although the mantra, “common things are common,” is generally a respectable guide for these physicians, distinguishing between multiple common disorders in this region has been a problem and is now the focus of cross-specialty efforts to educate whichever physicians may see these patients first.
There is good reason for confusion and misdiagnosis, because symptoms seen in multiple primary headache disorders as well as common rhinologic disorders overlap extensively. Otolaryngologists are often guilty of assuming all headaches not attributable to an ear, nose, and throat (ENT) disorder must be migraine. This review discusses the most common diagnoses that can masquerade as “sinus headache” or “rhinogenic headache”, including the trigeminal autonomic cephalalgias (TACs), which include cluster headache (CH) and paroxysmal hemicrania (PH), hemicrania continua (HC), trigeminal neuralgia (TN), and tension-type headache (TTH); temporomandibular joint dysfunction (TMD); giant cell arteritis (GCA), which is also known as temporal arteritis; medication overuse headache (MOH); and migraine. We will go through the diagnostic criteria for each and outline the evidence that will allow physicians to make better clinical diagnoses and point their patients toward better treatment options.
Diagnostic criteria
First published in 1997 and then revised in 2003, a rhinosinusitis task force (RTF) established by the American Academy of Otolaryngology–Head and Neck Surgery designated criteria for the diagnosis of acute and chronic rhinosinusitis, which are set forth in Tables 1–3 . Facial pressure or pain must be combined with at least one other major factor to warrant a chronic sinusitis diagnosis; each is not enough on its own.
| Major Factors | Minor Factors |
|---|---|
| Facial pain/pressure (must be associated with another major factor) | Headache |
| Facial congestion/fullness | Fever (must be associated with another major nasal symptom) |
| Nasal obstruction/blockage | Halitosis |
| Nasal discharge/drainage | Fatigue |
| Hyposmia/anosmia | Dental pain |
| Fever (in acute) | Cough |
| Ear pain/pressure/fullness |
| Acute Sinusitis | Chronic Sinusitis |
|---|---|
| Duration 4 or less weeks | Duration 12 or more weeks |
| 2 or More major factors OR | 2 or More major factors OR |
| 1 Major + 2 minor factors OR | 1 Major + 2 minor factors OR |
| Nasal purulence on examination | Nasal purulence on examination |
| Discolored nasal drainage from the nasal passages, nasal polyps, or polypoid swelling as identified on physical examination with anterior rhinoscopy after decongestion or nasal endoscopy |
| Edema or erythema of the middle meatus or ethmoid bulla on nasal endoscopy |
| Generalized or localized erythema, edema, or granulation tissue (if the middle meatus or ethmoid bulla is not involved, radiologic imaging is required to confirm a diagnosis) |
| CT scanning demonstrating isolated or diffuse mucosal thickening, bone changes, or air-fluid levels OR |
| Plain sinus radiography revealing air-fluid levels or greater than 5 mm of opacification of 1 or more sinuses |
The International Headache Society (IHS) has diagnostic criteria for all headache syndromes, and the criteria for the headache disorders are in Boxes 1–9 and Table 4 .
- 1.
Frontal headache accompanied by pain in 1 or more regions of the face, ears, or teeth and fulfilling criteria 3 and 4
- 2.
Clinical, nasal endoscopic, CT and/or MRI, and/or laboratory evidence of acute or acute-on-chronic rhinosinusitis a
- 3.
Headache and facial pain develop simultaneously with onset or acute exacerbation of rhinosinusitis
- 4.
Headache and/or facial pain resolve within 7 days after remission or successful treatment of acute or acute-on-chronic rhinosinusitis
a Clinical evidence may include purulence in the nasal cavity, nasal obstruction, hyposmia, anosmia, and/or fever.
- A.
Recurrent pain in 1 or more regions of the head and/or face, fulfilling criteria C and D
- B.
Radiograph, MRI, or bone scintigraphy demonstrates temporomandibular joint (TMD) disorder
- C.
Evidence that pain can be attributed to the TMD disorder, based on at least 1 of the following:
- 1.
Pain is precipitated by jaw movements and/or chewing of hard or tough food
- 2.
Reduced range of or irregular jaw opening
- 3.
Noise from 1 or both TMDs during jaw movements
- 4.
Tenderness of the joint capsule(s) of 1 or both TMDs
- 1.
- D.
Headache resolves within 3 months and does not recur after successful treatment of the TMD disorder
- A.
Headache lasting from 30 minutes to 7 days (or even more persistent if diagnosing chronic TTH)
- B.
Headache has at least 2 of the following characteristics:
- 1.
Bilateral location
- 2.
Pressing/tightening (nonpulsating) quality
- 3.
Mild or moderate intensity
- 4.
Not aggravated by routine physical activity, such as walking or climbing stairs
- 1.
- C.
Both of the following:
- 1.
No nausea or vomiting (anorexia may occur)
- 2.
No more than one of phonophobia or photophobia
- 1.
- D.
Not attributed to another disorder
- A.
Paroxsysmal attacks of pain lasting from a fraction of a second to 2 minutes, affecting 1 or more divisions of the trigeminal nerve and fulfilling criteria B and C
- B.
Pain has at least 1 of the following characteristics:
- 1.
Intense, sharp, superficial, or stabbing
- 2.
Precipitated from trigger areas or trigger factors
- 1.
- C.
Attacks are stereotyped in the individual patient
- D.
There is no clinically evident neurologic deficit
- E.
Not attributed to another disorder
- A.
Any new persisting headache fulfilling criteria C and D
- B.
At least 1 of the following:
- 1.
Swollen tender scalp artery with elevated ESR or CRP
- 2.
Temporal artery biopsy demonstrating GCA
- 1.
- C.
Headache develops in close temporal relation to other symptoms and signs of GCA (these may include jaw claudication, polymyalgia rheumatica, recent repeated attacks of amaurosis fugax) a
- D.
Headache resolves within 3 days of high-dose steroid treatment
a Signs and symptoms may be so variable that any recent persisting HA in a patient over 60 years old should suggest this diagnosis. There is a major risk of blindness that is preventable by immediate steroid treatment and the time interval between visual loss in one eye and in the other is usually less than a week.
- A.
Headache present on ≥15 days/month fulfilling criteria C and D
- B.
Regular overuse for ≥3 months of 1 or more drugs that can be taken for acute and/or symptomatic treatment of headache
- C.
Headache has developed or markedly worsened during medication overuse
- D.
Headache resolves or reverts to its previous pattern within 2 months of discontinuation of overused medication
- A.
At least 5 attacks fulfilling criteria B–D
- B.
Severe or very severe unilateral orbital, supraorbital, and/or temporal pain lasting 15–180 minutes if untreated
- C.
Headache is accompanied by at least 1 of the following:
- 1.
Ipsilateral conjunctival injection and/or lacrimation
- 2.
Ipsilateral nasal congestion and/or rhinorrhea
- 3.
Ipsilateral eyelid edema
- 4.
Ipsilateral forehead and facial sweating
- 5.
Ipsilateral miosis and/or ptosis
- 6.
A sense of restlessness or agitation
- 1.
- D.
Attacks have a frequency from 1 every other day to 8 per day
- E.
Not attributed to another disorder
- A.
At least 20 attacks fulfilling criteria B–D
- B.
Attacks of severe unilateral orbital, supraorbital, or temporal pain lasting 2–30 minutes
- C.
Headache is accompanied by at least 1 of the following:
- 1.
Ipsilateral conjunctival injection and/or lacrimation
- 2.
Ipsilateral nasal congestion and/or rhinorrhea
- 3.
Ipsilateral eyelid edema
- 4.
Ipsilateral forehead or facial sweating
- 5.
Ipsilateral miosis and/or ptosis
- 1.
- D.
Attacks have a frequency above 5 per day for more than half the time, although periods with lower frequency may occur
- E.
Attacks are prevented completely by therapeutic doses of indomethacin (in order to rule out incomplete response) and should be used in a dose of ≥150 mg qd orally or rectally, or ≥100 mg IV, but for maintenance, smaller doses are often sufficient
- F.
Not attributed to another disorder
- A.
Headache for >3 months fulfilling criteria B–D
- B.
All of the following characteristics:
- 1.
Unilateral pain without side shift
- 2.
Daily and continuous without pain-free periods
- 3.
Moderate intensity but with exacerbations of severe pain
- 1.
- C.
At least 1 of the following autonomic features occurs during exacerbations and ipsilateral to the side of the pain:
- 1.
Conjunctival injection and/or lacrimation
- 2.
Nasal congestion and/or rhinorrhea
- 3.
Ptosis and/or miosis
- 1.
- D.
Complete response to therapeutic doses of indomethacin
- E.
Not attributed to another disorder
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