Is it a sinus headache or a migraine?

If you have recurring “sinus headaches” without fever or discolored nasal discharge, migraine is the more likely explanation — and it is treatable. Sinus pain is one of migraine’s own symptoms, not evidence against it.

This is one of the most common misroutings in headache care. People spend years on decongestants, antihistamines and repeated antibiotic courses for a condition that antibiotics cannot touch.

Why migraine feels like sinus disease

The trigeminal nerve supplies both the sinuses and the meninges. When the trigeminal system is activated during a migraine, the pain is referred across that whole territory — which includes the cheek, the bridge of the nose, and behind the eye. It genuinely feels like pressure in the sinuses, because the same nerve reports both.

Migraine also produces cranial autonomic symptoms in a substantial minority of people: nasal congestion, a runny nose, watering eyes. Those are the exact symptoms that make people reach for a decongestant.

Add the weather trigger — barometric pressure change is a well-recognized migraine trigger and also what people associate with sinus trouble — and the misattribution becomes almost inevitable.

What actually distinguishes them

Points toward migraine

• Attacks that come and go over hours and then fully resolve, leaving you well between them
• Nausea, or sensitivity to light or sound
• Pain made worse by routine physical activity such as climbing stairs
• A history of “sinus headaches” that respond to a triptan or to lying down in the dark
• No fever and no thick discolored discharge

Points toward genuine bacterial sinusitis

• Fever
• Purulent, discolored nasal discharge
• Symptoms that persist continuously for more than ten days without improving, or worsen after initially improving
• Facial pain and congestion that do not remit between episodes

Acute bacterial sinusitis is an illness with a beginning and an end. Migraine is a recurring attack disorder with well periods in between. The pattern over months separates them more reliably than any single symptom.

The diagnostic criteria are explicit about this

The International Classification of Headache Disorders is direct: headache attributed to rhinosinusitis requires clinical, endoscopic or imaging evidence of the sinus disease, and the headache must develop in temporal relation to it and resolve as it resolves.¹ Chronic or recurring sinusitis is not accepted as a cause of recurrent headache unless there is a demonstrated acute exacerbation. In other words, “chronic sinus headache” as a standing diagnosis is not a recognized entity.

Migraine, by contrast, requires attacks lasting 4 to 72 hours with at least two of: one-sided location, pulsating quality, moderate or severe intensity, or aggravation by routine activity — plus either nausea/vomiting or both photophobia and phonophobia.² Read those criteria against your own “sinus” attacks and the fit is often immediate.

The other thing hiding under the sinus label

One-sided facial pain with a blocked nostril and a watering eye, arriving at the same hour and lasting under three hours, is not migraine either. That is cluster headache, and it is misdiagnosed as sinus disease even more often than migraine is. If your “sinus headaches” are always on the same side and always at the same time of day, read that page instead.

Persistent pain in the upper teeth or cheek after dental work is a third possibility — see persistent pain after dental treatment.

What treatment actually looks like

If the diagnosis is migraine, the plan is migraine-specific. For an attack that has not broken with oral medication, intravenous therapy removes absorption from the equation. For attacks with a strong autonomic component — the ones that feel most “sinus-like” — an SPG block targets the relay behind the nose directly, with no needle and no sedation.

If you have been treating these headaches most days with decongestants or combination painkillers, read headache prevention first. Frequent acute dosing can sustain the very headache you are treating.

Common questions

My CT scan showed sinus changes. Doesn’t that prove it’s sinus?

Not on its own. Incidental mucosal thickening is common in people with no facial pain at all. ICHD-3 requires the headache to develop in time with the sinus disease and resolve as it resolves. See migraine treatment.

Why did antibiotics seem to help last time?

Migraine attacks end on their own, usually within 4 to 72 hours, which is about the time a course starts. Improvement that coincides with an antibiotic is not evidence the antibiotic caused it. See migraine treatment.

Can weather changes really trigger migraine?

Barometric pressure change is a recognized migraine trigger, and it is also what most people attribute to sinuses — which is part of why the two get confused. See headache prevention.

I get facial pain and a runny nose with mine. Isn’t that sinus?

Cranial autonomic symptoms occur in migraine and are prominent in cluster headache. They point at the trigeminal-autonomic system, not at infection. See cluster headache treatment.

What if I actually do have sinusitis?

Then you need it treated as an infection, and we will tell you so. This clinic treats headache disorders; a genuine acute bacterial sinusitis belongs with primary care or ENT. Contact us if you are unsure which you have.

Sources

1. Headache Classification Committee of the International Headache Society. ICHD-3, 11.5 Headache attributed to disorder of the nose or paranasal sinuses. ichd-3.org
2. Headache Classification Committee of the International Headache Society. ICHD-3, 1.1 Migraine without aura. ichd-3.org