What Is a Sinogenic Headache?

A sinogenic headache is a secondary headache caused by sinus disease, most often sinus inflammation or infection (rhinosinusitis). This type of headache is distinct from primary headache disorders like migraines, yet it’s frequently confused with them in clinical practice and in patient descriptions.

In medical classification, headaches caused by sinus pathology are recognized under the International Classification of Headache Disorders (ICHD-3) as “headache attributed to rhinosinusitis,” which requires evidence that sinus disease is actually causing the pain. But in real-world practice, the lines between sinus disease and migraine overlap so often that misdiagnosis is a major issue.

The Anatomy Behind Sinogenic Headaches

Sinuses are air-filled cavities located behind the forehead (frontal sinuses), cheeks (maxillary sinuses), between the eyes (ethmoid sinuses), and behind the eyes (sphenoid sinuses). These cavities are lined with mucous membranes that help trap and drain pathogens and debris.

When sinus drainage becomes blocked, or the sinus lining becomes inflamed or infected (a condition called rhinosinusitis), pressure can build up and activate pain-sensitive structures in the sinus walls, leading to a sinogenic headache.

Key mechanisms include:

Obstruction of sinus drainage
Inflammation of mucosa
Pressure buildup in sinus cavities
Stimulation of trigeminal nerve pain fibers

This is why true sinogenic headaches often involve facial pressure, sinus pain, and sometimes dental or forehead discomfort.

Clinical Definition vs. Common Usage

In medical research and classification:

A headache is sinogenic only if there is objective evidence of sinus disease (clinical findings, imaging, or diagnostic endoscopy).
The International Classification of Headache Disorders (ICHD-3) provides criteria for “headache attributed to rhinosinusitis,” which includes evidence that pain is directly linked to sinus pathology and that it resolves when the sinus disease is treated.

But in everyday language and even some clinical settings, people often call any headache with facial pressure or sinus-like symptoms a “sinus headache,” regardless of whether the sinuses are truly diseased. This is where misclassification happens.

Research on Misdiagnosis: Sinogenic vs. Migraine

Multiple primary studies show that true sinogenic headaches are much less common than migraine headaches that feel like sinus headaches. In patients who believe they have frequent sinus-related headaches, the majority actually meet diagnostic criteria for migraine or another primary headache disorder:

Key Research Findings

A major clinical study involving nearly 3,000 patients with self-described or physician-diagnosed “sinus headache” found that 88% actually met criteria for migraine or migrainous headache, according to International Headache Society standards. Only a very small minority had headaches attributable to rhinosinusitis.
The Sinus, Allergy and Migraine Study (SAMS) evaluated 100 patients with self-diagnosed sinus headaches and found that most were diagnosed with migraine with or without aura or other primary headache disorders. Only 3% had headaches truly secondary to rhinosinusitis.
Another study found that over 80% of patients with migraine were initially misdiagnosed as having sinusitis, which delayed proper diagnosis by an average of years or decades.
A systematic review evaluating the etiology of “sinus headache” concluded that primary headaches (especially migraine) are the most prevalent causes of what patients report as sinus headaches, and that sinus-attributed cases are overdiagnosed.

In other words: A patient feeling pressure in the forehead or face and attributing it to a sinus headache may actually be experiencing a migraine with sinus-like symptoms rather than a headache caused by sinus inflammation.

Symptoms: Sinogenic Headache vs. Migraine

Understanding the symptom patterns can help differentiate sinogenic headache from migraine.

Typical Features of Sinogenic Headache

Facial pain and pressure, especially over the cheeks and forehead
Worsening with head movement or bending forward
Nasal obstruction, possibly with purulent (thick, discolored) discharge
Reduced smell
Pain that persists as long as sinus inflammation is present

These symptoms occur because the sinus cavities are inflamed or blocked, increasing pressure and activating nearby sensory nerves.

Typical Features of Migraine (That Can Mimic Sinogenic Symptoms)

Migraines are a neurological condition, but they can produce symptoms that feel like sinus pressure:

Facial or forehead pressure and pain
Nasal congestion or watery discharge
Sensitivity to light (photophobia) and sound (phonophobia)
Nausea or vomiting
Pain that is pulsating or throbbing and worsens with activity

These cranial autonomic symptoms (like nasal congestion and tearing) are not required for migraine diagnosis, but they occur in many migraine patients and can be mistaken for sinus disease.

How Sinogenic Headaches Are Diagnosed

Diagnosis involves distinguishing sinus disease from other causes of facial pain:

Clinical Evaluation

A clinician will:

Take a detailed history, including onset, duration, triggers, and associated symptoms
Perform an exam of the nasal passages
Assess for fever, discharge quality, and smell changes

Imaging

Often, CT scans or sinus imaging are used to confirm sinus pathology if a sinogenic cause is suspected.

Diagnostic Criteria

Diagnosis of headache attributed to rhinosinusitis (sinogenic) requires:

Evidence of sinus inflammation (clinically or on imaging)
Correlation between sinus disease and headache pattern
Headache resolves when sinus disease is treated

These criteria help differentiate true sinogenic headache from migraine with sinus-like symptoms.

Why Accurate Diagnosis Matters

Getting the diagnosis right isn’t just semantics—it radically changes treatment and outcomes.

Sinogenic Headache Treatment

If the headache is truly sinogenic (caused by sinus disease), treatment focuses on:

Antibiotics, if a bacterial infection is present
Nasal corticosteroids or decongestants to reduce inflammation
Saline irrigation
Surgical intervention in chronic or complicated cases

Migraine Treatment

If the headache is migraine (even if it feels sinus-related), treatment strategies are very different:

Preventive medications (propranolol, topiramate, etc.)
Acute migraine therapies (triptans, NSAIDs targeted for migraine)
Lifestyle and trigger management

Studies show that patients misdiagnosed with sinus headache often experience better outcomes when treated for migraine, because the underlying mechanism is neurological rather than purely sinus pathology.

Sinogenic Headache in Special Populations

Some research has looked at how sinogenic headache presents differently in specific groups:

In children, headache attributed to rhinosinusitis is less common than migraine or tension-type headache, and symptoms can overlap. Using structured clinical predictors improves accuracy.
Headache associated with acute sinonasal inflammation (such as in viral infections like COVID-19) shows that sinus symptoms can occur without true sinus headache per se, suggesting the need to refine diagnostic criteria.

Practical Tips: Sinogenic vs. Migraine

Here’s a concise comparison to help distinguish the two in practice:

Suggestive of True Sinogenic Headache:

Thick, discolored nasal discharge
Reduced sense of smell
Pain closely tied to sinus infection episodes
Imaging evidence of sinus blockage

Suggestive of Migraine:

Sensitivity to light and sound
Nausea or vomiting
Pain that’s pulsatile or worsened by movement
Nasal symptoms that occur concurrently but without sinus infection signs

Diagnostic Questions Clinicians Use

Sinogenic Headache vs. Migraine

These aren’t casual questions — they’re the kinds of things neurologists and ENTs use to decide what category the headache actually belongs to.

1. Evidence of Sinus Disease

Without this, a headache is not considered sinogenic.

Do you currently have objective signs of sinus inflammation (seen on nasal exam, endoscopy, or CT)?
Have you had thick, purulent (yellow/green) nasal discharge?
Is there documented rhinosinusitis diagnosed by a clinician?
Did imaging show mucosal thickening, air–fluid levels, or sinus obstruction?

2. Timing & Causality

Clinicians look for cause-and-effect, not just overlap.

Did the headache start at the same time as sinus infection symptoms?
Does the headache worsen when sinus inflammation worsens?
Does the headache resolve when the sinus disease resolves?

3. Pain Description

Doctors pay close attention to how pain is described.

Questions they ask (or infer):

Is the pain constant and pressure-like, or throbbing/pulsatile?
Is it dull and steady, or wave-like and escalating?
Does it feel more like weight/pressure than a pulse?

Sinogenic pain is usually steady and pressure-dominant. Migraine pain is often pulsating, even when it feels like pressure

4. Associated Neurological Symptoms

These symptoms strongly favor migraine, even if sinus pressure is present.

Do you experience light sensitivity (photophobia)?
Do sounds feel painful or overwhelming?
Is there nausea or vomiting?
Does physical activity worsen the pain?

These are not features of sinogenic headache. They are core migraine features

5. Autonomic “Sinus-Like” Symptoms

Migraines can cause sinus-type symptoms.

Clinicians ask:

Do you get nasal congestion without infection?
Watery nasal discharge rather than thick mucus?
Tearing or eye redness during headache attacks?

These are cranial autonomic symptoms of migraine, not sinus disease.

6. Response to Treatment

Doctors look at what actually helps.

Do antibiotics consistently resolve the headache?
Do nasal steroids alone stop the pain?
Or… do migraine medications (triptans, NSAIDs) work better?

Sinogenic headache tends to improve with sinus treatment. Migraine may improve with neurological headache treatment

7. Headache Pattern Over Time

Clinicians zoom out and ask about history.

Are headaches episodic and recurring, even without sinus infections?
Do they follow hormonal, stress, sleep, or weather triggers?
Have “sinus headaches” recurred for years without sinus infection signs?

Recurrent “sinus headaches” without infection almost always = migraine.

Why This Matters (Clinically)

NIH-indexed studies consistently show that:

80-90% of self-diagnosed sinus headaches are migraines
Misdiagnosis delays proper migraine treatment by years
Many patients undergo unnecessary antibiotics or sinus procedures