As advanced imaging became available and the technology progressed to provide more and more highly detailed images of the nervous system, it was often joked that the role of the neurologist would become diminished and relegated to providing a differential diagnosis for the negative scan. Obviously, this dire prediction for neurology never came to fruition. In rhinogenic headache, the tables have clearly been turned, and the challenge for the otolaryngologist has become that of providing a differential diagnosis for a positive scan.

Our patients’ perceptions can often lead the diagnostic evaluation. As Dr Mehle wisely points out, the term sinus headache should really be reserved to describe a symptom and not a pain mechanism. For a patient, any head pain that occurs in the frontal or maxillary regions might have the convincing feel of sinus discomfort and therefore may be interpreted as originating from the underlying sinuses. This issue was brilliantly illustrated to me when we recruited a small study of patients with both sinus headache and diagnosed migraine. A well-educated woman presented for the study who had been diagnosed with migraine by her medical care provider and who had an effective treatment plan for her migraines. She also had self-diagnosed sinus headaches, which were not responding to her over-the-counter sinus medication treatment regimen. For our study, we needed to be sure that the patients were able to differentiate their headache types at the onset of the headache attack. This patient reported that it was easy for her to determine which type of headache was occurring. Her main differentiating feature was that before her sinus headache she had sparkling lights in her peripheral vision. Despite what is obvious to the clinician, that she was having a migraine aura, she knew that the headache that followed the sparkling lights was a sinus headache, because it centered in the frontal area and she had mild nasal congestion. She never even thought of treating her sinus headache with her migraine-specific medication and continued to do poorly with her management of these headaches. The headaches that she identified as migraine did not have a visual aura and responded nicely to her prescribed migraine medication.

Another significant issue that we all face when evaluating patients with headaches is the reliance on imaging by the medical community and the expectation of patients that imaging is required for accurate diagnosis. In a busy primary care office, an order for an imaging procedure may be more quickly offered than a thorough history and physical examination. An abnormal scan report may prompt a referral to a specialist rather than a recheck with the primary care provider. It is also true that patients often not only expect, but often demand, imaging procedures for their complaints. When something is found on the imaging study, they expect a specialist to provide consultation and definitive treatment. As Dr Mehle’s review has pointed out, abnormal findings on scans do not always implicate a pathophysiologic mechanism. Similar issues are commonly seen as a result of the prevalence of radiographic evidence for spinal disease in patients without back pain and Arnold-Chiari malformation in patients without headache.

Our professional societies are trying to provide us with a better framework for understanding these patients and to give us better guidance in their management. This guidance is clearly a work in progress. As Dr Mehle has pointed out, the headache bible, the International Classification of Headache Disorders by the International Headache Society (IHS), is a work in progress. This work is progressing, but at an agonizingly slow pace. The third and most recent revision (2013) took 9 years for the expert panel to finalize after the second revision appeared in 2004. Although these criteria are the current gold standard for headache diagnosis, they are clearly a work in progress and will evolve as our understanding of the headache patient progresses. The acceptance of structural disease as the cause has long been contentious in the headache field, and its incorporation in the appendix (“Headaches attributed to disorders of the nasal mucosa, turbinates or septum”) rather than in the main classification system indicates that this is still a work in progress and has not been completely adopted. Although the IHS criteria are a useful classification system and are widely accepted as a way to find a reasonably homogeneous group of patients for research studies, it has had poor penetration into the daily practice of primary care clinicians. As specialists on the receiving end of the headache patient referral, it is our responsibility to apply our knowledge of the patient, their history and physical examination, and our review of their imaging findings as we establish a diagnosis and recommend a treatment plan. Having a working knowledge of the current diagnostic criteria for the commonly seen headache types certainly aids in our diagnostic approach.

So where does this leave the otolaryngologist? Often, the otolaryngologist is in the position of considering the differential diagnosis of the positive scan. I recommend that if you have made it to this point of this article, you go back to the end of Dr Mehle’s article and reread the section on patient management. His is a well-considered and practical approach for evaluating patients with the symptom of sinus headaches. Maximal medical management should be required before consideration of surgical intervention. You need to consider the medical management that the patient has undertaken before considering surgery. Did they have adequate trial of at least 2 headache preventive medications? Did they modify factors that could potentially worsen headache (eg, eliminate caffeine and overuse of analgesics)? If appropriate, did they have an adequate trial of migraine-specific medications for the headache attacks? Not all neurologists have an interest in headache, and not all clinicians who provide excellent headache care are neurologists. You may need to make the referral forward to a headache specialist rather than sending the patient directly back to the originator of the referral. The otolaryngologist can play a pivotal role in improved patient care, even when a positive scan is really negative.