11 Rhinogenic Headache

In 2004, the International Headache Society (IHS) published its guidelines for diagnostic criteria for recognized headache syndromes. Within the guidelines, there is a “headache secondary to rhinosinusitis,” which requires a diagnosis of acute sinusitis to meet the criteria.1 The IHS does not currently accept that chronic sinusitis can be the cause of a headache syndrome. More commonly, the symptoms of a patient with “sinus headaches” will meet the diagnostic criteria associated with one of several other primary headache disorders. Discordantly, most current guidelines for chronic sinusitis recognize facial pain and pressure as a symptom.^2–5 Additionally, some have advocated that anatomic abnormalities might lead to headache even in the absence of infection or inflammation.⁶ Surgical intervention in the absence of inflammation remains controversial.

Current research and expert opinion allow us to differentiate most “sinus headaches” into one of the five major categories: (1) acute sinusitis, (2) chronic sinusitis, (3) primary headache disorders including migraines and cluster headaches, (4) trigeminal neuralgia, or (5) anatomic contact point headaches (which are controversial).

Historical Perspective

In the 1940s, Wolff demonstrated that mechanical and chemical stimulation within the nasal cavity led to resultant cephalgia in several healthy volunteers.⁷ Despite this knowledge, little research had been undertaken to further describe the relationship between headache and sinonasal abnormalities. With the advent of nasal endoscopes and computed tomography (CT), the ability to evaluate anatomy and pathology within the sinonasal tract has dramatically advanced. Before these modalities, clinicians reasonably presumed sinonasal pathology as the impetus for headaches. However, studies using endoscopy and sinus CT scans revealed a more complicated relationship between headaches and sinonasal pathology.

The IHS released their consensus classification of headaches in 2004. This classification system describes headache syndromes and diagnostic criteria. Headaches with sinus symptoms are restricted to acute rhinosinusitis, migraines with cranial autonomic symptoms, and cluster headaches. Headaches caused by anatomic aberrancies and chronic rhinosinusitis are not an accepted cause of primary headaches by the IHS.

“Sinus Headache”: A Misnomer

“Sinus headache” is a common ailment among the general public; however, sinusitis is likely a rare cause of recurrent headaches. Physicians frequently treating sinonasal complaints have recognized that a significant portion of “sinus” headache sufferers have symptoms more consistent with a diagnosis of headache disorder and lack endoscopic and radiographic evidence of sinusitis. As evidenced by the Sinus, Allergy, & Migraine Study by Eross et al, only 3% of patients who believe they suffer from “sinus headache” actually suffer headache secondary to rhinosinusitis. This diagnosis was made based on the IHS criteria following a detailed headache history and complete general and neurological examination by a neurologist. In select cases with high suspicion, investigators utilized brain and sinus imaging.⁸

Several independent studies have found that 58 to 80% of patients who were diagnosed with “sinus headache” meet criteria for migraine.^8–10 Reasons cited for this confusion included pain located over the sinuses, triggered by weather changes, or associated with rhinorrhea. Eross et al in their study had suggested the diagnosis of sinusitis in 78% of these patients.⁸ Schreiber et al studied nearly 3000 patients and found a similar over diagnosis of sinus headache which they also attributed to overlapping symptoms. They concluded that there is a lack of recognition that sinonasal symptoms are typical of migraine.¹⁰ With nearly 30 million Americans who suffer from migraines,¹¹ otolaryngologists should be familiar with the differential diagnosis of headaches in evaluating sinus pain.

Differential Diagnosis of “Sinus Headaches”

Acute Rhinosinusitis

In a patient with new onset headache associated with nasal symptoms, clinicians should consider a sinus infection. The symptoms are particularly suggestive if the patient reports a combination of bilateral, dull, pressure-like, and periorbital facial pain.¹² According to the American Academy of Otolaryngology-Head and Neck Surgery, a diagnosis of acute bacterial rhinosinusitis (ABRS) first requires it to be distinguished from viral rhinosinusitis. Recommendations for making this distinction include that ABRS be diagnosed when (1) symptoms or signs of acute rhinosinusitis are present 10 days or more beyond the onset of upper respiratory tract infection symptoms, or (2) symptoms or signs of acute rhinosinusitis worsen within 10 days after an initial improvement (double worsening). There is no indication for the use of sinus imaging in an uncomplicated ABRS.5 These represent updated recommendations from a previous system utilizing major and minor criteria for diagnosis based on symptoms. For this constellation of symptoms to be defined as acute rhinosinusitis, symptoms must be present for less than 4 weeks. In the patient suffering from headache and who also meets diagnostic criteria for acute rhinosinusitis, the two must be temporally related to attribute the headache symptom to an underlying inflammatory/infectious pathology. The IHS specified this relationship in their consensus statement with a headache caused by rhinosinusitis as the following: (1) frontal headache accompanied by pain in one or more regions of the face, ears, or teeth and fulfilling criteria (3) and (4); (2) clinical, nasal endoscopic, CT scan and/or magnetic resonance imaging (MRI), and/or laboratory evidence of acute or acute-on-chronic rhinosinusitis; (3) headache and facial pain develop simultaneously with onset or acute exacerbation of rhinosinusitis; (4) headache and/or facial pain resolves within 7 days after remission or successful treatment of acute or acute-on-chronic rhinosinusitis.¹ These criteria are summarized in Table 11.1.

Treatment of headache in the patient suffering from acute rhinosinusitis, should be directed at underlying cause. Antibiotics are the mainstay of treatment for ABRS. Symptomatic treatment with decongestants, and topical or oral corticosteroids,² along with nonsteroidal anti-inflammatory agents are additional recommended options.

Chronic Rhinosinusitis

The IHS maintains that chronic sinusitis is “not validated as a cause of headache or facial pain unless relapsing into an acute stage.” The exception to this instance is an acute exacerbation of chronic rhinosinusitis (CRS). This may be characterized by increased nasal mucus or purulence of nasal mucus, worsening congestion and hyposmia, and even systemic symptoms of malaise, fatigue, and occasionally fever. These exacerbations might require systemic corticosteroid therapy in addition to antibiotic therapy (ideally, culture-directed antibiotic therapy).¹³

However, recent otolaryngology, asthma, and allergy consensus guidelines for the diagnosis of chronic rhinosinusitis frequently include facial pain or pressure along with hyposmia, duration greater than 8 to 12 weeks, and objective findings on CT scan or endoscopy.^2–5 The importance of facial pain as a key sign of chronic rhinosinusitis has been called into question. One study examined 75 patients who had persistent facial pain following endoscopic sinus surgery, of these, only half had CT or endoscopic findings consistent with sinus disease at presentation.¹⁴ Another study demonstrated poor correlation between facial pain localization and the affected paranasal sinus by CT scan. Mudgil et al showed no significant difference in the number of points of facial pain regardless of CT findings and that the most frequently cited location of pain was the right temporal area while the most affected sinus was the maxillary sinus.¹⁵

Table 11.1 Diagnosing Headache Secondary to Acute Rhinosinusitis

While facial pain does not seem to be sensitive or specific in CRS, some patients with CRS do report facial pain. For example, authors reviewing chronic sphenoiditis reported headache lasting 4 to 30 months.16 Chronic rhinosinusitis guidelines continue to include the presence of facial pain or pressure in the diagnostic criteria for chronic rhinosinusitis but emphasize the necessity to correlate with objective findings.

Primary Headache Disorders

The IHS system identifies two primary headache disorders where sinonasal symptoms are included in the diagnostic criteria: migraine and cluster headaches. Criteria for tension headaches do not include sinus symptoms (Table 11.2).

Migraine

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