by Dr. Christopher Chang, last modified on
Perhaps one of the most common reason for a patient visit to an ENT office is for a chronic "sinus headache." Symptoms include:
- Chronic pain/pressure over the cheeks or behind/around the eyes
- Nasal congestion
- No fever, no purulent drainage
- Light and/or Noise Sensitivity
- Movement makes pain worse
- Nausea and/or vomiting
- Usually lasts ~4-72 hours with or without antibiotics
- Occurs regularly, often as many as several times a month
These headaches have often been treated with antibiotics without long-lasting relief and allergy medications have provided minimal if any relief.
The assumption that many primary care physicians and patients have in this situation is that there must be a terrible sinus issue going on. It certainly would make sense since the pain/pressure is right over where the sinus cavities are located. The reality may be more surprising, but ~80% of such patients are actually suffering from a phenomenon called "trigeminal migraines." Migraines masquerading as sinus headaches was a featured article in the New York Times on May 24, 2018.
Unfortunately, even with correct diagnosis, many patients express skepticism that their sinus headaches are due to anything but some type of underlying sinus condition. Due to this combination of incorrect diagnosis and patient skepticism even with a correct diagnosis, it usually takes about 7 years before proper treatment is provided!
Of course an ENT physician will perform a thorough workup to ensure no sinus pathology is present whether due to chronic sinusitis, nasal polyps, sinus tumors, anatomic contact points, allergies, etc... but if everything comes back essentially normal or is throughly treated without headache resolution, trigeminal migraines must be taken into consideration, especially when over 80% of patients presenting to an ENT clinic with sinus headaches ultimately are found to have this condition (see references below).
According to the International Headache Society, the criteria for migraine is an episodic recurrent headache lasting 4-72 hours with:
Any TWO of these pain qualities:
Any ONE of these associated symptoms:
Keep in mind that migraines could be BILATERAL, as long as two other pain criterias are met.
Trigeminal migraines are distinguished from other migraine headaches mainly due to the primary location which is in the distribution of the V1 (purple) and V2 (red) trigeminal nerve which innervates the forehead, cheeks, around the eyes, and ears.
Because the trigeminal nerve also supplies innervation to the mucus glands of the sino-nasal lining, symptoms of congestion, post-nasal drainage, runny nose, etc may also be present with these migraine headaches. Ear symptoms may include tinnitus, clogging, ear skin sensitivity, etc.
Once trigeminal migraine has been diagnosed, there are ways this can be treated successfully. Antibiotics are NOT one of those ways and the common history of patients who report improvement with antibiotics would have improved even if they did NOT take antibiotics (migraines typically resolve after several days... typically around the time a patient would have received and taken antibiotics and mistakenly attributed improvement to the medication).
The first step is to reduce and eventually eliminate drugs that can exacerbate migraines, even if they may temporarily help with pain in the short-term. Such medications exacerbate migraines in the long-run and make it more difficult to control. Such medications commonly used that should be tapered and eventually stopped include:
- fioricet / fiorinal
- ibuprofen (if taken more than 5 times per week)
- etc, etc
Given above medications are avoided, over-the-counter (OTC) medications that have been found thru good research to help prevent or reduce the frequency and severity of trigeminal migraines include:
- Petasites (Butterbur): Dose is 75mg 2x per day for no more then 16 weeks unless liver monitoring performed
- Magnesium Oxide: Dose is 400-500mg once per day
- Riboflavin: Dose is 100mg 2x per day
- CoEnzyme Q-10: Dose is 100mg 2x per day
Keep in mind that you have to take these OTC medications daily for 2 months before benefit is fully realized. Prescription medications found to be helpful to prevent migraines include:
- Nortriptyline / Amitriptyline
- etc, etc
Only the first four meds are something an ENT would be willing to offer, but the others on the list are prescriptions you would need to see a neurologist.
Prevention is great, but what can be done with an acute, happening right now migraine headache? In this situation, ibuprofen may work well (but avoid taking more than 5 times in one week) as well as prescription medications like sumatriptan. However, the catch is that in order for it to work well, the medication should be taken as soon as the headache starts.
Should such treatment fail, a neurology consultation may be required for further and more aggressive management who are the true migraine headache experts.
Beyond medical intervention, avoiding certain triggers may help to minimize trigeminal migraines. Triggers may include foods or other factors.
Foods to Avoid:
Non-Food Triggers to Avoid:
The Sinus, Allergy and Migraine Study (SAMS). Headache 2007 Feb; 47 (2) : 213-24.
Prevalence and diagnosis of migraine in patients consulting their physician with a complaint of headache: data from the Landmark Study. Headache. 2004 Oct;44(9):856-64. doi: 10.1111/j.1526-4610.2004.04167.x. PMID: 15447694.
Prevalence of migraine in patients with a history of self-reported or physician-diagnosed "sinus" headache. Archives of Internal Medicine 2004 Sep 13; 164 (16) : 1769-72.
Sinus headache: a clinical conundrum. Otolaryngol Clin North Am. 2004 Apr;37(2):267-88.
Etiology of 'Sinus Headache'-Moving the Focus from Rhinology to Neurology. A Systematic Review. Brain Sci. 2021 Jan 9;11(1):79. doi: 10.3390/brainsci11010079.
Evidence-based guideline update: pharmacologic treatment for episodic migraine prevention in adults: report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society. Neurology. 2012 Apr 24;78(17):1337-45. doi: 10.1212/WNL.0b013e3182535d20.
Evidence-based guideline update: NSAIDs and other complementary treatments for episodic migraine prevention in adults: report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society. Neurology. 2012 Apr 24;78(17):1346-53. doi: 10.1212/WNL.0b013e3182535d0c.
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