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. It is not evidence against it.

This is one of the most common wrong turns in headache care. People spend years on decongestants and antihistamines. They take antibiotics again and again. Antibiotics cannot touch this condition.

Why migraine feels like sinus disease

The trigeminal nerve supplies both the sinuses and the meninges (the lining around the brain). During a migraine, the trigeminal system turns on. The pain is then referred across that whole area. That includes the cheek, the bridge of the nose, and behind the eye. It truly feels like pressure in the sinuses. That is because the same nerve reports both.

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

Then add the weather trigger. A change in barometric pressure is a well-recognized migraine trigger. It is also what people link to sinus trouble. So the wrong blame becomes almost certain.

What actually distinguishes them

Points toward migraine

• Attacks that come and go over hours and then fully clear, 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
• Pus-filled (purulent), discolored nasal discharge
• Symptoms that last without a break for more than ten days without getting better, or get worse after first getting better
• Facial pain and congestion that do not go away 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 tells them apart 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 needs clinical, endoscopic or imaging evidence of the sinus disease. The headache must start in step with it and clear as it clears.¹ Chronic or recurring sinusitis is not accepted as a cause of recurrent headache. The one exception is when an acute flare has been demonstrated. In other words, “chronic sinus headache” as a standing diagnosis is not a recognized condition.

Migraine, by contrast, needs attacks lasting 4 to 72 hours. They need at least two of these: one-sided location, a pulsing quality, moderate or severe intensity, or getting worse with routine activity. They also need either nausea/vomiting or both photophobia and phonophobia (light and sound sensitivity).² Read those criteria against your own “sinus” attacks. 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 is not migraine either, when it comes at the same hour and lasts under three hours. That is cluster headache. It is misdiagnosed as sinus disease even more often than migraine is. Are your “sinus headaches” always on the same side and always at the same time of day? Then read that page instead.

Lasting 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. Some attacks have not broken with oral medication. For those, intravenous therapy takes absorption out of the equation. Some attacks have a strong autonomic component. These are the ones that feel most “sinus-like”. For them, an SPG block targets the relay behind the nose directly, with no needle and no sedation.

Have you been treating these headaches most days with decongestants or combination painkillers? Then read headache prevention first. Frequent acute dosing can keep alive 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 (swollen sinus lining found by chance) is common in people with no facial pain at all. ICHD-3 requires the headache to start in time with the sinus disease and clear as it clears.

Why did antibiotics seem to help last time?

Migraine attacks end on their own, usually within 4 to 72 hours. That is about when a course of antibiotics starts. Getting better at the same time as an antibiotic is not evidence the antibiotic caused it.

Can weather changes really trigger migraine?

A change in barometric pressure is a recognized migraine trigger. It is also what most people blame on their sinuses. That is part of why the two get confused.

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

Cranial autonomic symptoms occur in migraine. They 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 true 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