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Consultant: Volume 56 - Issue 8 - August 2016

SINUS HEADACHE AND MIGRAINE: OVERLAPPING SYMPTOMS OFTEN RESULT IN CASES OF MISTAKEN IDENTITY

August 4, 2016

 

Sheldon P. Hersh, MD, and Joshua N. Hersh, MD Citation: Consultant. 2016;56(8):683-687.

 Despite overwhelming evidence to the contrary, many patients and health care providers continue to believe that facial pain and headache are a direct consequence of underlying sinus infection. This persistent notion brings to mind Mark Twain’s reported quip that “It’s not what we don’t know that hurts us. It’s what we know for sure that just ain’t so.”

The oft used term sinus headache is particularly misleading, given that the majority of these headaches have little at all to do with rhinosinusitis, the preferred designation that accentuates the nasal symptoms common to infection or inflammation of the paranasal sinuses. Reports of up to 90% of self- or provider-diagnosed sinus headaches have been found to be unrelated to any sinus involvement and often satisfy criteria established by the International Headache Society (IHS) in diagnosing migraine.1-3

Although recently deemed “outmoded” by the IHS,4 sinus headache remains firmly fixed in the American psyche, particularly during cold, flu, and allergy season. Davidoff5 suggests that the diagnosis of sinus headache continues “partly as a result of advertising media that oversell so called ‘sinus’ medication.” This incessant advertising campaign clearly reinforces the mistaken view that headaches associated with nasal symptoms are, most assuredly, a direct result of underlying sinus disease. Many of these sinus preparations contain analgesics and decongestants, ingredients that may lessen headache and related nasal symptoms, prompting patients and health care providers alike to focus on rhinosinusitis rather than the far more prevalent migraine. Familiarity with the clinical features that distinguish rhinosinusitis from migraine and recognition of the symptoms shared by both should help lessen the likelihood of misdiagnosis, inappropriate testing, and delayed treatment.

Sinus Headache or Migraine?

Headaches are among the 20 most prevalent conditions encountered in outpatient settings, as well as the fifth leading cause of emergency department visits in the United States, based on data from the National Ambulatory Care Survey and National Hospital Ambulatory Medical Care Survey.6Sinus headache has been characterized as a common but nonspecific entity7 and often is the go-to diagnosis for many primary care providers when patients first present with headache, facial pain, and/or pressure. This widespread notion often results in the misdiagnosis and entirely inappropriate treatment of migraine headache.8 Despite its popularity among patients and primary care providers, the relevance of sinus headache has been declining steadily within the headache community. Having once been identified as a major manifestation of acute rhinosinusitis, sinus headache has subsequently been downgraded to minor symptom status and now receives little if any mention in numerous clinical reviews.1,2,9 Of particular note, headache specialists tend to agree that sinus-related headaches are generally uncommon during acute episodes and decidedly rare in chronic cases.2,10

Based on national ambulatory care data, rhinosinusitis is among the most frequent diagnoses encountered in ambulatory care settings.5 Varying reports indicate that the overwhelming majority of these patients are attended to by primary care providers whose familiarity with both routine and endoscopic examination of the nose is generally lacking.7,11 In studies of patients from primary care and headache clinics with self-diagnosed sinus headache, the overwhelming majority met IHS proposed migraine criteria and responded favorably to triptan therapy.12 Of the patients who sought consultation for headache, none received a diagnosis of migraine, and they often were inappropriately treated for sinus headache even in the absence of any sinus assessment. With primary care practitioners relying primarily on clinical investigation, Hadley and Schaefer13 stress that this evaluation should concentrate on a comprehensive history and well-structured physical examination as a critical first step in diagnosing rhinosinusitis.

Diagnostic Criteria

Providers continue to rely on a number of outmoded major and minor criteria in diagnosing sinusitis. Major criteria include facial pain and pressure, nasal congestion/obstruction, discolored nasal discharge/purulence, fever (nonacute cases), and olfactory disturbances. Minor criteria consist of headache, fever (nonacute cases), fatigue, dental pain, cough, aural fullness, and halitosis.9 Williams and colleagues14 proposed 5 independent clinical predictors of sinusitis among patients in general medical clinics that include maxillary toothache, abnormal transillumination, poor response to decongestants, and history or clinical findings of purulent nasal discharge. Currently, however, providers need to entertain significantly fewer criteria in diagnosing rhinosinusitis in that many criteria are now regarded as irrelevant.

Lanza and Kennedy9 emphasize that both the need for effective communication among physicians and consistency in reporting of disease mandate that a uniformly acceptable definition of rhinosinusitis, with criteria that are periodically reassessed, be in place should the demand arise. Each medical specialty, however, has its own frame of reference that often influences the choice of diagnostic criteria needed to arrive at a proper diagnosis. Such is indeed the case with sinus headache. Two distinct groups, the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) and the IHS have each established their own respective criteria in diagnosing rhinosinusitis. The IHS system stresses headache or lack thereof, while the AAO-HNS system emphasizes clinical signs and symptoms, with scant attention being paid to the presence of headache. Though differences clearly exist, an awareness of each organization’s criteria is important.15


Figure 1. Essential symptoms in the diagnosis of acute sinusitis.16

 

In a 2015 clinical practice guideline,16 the AAO-HNS Foundation emphasizes 3 cardinal features to be used in diagnosing acute rhinosinusitis (Figure 1). The presence of purulence within the nasal cavity or posterior pharynx together with nasal congestion/obstruction and/or facial pressure/pain are sufficient for arriving at the correct diagnosis. Though considered significant in previous reporting, minor symptoms such as fever, altered smell, cough, and upper dental pain should no longer be combined with the above 3 major criteria when diagnosing acute rhinosinusitis. In the event that headache or facial pain occurs in the absence of either nasal congestion or nasal congestion along with discolored nasal discharge, diagnoses other than acute rhinosinusitis should be entertained.

Listed under the general heading of headache attributed to disorders of the nose or paranasal sinuses, the IHS4 enumerates specific diagnostic criteria that must be met when attributing headache to acute rhinosinusitis (Figure 2). Notable comments relate that migraine and tension-type headache may be mistaken for headache attributed to rhinosinusitis due to the common sites of involvement shared by all 3 entities. The appearance of autonomic nasal symptoms in persons with migraine also adds to the confusion, particularly when sinonasal pathology may serve to either initiate or intensify migraine. The absence or presence of nasal purulence can prove helpful in identifying the actual headache type.

Clinical Presentations

Sinus headache’s continued relevance and popularity among patients and primary care providers has clearly been at the expense of primary headaches in general and migraine in particular. The scope of this misdiagnosis can only be appreciated when one considers that migraine represents the third most frequent disorder and seventh most common cause of disability worldwide, based on the Global Burden of Disease Study 2010.4 The American Migraine Study II17 identifies migraine as a common, often debilitating condition that is often underrecognized and undertreated, resulting in significant pain and disability. Migraine symptoms commonly include pulsatile pain (85%), light sensitivity (80%), sound sensitivity (76%), nausea (73%), unilateral pain (59%), blurred vision (44%), aura (36%), and vomiting (29%).17 Yet despite these obvious clinical disparities, why migraine continues to be underdiagnosed or misdiagnosed has been a topic of ongoing discussion, with a number of contributing factors having been identified.

Variability in the clinical presentation of migraine, particularly when accompanied by unexpected nasal and ocular symptoms, may well result in sinus headache overshadowing any consideration of migraine.2 Primary headache often is misdiagnosed because, apart from the presence of nasal congestion and rhinorrhea, pain distribution may involve the periorbital and midface region, areas commonly associated with sinusitis.8 In a primary care study of almost 3000 patients with either self- or provider-diagnosed sinus headache, nearly 90% of cases satisfied the criteria for migraine.2Nasal/ocular symptoms were commonly described and contributed to an erroneous diagnosis of sinus headache (Figure 3).


Figure 3. Autonomic symptoms occurring in migraine.

 

Presentations that appear to influence patients to self-diagnose sinus headache have been neatly categorized by Eross and colleagues18 as “guilt by provocation, location, and association.” Provocation refers to headache triggers, including weather, seasonal and altitude changes, and exposure to allergens. Pain location typically centers about areas innervated by the second division of the trigeminal nerve, including the forehead and areas overlying the maxillae. Association relates to associated cranial autonomic features, including nasal congestion, rhinorrhea, eyelid edema, ptosis, conjunctival injection, and lacrimation.

Concomitant headache types, comorbid conditions, and the presence of symptoms thought to be associated with other headache types are described by Diamond as issues resulting in failure to diagnose migraine.19 Lack of recognition and misdiagnosis of migraine as an entirely different headache, such as sinus or tension headache, contribute to migraine being underdiagnosed or misdiagnosed. In addition, providers mistakenly assign associated nasal symptoms and comorbid conditions (eg, sinusitis, allergies) to headache varieties other than migraine. Migraine that occurs simultaneously with rhinosinusitis or allergy has proven to be particularly challenging. Cady and Schreiber12 discuss the possibility that migraine may be a manifestation of a particular allergen. Food allergies have been identified as migraine triggers among certain individuals. This allergy linkage may aid in understanding why nasal and/or ocular symptoms occasionally appear among certain migraineurs.

Apart from the issue of nasal symptoms, Cashman and Smyth8 introduce the process of chronification as a potential contributor to the misdiagnosis of rhinosinusitis. As it relates to migraine, chronification represents the progression of an episodic event to that of a chronic disorder. This evolution may bring about a diminution or loss of classic migraine symptoms such as aura, nausea, and vomiting. The onset of chronification may therefore influence the provider to suspect rhinosinusitis rather than a form of modified migraine.

The interchange between patient and provider has led to diagnostic inconsistencies and error. Poor patient-provider communication relative to migraine is a matter of concern, especially since the practitioner must rely on patient recollections of symptoms and is obligated to prioritize an assortment of complaints. The time constraints imposed upon most general practitioners often places limits on the time needed to arrive at an exact diagnosis.20

An appreciation of the pathophysiology of migraine along with the nature of nasal pain may well serve to explain why an inordinate number of patients are misdiagnosed with sinus headache. Mehle and Schreiber21 describe sensitization of the peripheral neurons of the trigeminal nerve with subsequent involvement of the first (ophthalmic) and/or second (maxillary) divisions. This particular sensitization may result in insignificant stimuli such as tactile sensation or cold air initiating pain in areas subserved by either or both trigeminal divisions.21

Autonomic symptoms, including nasal congestion, tearing, conjunctival injection, and eyelid edema, occur in nearly 50% of migraine patients and are likely the result of activation of the trigeminal autonomic reflex.22 With nasal symptoms commonly occurring in cases of both rhinosinusitis and migraine, health care providers are inclined to focus on the former while often ignoring the latter. Sinonasal symptoms are viewed as the probable result of parasympathetic activation, with consideration also being given to the possible involvement of neurogenic switching, a hypothetical process by which a stimulus at one location may bring about an inflammatory process at an entirely different site.23 The process of neurogenic or immunogenic switching may occur as a consequence of a crossover of neurogenic and immunogenic inflammatory processes. Neurogenic switching also may explain how rhinosinusitis or perhaps even allergies could potentially act as a migraine trigger.12

Identifying Headache Types

With migraine continuing to be both underdiagnosed and misdiagnosed in the primary care setting, providers are in need of simple straightforward means by which to identify this most prevalent and disabling headache. Lipton and colleagues24 put forward a self-administered migraine screener with questions focusing on nausea, photophobia, and headache-related disability. This 3-item ID Migraine Screener has proven to possess a positive predictive value of 93.3% when used in a primary care setting.

Response to an empirical trial of triptans may help confirm a diagnosis of migraine. In a study of patients with physician- or self-diagnosed sinus headache that lacked clinical or imaging evidence of sinusitis, 82% of participants responded positively to empirical treatment with triptans.25 Although this positive response may prove helpful in diagnosing migraine when clinical criteria are either absent or poorly defined, others caution against such use, relating that some cases of intracranial pathology may respond to triptan therapy, as well.21

Conclusion

In the preface to an issue of Otolaryngology Clinics of North America devoted to headache and facial pain,26 Jacobson and Donlon emphasize that the reader hopefully will recognize “the tremendous overlap between specialties and the need to look beyond the confines of our particular professional biases in order to reach an accurate diagnosis and provide proper care.” Irrespective of specialty, providers should not only incorporate criteria from both the IHS and AAO-HNS, but also avoid having their diagnostic and treatment strategies influenced by patients presenting with self- or provider-diagnosed sinus headaches. Providers should give careful thought to patients presenting with facial pain and/or headache accompanied by nasal symptoms. The heretofore near-reflexive diagnosis of rhinosinusitis/sinus headache should be avoided, and consideration given to the more than likely presence of migraine or other primary headache types. 

Sheldon P. Hersh, MD, is an otolaryngologist affiliated with the Department of Otolaryngology-Head and Neck Surgery at Northwell Health Lenox Hill Hospital in New York, New York.

Joshua N. Hersh, MD, is a neurologist at Princeton & Rutgers Neurology in Somerset, New Jersey.


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