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Migraine, "Sinus" headaches and "Sinusitis" - Facts we need to know


                     "A correct diagnosis is three-fourths the remedy." - M.K. Gandhi 

Several studies and reports indicate that migraine is often misdiagnosed by ourselves or our physicians as sinus headache or sinusitis. In a recent study designed to estimate the frequency of misdiagnosis of sinusitis among migraine patients (Al-Hashel et al., 2013) results showed: 

  • of 130 migraine patients who met the ICHD-III-beta criteria (International Classification of Headache Disorders, 3rd edition), 106 patients were misdiagnosed as sinusitis.
  • the delay in diagnosis ranged from 1-38 years.
  • chronic migraine was significantly higher in misdiagnosed patients compared to patients with the correct diagnosis.
  • medication overuse headache (MOH) was reported only in patients misdiagnosed as sinusitis.
  • a delay in the diagnosis of migraine led to chronification of the headache and transformation, in some cases, into MOH. 

The authors propose that the delay in diagnosis could be attributed to the presence of sinus pain, sinus congestion, and nasal discharge during headache attacks. They go on to say that these autonomic symptoms have been reported in previous studies which concluded the "presence of autonomic symptoms during migraine attacks often leads to confusion and incorrect diagnosis of sinusitis." They add, "appropriate recognition of migraine in patients who complain about sinus headaches may help to minimize the suffering and unnecessary interventions, start migraine directed therapy, and improve quality of life".

Therefore, to increase our knowledge about "sinus" headache, "sinusitis" and migraine, and help us receive appropriate diagnosis and treatment, this article addresses:

  • what is "sinus" headache?
  • what is "sinusitis"?
  • how to differentiate "sinusitis" from migraine.
  • can "sinusitis " trigger a migraine? 

What is "sinus" headache? 

Sinus headache is commonly thought of as pain and pressure in the forehead, behind the eyes, or in the face, but may be referred posteriorly. The areas are tender to touch and the headache is often accompanied by: 

  • nasal and sinus congestion,
  • clear nasal discharge, and 
  • watery eyes.

We should know that the ICHD-III-beta criteria states that "the term 'sinus headache' is outmoded because it has been applied both to primary headaches (migraine and tension-type) and headaches supposedly attributed to various conditions involving nasal or sinus structures."  The previously used term "sinus headache' has been replaced with "Headache attributed to disorder of the nose or paranasal sinuses" and is associated with other symptoms and/or clinical signs of the disorder. 

What is "sinusitis"? 

True sinus headache is more properly called "sinusitis" or rhinosinusitis (Cady, 2008, and Hutchinson, 2011). It is often associated with viral or bacterial infection and may be characterized by:

  • purulent (thick yellow or green) nasal discharge,
  • decreased smell and taste,
  • bad breath,
  • fever,
  • cough, (may be productive of mucous and worse at night),
  • general feeling of illness (malaise), 
  • pain and pressure in our upper teeth, forehead, behind our eyes and in our face, and
  • pain may worsen when we lean forward or bend our heads.

The pain should improve with remission of a viral infection (within 7days) or, if our infection is bacterial, successful treatment with antibiotics. With persistent or recurrent infection, we may have to undergo a CT scan or nasal endoscopy to rule out signs of obstruction, polyps or other signs of sinus disease.

We should know the ICHD-III-beta criteria says, "simply finding pathological changes on imaging of acute rhinosinusitis, correlating with the patient's pain description, is not enough to secure the diagnosis of acute rhinosinusitis. Evidence of causation should be demonstrated by at least two of the following: 

  1. headache has developed in temporal relation to the onset of the rhinosiusitis
  2. either or both of the following: headache has significantly worsened in parallel with worsening of the rhinosinusitis; headache has significantly improved or resolved in parallel with improvement in or resolution of the rhinosinusitis
  3. headache is exacerbated by pressure applied over the paranasal sinuses
  4. in the case of unilateral rhinosinusitis, headache is localized ipsilateral to it."

How to differentiate sinusitis from migraine:

According to the ICHD-III-beta criteria, the presence or absence of purulent discharge and other features of acute rhinosinusitis help differentiate these conditions. Or, in the words of Dr. Susan Hutchinson (2011),  "in the absence of fever, pus from your nose, alteration in smell or foul smelling breath, you likely have a migraine headache".

Dr. Hutchinson suggests an additional way to determine whether our headaches are migraine is to ask ourselves the following questions taken from Dr. Richard Lipton of Einstein College of Medicine ID Migraine Questionnaire:

  •  In the last 3 months, how disabling are your headaches; do they interfere with your ability to function? (Are you missing work; school; family activities?)
  • Are your headaches ever associated with nausea? 
  • Are your headaches ever associated with sensitivity to light?

If we meet two of the three above criteria, migraine is likely present 93% of the time. When all three are present, migraine is likely 98% of the time.

Dr. Hutchinson adds, "your diagnosis needs health practitioner confirmation for accuracy and best treatment. She goes on to say "getting the right diagnosis and treatment can free you from the recurring burden of failed headache treatment and disability".

Can sinusitis trigger a migraine? 

According to ICHD-III-beta criteria, an episode of migraine may be triggered or exacerbated by nasal or sinus pathology. Dr. R. Cady, (2008), explains this as, "People with migraine inherit a nervous system that is more sensitive to change than those without migraine. If the nervous system perceives a threat from either the external or internal environment, the nervous system response can be an attack of migraine."

Every addition to true knowledge is an addition to human power."- Horace Mann   

In my situation, I was misdiagnosed with sinus headache for a number of years. Like many patients, I went through a number of failed treatments, including over the counter and prescription decongestants, antihistamines, nasal sprays, analgesics, and anti-inflammatory medications, before I went to a migraine clinic and was told my symptoms were part of my migraine.

However, along with migraine disease, I can still have an episode of acute rhinosinusitis. To help prevent the rhinosinusitis from triggering or exacerbating a migraine attack, I monitor other internal and external trigger factors that might increase the probability of an attack and, where possible, initiate protective factors (Lipton et al., 2014 and Pavlovic et al., 2014). These include:

  • Stay hydrated as mouth breathing and fever can lead to dehydration. Drinking plenty of fluids also helps keep mucous thin.
  • Eat regular meals or, if my appetite is poor, 6 small meals a day to avoid hunger.
  • Avoid dairy products as increase mucous.
  • Maintain a regular sleep routine to avoid altered sleep patterns. This is sometimes difficult because night time cough, snoring, and sinus pressure, along with a dry mouth may inhibit sleep. A humidifier is helpful to increase moisture in my room. A glass of water by my bedside helps with dry mouth.  
  • Consult with my doctor if I need medication to relieve my symptoms.
  • Monitor my stress levels and use techniques like meditation and biofeedback to help me relax (quiet my mind and calm my body).

In summary: 

  • migraine is commonly misdiagnosed as sinus headache.
  • sinus headaches are more properly called rhinosinusitis .
  • rhinosinusitis is associated with purulent nasal discharge.
  • migraine may be associated with watery eyes and runny nose, but the fluid is clear.
  • patients with rhinosinusitis may also have migraine.
  • rhinosinusitis may trigger or exacerbate a migraine attack.
  • see your doctor for a full diagnosis for your headaches as treatment of rhinosinusitis differs significantly from treatment for migraine (Cady, R., 2008, and Hutchinson, S., 2011).



Al-Hashel, J., Y., Ahmed, S., F., Alroughani, R., & Goadsby, P., J. (2013). "Migraine misdiagnosis as a sinusitis, a delay that can last for many years." The Journal of Headache and Pain. 14:97. doi: 10.1186/1129-2377-14-97.

Cady, R., K., MD. (2008). "Sinus Headaches, Allergies, Asthma and Migraine: More Than a Causal Relationship?" Headache, The Newsletter of ACHE. Summer 2001, Volume 12, Issue 2. Updated November, 2008. 

Eross, E., Dodick, D., & Eross, M. (2007). "The Sinus, Allergy and Migraine Study (SAMS)." Headache. Feb;47(2):213-24.  

Hutchinson, S., MD. (2011). "'Sinus Headache'"or Migraine". Headache, The Newsletter of ACHE.   

International Classification Committee of the International Headache Society (IHS). "The International Classification of Headache Disorders, 3rd edition (beta version)". Cephalalgia.  33(9) 764-765 (629-808).

Lipton, R., B., Pavlovic, J., M., Haut, S., R., Grosberg, B., M., & Buse, D., C. (2014). "Methodological Issues In Studying Trigger Factors and Premonitory Features of Migraine." Headache. Nov;54(10):1661-9. doi:10.1111/head.12464. Epub 2014 Oct 23.

Pavlovic, J., M., Buse, D., C., Sollars, M.,Haut, S., & Lipton, R., B. (2014). "Trigger Factors and Premonitory Features of Migraine Attacks: Summary of Studies." Headache. Nov;54(10):1670-9. doi:10.1111/head.12468.

Schreiber, C., P., Hutchinson, S., Webster, C., J., Ames, M., Richardson, M.,S., Powers, C. (2004). "Prevalence of migraine in patients with a history of self-reported or physicain-diagnosed "sinus" headache." Arch Inter Med. Sep 13;164(16):1769-72.

Sharron is a health and wellness author. A migraineur herself, her most recent book, "Migraine: Identify Your Triggers, Break Your Dependence On Medication, Take Back Your Life-An Integrative Self-Care Plan For Wellness", (2013), is a Conari Press Publication.

Follow Sharron on twitter @murraysharron, her Facebook page: Sharron Murray MS, RN and her website 

This article is not intended as a substitute for medical advice. If you have any specific concerns about your health or nutrition, please consult a qualified health professional. 



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