How to Diagnose Sinus Headache vs Migraine

[Dr. Ashley Agan]
Diving into the topic of sinus headache. Let's just set the stage because I think we all, as ENTs, this is such a common thing that comes in, whether people are describing it as sinus headache or just sinus. Some people just have-

[Dr. Jessica Lee]
No pressure.

[Dr. Ashley Agan]
-sinus or they're pointing. What is that, and how do you think about it?

[Dr. Jessica Lee]
I think that's an important point to start with, that this is what patients tell us, right? They come in and they say, "I have sinus headache or I have sinus or sinus issues." When you start to question them further, a lot of times it is going to include some type of symptom of pain or pressure in the face, typically, but I have had people tell me I have sinus issues, and they'll point to their temple or the back of their neck. I can sometimes gently say, "Well, there really aren't sinuses there." Anyway, point being, it's some type of facial or head pain or pressure.

Usually, they're going to also use the word congestion, which I find to be one of the least helpful words in our vocabulary because it means so many different things for so many different people. Again, I usually end up questioning further, "Is that airflow problems in your nose when you breathe in? Is it airflow problems when you breathe out? Is it pressure? Is it heaviness? Is it fogginess?" You have to dig through what that actually means because it's different. Essentially, I like to talk to patients about sinus headaches because what I began to notice is how often that symptom is misdiagnosed as a sinus infection.

We have to be very careful, I think, in our field because people are going to come to us for this. If we're not, honestly, the experts at teasing this out, then that misdiagnosis cycle is going to continue. If you really want to be technical about the terms, there's rhinogenic headache, which is a headache that we attribute to a true acute sinusitis or a chronic sinusitis or sinusitis with polyps. Then there's non-rhinogenic headache, which is really more in that primary headache bucket, which includes things like tension headache and migraine disorder and things like that. That's where that it all starts.

[Dr. Gopi Shah]
The sinus headache, is it its own entity, or are we just talking about a symptom of sinusitis?

[Dr. Jessica Lee]
I actually think it's a symptom, correct. Actually, there is not an ICD-10 code for sinus headache, right? That's the other confusing part is when you're starting to try to think, "Well, how can we study this?" You're going to have to use the migraine codes, the atypical facial pain, tension headache. Honestly, the term sinus headache, they group it under-- I think it's one of the J32 codes of chronic sinusitis, but in actual fact, there's a review that says 80% of sinus headache complaints actually meet criteria for migraine disorder.

I don't think it's, "Well, we don't have a great code for it. We don't have a good way to talk about it. We don't have a way to code for it." It makes it, I think, hard for us to start teasing it apart completely, I don't know, at the big level, right?

[Dr. Ashley Agan]
Yes. I would say, when I have patients that come in specifically with that as the main, that's the chief thing that's bothering them, it is more likely for the exam to be unimpressive. If I actually see polyps or pus or some sort of sinus pathology, I'm surprised and like, "Oh, yes. You do have a sinus infection or whatnot." I would say, most commonly, there is not an obvious sinus pathology. I think as ENTs, we are trained really well to treat sinus pathology. If we see polyps, if we see pus, I think we're really good at that. I think these patients can be really tricky because a lot of times, they might have an exam that is not super remarkable. I don't know. What is your experience?

[Dr. Jessica Lee]
Again, I like to use real-world data. Again, there was a review, and it said that 50% of patients diagnosed with sinus infection actually have completely normal endoscopy and CT scans. It's a problem of misdiagnosis mostly, but you're right. We are trained as people who know sinus pathology. What do you do when that patient walks in and they're telling you, and they're usually going to say, "I've got sinus headaches. I've got congestion. Yes, maybe I have a little post-nasal drip." Then you're ticking off those criteria for ARS and CRS and you're thinking, "Well, it could be." Then you do their CT or you do their endoscopy, and it's nothing.

The question is, what do you do next? I think there's a tendency, maybe, with some of the training that, "We're done. We're out. It's not us. It's a headache issue." The problem is there's only, I think, 700 headache specialists in the US versus there's 10,000 ENTs. Again, when patients start saying the word sinus, congestion, headache, whatever they want to add to the word after it, they're going to be referred to us. I think there's a gap in our training, but also in our comfort level and working with these patients. I think that can change.

[Dr. Gopi Shah]
Do a lot of these patients, I feel like they also have allergies, too. How often is it not a sinus issue, but it's a symptom of allergies? Because I see a lot of that as well, where it's boggy turbinate, clear rhinorrhea, and then the pressure. It's not quite sinusitis, but they have the headache, and it's that allergy season. Is it different?

[Dr. Jessica Lee]
No, I think it can be both. That's the other hard part, is you can have patients who are having headache symptoms, and you happen to allergy test them or scan them, and they come back positive. Then again, what do you do? What do you treat first? I think most ENTs would agree, we're going to go with what's abnormal, right? You're going to treat their allergies or you're going to treat their sinusitis, but then what if they still have headaches? One of the most clear examples of this I had a few years ago was a young woman. She was about 31 years old.

She had been years of symptomatic or she had symptoms for years, and she had been through allergy testing and immunotherapy, completed her five years, and didn't really get that much better. Then she had sinus surgery, although we'll talk about her CT being normal, actually, but she did have sinus surgery, didn't really change her symptoms. Finally, by the time she came to me, she said, "The place I go has recommended I do allergy immunotherapy a second time. I was like, "Hang on, let's just pause for a minute." We went through and we dissected it out. For her, it was absolutely migraine.

She just continued to go to urgent care or primary care and be prescribed antibiotics and steroids, and things would get better temporarily, because migraines do get better. Really, it can be difficult because you have patients that have not just one problem. Our bodies don't read the textbooks, and so it's not always clear-cut, so you have to detect a bit.

[Dr. Gopi Shah]
Let's say you have that patient who is able to see you in clinic, the symptoms of headache and congestion, some ear fullness started, you see them in clinic, what do you do? What is that visit like? Tell me what sometimes you'll see in these patients and your findings.

[Dr. Jessica Lee]
Like Ashley said earlier, I think, honestly, most of the time their scope is normal if it's a migraine patient. Now, you're right. Sometimes, you're going to get the overlap. Maybe they have allergies as well, and you'll see some buggy turbinates or a little bit of clear mucus in the nasal cavities. If you see purulence, you're obviously going to treat it along the guidelines for acute or chronic sinusitis, but let's assume in this case that this is a normal endoscopy. Then, at that point, like I said, if it's recurrent acute, I'll usually say, "Okay, let's think about the possibility."

I sometimes won't even use the word migraine. I'll say, "What if this could be like a nerve hypersensitivity," which is migraine. I'll explain how the trigeminal nerve gives them sensation in their face and in their sinuses, and how you can have autonomic symptoms. You can have runny nose and congestion because of the parasympathetics in that area. I give them a little brief, like, "Hey, this is how your nerves in your face work." I say, "Let's think about what makes nerves hypersensitive, and it's anything that impacts your brain health. That's your sleep. That's your nutrition. That's your stress levels. That's your hormones, all those things."

From there, I usually will try to have a little conversation about their daily habits. I'll give you another example. This is a young man in clinic a couple of weeks ago, and he, again, had been treated for recurrent sinus infections all coming up in the past couple of years, but when he told me about where his headaches are, he kept pointing to his temple. I was like, "Okay." His scope was normal and everything. I said, "Let's just talk about some of these other things like we just listed." It turns out, for him, he fasts all day long.

I was asking about his normal routine of eating because a lot of times, too, with migraine, I'll tell people, 'It's not as much what you eat. There are certainly foods that are known to be triggers, and it can be different for everybody." A lot of it is the pattern and how long you go in between and those periods of hypoglycemia. For him, he was like, 'Oh, I rush out the door in the morning to get to my job. I sit at my desk all day long. I don't take a break for lunch. I basically eat dinner, and that's it." I was like, "Okay, we're going to think about getting you on a more stable nutrition plan."

Also talked about like that constant screen time with no break and that constant visual stimulation and taking a break every hour, get up, go walk around, go step outside for two minutes or something. He came back in and is already feeling better just from tweaking a couple of things like that.

[Dr. Gopi Shah]
When you talk about hypoglycemia, that makes me think about a CGM, a continuous glucose monitor. Are you using those in your practice at all to help patients have more insight into what might be happening, how they can track their symptoms with how their glucose is tracking? Do you have any thoughts on that?

[Dr. Jessica Lee]
I'll tell you, I've done a CGM just for curiosity's sake. It's not hard to do, and you can gain some really interesting insights. What I will say is, number one, for most people, it's going to be an out-of-pocket expense. It's not going to be covered by insurance unless they have diabetes. In my experience, you don't even need that. You can tell just by asking a few questions about what time do they normally eat breakfast? What time do they normally eat lunch? What time do they normally eat dinner?

Right away, you're going to get an idea of is this someone who-- or you'll have a patient who comes in and says, "Oh, I started intermittent fasting, and now I'm having these headaches." I haven't found that I needed to use it clinically. I do have some patients who I work really in-depth with from this integrative standpoint. We have kept it in the sides as like a, "Hey, if we feel like we're struggling and we really want to get further insight, we can use this." Honestly, none of them have needed it.