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Migraine vs. Sinus Headache: How to Tell the Difference

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If you’ve ever felt the deep throb behind your eyes or pressure in your cheeks and forehead, you’ve probably pondered whether it’s a sinus headache or a migraine episode. Making that distinction is important because treatment and management strategies vary significantly. Also, it could have a significant impact on your quality of life.

What Is Migraine?

Migraine is a neurological disease characterized by a predisposition to recurrent episodes of symptoms, typically including head pain but not limited to it.

A migraine attack or episode is the actual occurrence of symptoms ranging from mild to severe. A migraine attack is a complex event with multiple phases and a broad spectrum of symptoms.

It’s a common misconception that migraine is synonymous with a headache. In reality, a migraine attack can sometimes occur without any head pain, known as a “silent migraine.” Symptoms of a migraine attack can include visual disturbances, sensory changes (like numbness or tingling), speech or language difficulties, dizziness, vertigo, or mood changes, among others. These neurological symptoms reflect the complex brain processes involved in a migraine attack, extending far beyond just a headache.

Headaches, on the other hand, are just one component of a migraine attack, and they are not always present. When they do occur, they’re often described as throbbing or pulsating and are aggravated by physical activity. They are typically one-sided, although not exclusively, and often accompanied by nausea, vomiting, and sensitivity to light and sound.

What Is a Sinus Headache?

A sinus headache presents with pain and pressure in the forehead, cheeks, and around the eyes. It’s commonly assumed to be related to sinusitis, which is the inflammation of the sinuses typically caused by an infection or allergy. The pain from a sinus headache is primarily due to blocked sinuses leading to pressure buildup. This pain may worsen with movement or strain and is often accompanied by other symptoms such as nasal congestion, runny nose, fever, and facial swelling.

Sinus Headache or Sinus Migraine?

Many headaches that people think of as sinus headaches are actually migraine attacks. The confusion arises because some symptoms of a migraine attack, such as pressure in the forehead, nasal congestion, and watery eyes, can mimic those of sinusitis.

A key difference is that sinusitis symptoms are often associated with an infection (yellow or green nasal discharge, fever), while a migraine attack typically does not have these infection-related symptoms. Instead, migraine attacks might come with sensitivity to light and sound, nausea, or visual disturbances (aura).

Research indicates that 90% of self-diagnosed “sinus headaches” are often migraine attacks in disguise. This misclassification can lead to inadequate treatment, such as using decongestants or antibiotics that are ineffective for migraine attacks.

Studies show that sinus migraine involves activating the trigeminal and autonomic nervous systems. The trigeminal system plays a role in head pain, while the autonomic system governs the production of nasal mucus and sinus discomfort. During a migraine episode, a phenomenon known as cortical spreading depression, along with inflammation in the brain, triggers an overactivity in these brainstem nerves. This recurrent inflammation over successive episodes may gradually degrade the nervous system’s integrity, potentially causing central sensitization and increasing the risk of migraine becoming chronic.

Causes and Triggers of Sinus Headaches and Sinus Migraine

Sinus headaches primarily result from sinusitis, the inflammation of the sinuses. Here are some common causes:

  • Infections: Bacterial, viral, or fungal infections can irritate the sinus tissues, leading to blockages and pressure pain.
  • Allergies: Allergic reactions can trigger sinus congestion and inflammation, resulting in a headache.
  • Structural issues: Deviated septum or nasal polyps can obstruct the sinus passages, increasing the likelihood of infections and subsequent headaches.
  • Environmental irritants: Smoke, strong odors, or pollutants can aggravate the sinuses and cause headache pain.

Sinus Headache Causes

Triggers for sinus headaches often involve factors that promote inflammation or infection in the sinuses, such as:

  • Cold and flu: Respiratory infections can lead to sinusitis and a sinus headache.
  • Weather changes: Shifts in barometric pressure can affect the sinuses and trigger headaches.
  • Temperature fluctuations: Extreme cold or heat can exacerbate sinus pain.

Sinus Migraine Triggers

On the other hand, a sinus migraine — a migraine attack that presents with sinus symptoms — can have triggers that overlap with typical migraine triggers:

  • Food and beverages: Certain foods and drinks, like aged cheeses, red wine, and processed meats, can prompt a migraine attack.
  • Hormonal changes: Fluctuations, especially in estrogen, can trigger migraine attacks in some people.
  • Stress: High levels of stress are known to provoke migraine episodes.
  • Sensory stimuli: Bright lights, loud sounds, or strong smells — even those that can irritate the sinuses — might lead to a migraine attack.
  • Weather changes: Like sinus headaches, barometric pressure changes can trigger migraine attacks.

Treatment Options for Sinus Headaches

When dealing with a sinus headache, the primary goal is to reduce the inflammation and relieve the blockage in your sinuses. Here are common treatment approaches:

  • Decongestants: Medications like pseudoephedrine can help shrink the swollen nasal passages and improve sinus drainage.
  • Steam inhalation: Breathing in steam, perhaps with added menthol or eucalyptus oil, can soothe inflamed sinus tissues and help loosen congestion.
  • Nasal corticosteroids: Sprays such as fluticasone can reduce inflammation in the nasal passages.
  • Saline nasal irrigation: A saline spray can help clear mucus and allergens from the nasal passages.
  • Pain relievers: Over-the-counter pain medications can help alleviate the discomfort associated with sinus headaches.
  • Antibiotics: If a bacterial infection is confirmed, your doctor may prescribe antibiotics to clear it.

If allergies are a trigger, you might also consider:

  • Allergy medications: Antihistamines can reduce your reaction to allergens, potentially preventing sinus headaches.
  • Immunotherapy: Allergy shots or tablets may be recommended if allergies frequently trigger sinus headaches.

Treatment Options for Sinus Migraine

For a sinus migraine, which is essentially a migraine attack with sinus symptoms, the treatment will focus on mitigating the migraine itself:

  • Migraine-specific medications like triptans and gepants
  • NSAIDs or acetaminophen
  • Anti-nausea medication
  • Preventive medications like beta-blockers, antidepressants, anticonvulsants, or CGRP antagonists
  • Lifestyle modifications
  • Dietary adjustments
  • Neuromodulation devices

Diagnosing Migraine and Sinus Headache

It is possible, though less common, for sinusitis to contribute to headache pain, which symptoms of infection or imaging tests can confirm.

Sinus Headache Diagnosis

When you present with symptoms that suggest a sinus headache, your health care provider will typically:

  • Conduct a thorough physical examination focusing on the sinuses.
  • Check for nose, forehead, and cheek tenderness, which might be painful to touch if you have sinusitis.
  • Look for signs of infection, such as fever, nasal discharge, or swollen nasal passages.
  • Possibly recommend imaging tests like a CT scan or MRI to look for signs of sinus inflammation or other abnormalities.

Sinus Migraine Diagnosis

A sinus migraine attack, on the other hand, may not show any physical signs of sinusitis. Diagnosis often involves:

  • A detailed medical history to understand your symptoms and their patterns.
  • A neurological examination to rule out other diagnoses.
  • Keeping a headache diary to document the occurrence and details of your migraine attacks.
  • Using the ICHD-3 (International Classification of Headache Disorders) criteria to distinguish between migraine and other types of headaches. According to these criteria, a sinus headache is often misdiagnosed and is a migraine attack if it lacks purulent nasal discharge and fever.

Your doctor will evaluate the frequency, duration, and characteristics of your headaches and any associated symptoms like nausea, sensitivity to light, or aura. If your headaches present with migraine-specific symptoms rather than signs of sinus infection, they may be classified as sinus migraine.

Since the treatment for sinus headaches and sinus migraine attacks targets different underlying mechanisms, it’s crucial to have a precise diagnosis. Overusing treatments meant for sinus headaches when you’re experiencing a migraine attack can lead to medication overuse headaches and other complications.

Getty image by George Peters

Originally published: November 13, 2023
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