Podcast Transcript: Sinus Headaches vs. Migraines: Diagnosis & Treatment

[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.

(2) Importance of History Taking for Headache Diagnosis

[Dr. Ashley Agan]
Yes, I think that whole response to treatment, I think, does muddy the water because a lot of things will respond to prednisone. It's a very powerful anti-inflammatory, so when people say, "Oh, yes. I felt better for a little while." Even antibiotics can have anti-inflammatory effects, and so that can certainly make it confusing. Obviously, patients are coming in, and you mentioned a lot of the symptoms that they will present with. When you're taking your history, what are some things that you've started asking about that maybe you didn't ask 10 years ago that help with figuring out the etiology of this?

[Dr. Jessica Lee]
Yes, that's a great point because, like you said, you're going to get from your medical assistant or whoever's helping with your HPI, you're going to get the information typically about where the pressure and pain is, what it feels like. You're going to get the nasal symptoms, whether it's airflow obstruction or mucus or purulent drainage, and the loss of sense of smell, which is those four core components we always think to ask about, but I've started asking more about dizziness. Are they having dizziness when they're symptomatic? Do they have ear fullness? They'll often say, "Oh, yes. I go to urgent care, and I get diagnosed with an ear infection and a sinus infection, and I get put on my antibiotics."

I'm like, "Okay, we're going to double-check that. I ask about nausea and vomiting. I ask about sensory phobia. I say, "When you feel like this, do you feel like sounds are louder or more uncomfortable, or do you feel like you don't want to be around bright light as much, or smells, can you not tolerate certain smells?" I ask them about tinnitus. Do they have tinnitus during that time? Do weather changes stimulate it? That's back to, Gopi, what you asked about with allergies, is a lot of people assume, "Oh, will the weather change?"

[Dr. Gopi Shah]
I know when the weather's changing, because I'm that patient. I get the headaches, and sure enough, six hours later, there's clouds or something brewing. I'm like, "Okay."

[Dr. Jessica Lee]
It's that barometric pressure change, which we know is part of migraine pathology, and it can be part of allergy pathology, but which one is it? Hormones, for women especially, asking about, does this have any relationship to their menstrual cycle? That's a big clue. That's the list of things I've added to the HPI questions.

[Dr. Gopi Shah]
With those questions, I think of nausea, vomiting, sensory, that's my migraine bucket. I think of ear fullness, congestion with my sinus bucket. With dizziness, could it be vestibular migraine? My guess, if it has some sinus component, maybe that's still my sinus bucket. Tell me, how do you use some-- Do you get nausea, vomiting with your sinus headache, or is that no?

[Dr. Jessica Lee]
Yes. I think that's probably one that people don't get as much. Maybe a little nausea, maybe a little queasy, or maybe they just don't have an appetite, but they're typically not coming in saying, "I have a headache and I vomit and I'm sensitive to light," because if they say that, they go to neurology for migraine. It's more subtle. I think, for me, the ear fullness, the dizziness, the tinnitus questions bring in the vestibular migraine potential, which again is still a migraine diagnosis. Then, like I said, I think the sinusitis piece of it is what generally happens is if this is someone who's having recurrent acute episodes, what I will tell them, because by the time they come in, they're not in an episode anymore.

Very likely, their endoscopy does look normal. What I will tell them when they come in is, "The next time you get sick, I want to be the one to see you. I don't want you to go to urgent care. I don't want you to even go to your primary care. They do a great job, but I do this, and I want you to come see me." I'm lucky that I work in a practice where we are very accessible the way the practice is set up. I'll also give them my work email, and be like, "Look, if you call and you can't make it in, just email me and I will book you, because I want to see you when you are symptomatic. I want to see, is there pus dripping out of a sinus? Is there really fluid behind your eardrum."

In some cases, I'll even go as far as to say, "Next time you come in and you feel this symptom, I'm going to do a CT scan and we're going to see what it shows." I find that feedback for patients is extremely helpful, because unfortunately, you bring up the word migraine, there's a stigma. People shut down. They don't want to be diagnosed with migraine. A lot of people, it's hard to convince them that these sinus headache episodes are actually not infections. Sometimes, having that feedback where I can go over their CT scan with them is extremely helpful.

[Dr. Ashley Agan]
I'm so glad that you also have a hard time convincing people that it's migraine, because I have the same experience where we have good data to back up. Can you tell patients, "Actually, a lot of sinus headaches are migraine. Look, your sinuses are clear." You're right. People don't want to have migraine, or they're like, "No, I'm not a migraine patient. That's not me." I'm glad to hear that even you have this issue. In thinking about your differential, these sinus headache patients, where it's, what did you call it? Non-rhinogenic?

[Dr. Jessica Lee]
Yes. Non-rhinogenic headache, yes.

[Dr. Ashley Agan]
Right. There's not an acute sinusitis. Is the most common diagnosis migraine? Are there other things on your differential that you're thinking about?

[Dr. Jessica Lee]
Yes. Certainly, you have your warning signs. If you have someone who has new-onset headaches, especially if they're older. If they're having any other systemic symptoms, if they're having vision changes, you don't want to forget that headache differential and just automatically assume it's migraine. Again, I would say the vast majority of the time, that's not really on the radar. I would say, I think I did have a patient a couple weeks ago who was having vision changes with new-onset and progressively worsening headaches. I was like, "Okay. You were going to get an MRI because we need to take a closer look before we just label this."

I think the differential is still, if someone comes in, their primary complaint is sinus headache, I still think your differential will include acute sinusitis, chronic rhinosinusitis, migraine, tension headache. Then you've got some other things. You've got the more rare or less common things like cluster headache and things like that. Again, I'm not a neurologist. I'm not claiming to be a headache specialist, but I think that these types of headaches present in our clinics much more commonly than in other specialty clinics. Again, I think it's a place where we don't get the training, and I think that it's a place where we can do better for our patients.

(3) Why Nutrition, Sleep, & Stress Matter in Diagnosing Headaches