Timothy C. Hain, MD • Page last modified: March 6, 2021
You may also be interested in our many pages on migraine on this site (migraine is a far more common cause of headache than sinusitis).
Sinus headaches derive from infection or pressure in the paranasal sinuses. These include the maxillary sinus, frontal sinuses, ethmoid sinuses, mastoid, and sphenoid sinuses. Sinus disease is very common -- on casual observation of the author, about 1/3 of the MRI scans of the head in Chicago show changes in the sinuses. Mastoid sinus infections are discussed separately on this site.
|Air fluid levels in maxillary sinuses, in a patient who has no sinus pain or complaints at all.|
An MRI scan from a patient with no sinus complaints at all is shown above -- it has the classic "air-fluid" level seen in acute sinusitis. However, as noted below, the sinuses are generally pretty insensitive and it is common to see MRI or CT scans that look a lot worse than the patient.
The sinuses are not especially sensitive, and one can have a fairly active infection without causing much pain.
Sinusitis means inflammation of the sinuses. Causes can include infection (viruses, bacteria, fungi), allergy, and much more rarely, other processes that damage the area such as "barotrauma" from pressure injuries, radiation after treatment for head/neck cancer, and foreign bodies (such as when children stick beans where they shouldn't).
Pain from the maxillary sinus is typically over the cheeks or in the teeth. Frontal sinus pain is usually over the eyes. Ethmoid and sphenoid sinusitis usually causes pain between the eyes. Sphenoid sinusitis can also radiate to the occiput. Nasal drainage and congestion are common. Pain does not correlate with sinus disease seen on X-ray (Shields et al. 2003), and sinus headaches are probably much less common than the general population thinks. Migraine accounts for far more headaches than does sinus headache. As migraine has no biomarker, this observation really just means that most people who self-diagnose sinus headache (which has a biomarker) really have some other source of pain.
In acute sinusitis, there is pus in the middle meatus, facial pain and pressure lasting less than 4 weeks. Fever or pain without other nasal symptoms does not constitute a diagnostic history in absence of other nasal sinus symptoms.
Chronic sinusitis -- there are symptoms lasting more than 12 weeks.
Rarely sinus infections can erode into the brain or damage cranial nerves (Illing et al, 2015). This most commonly occurs in individuals who are immunosuppressed -- individuals on chemotherapy, on steroids, with diabetes, or with HIV infection.
When faced with someone who has facial pain and drainage, it is reasonable to suspect sinusitis. Usually the first step is to decide if the drainage is clear (generally due to allergy or viral infection), or purulent (any color other than clear or bloody, or bad smelling). Purulent (pus) is of course almost always bacterial. If there is no substantial drainage, if it does not improve on it's own, then one may want to proceed with additional investigations as below. In this situation, migraine headache becomes much more likely. (Eros et al, 2007)
CT and MRI sinus abnormalities are found in the majority of the population, when one looks hard. These include polyps, concha bullosa, septal deviation, etc. An "air-fluid" level is particularly telling as this generally means there is active sinus disease. An example of an air-fluid level is shown above.
CT scans of the sinus are much less expensive than MRI scans and also have the advantage over MRI that they show bone. However they have the disadvantage that they radiate the person. Whenever you can, it is best to avoid unnecessary radiation.
Nasal fiber-optic endoscopy is generally quicker than CT or MRI, as it is done in the office, and also has the advantage that there is no radiation damage from the CT scan. With endoscopy, the clinician can directly visualize many of the sinus openings, and quickly diagnose sinusitis. If the endoscopy is normal, then the index of suspicion for migraine headache should be increased. This is generally only done by sinus surgeons.
Migraine headaches are often misdiagnosed by patients themselves as sinus headaches. A study suggested that 88% of 2991 patients who had diagnosed themselves as having sinus headache, actually had migraine (Schreiber et al, 2004). Other studies have reinforced this idea (Eros et al, 2007). Triptan medication can be helpful in distinguishing migraine (Kari and DelGaudio, 2008), as sinus headaches do not respond to triptans. As Migraines have no biomarker, and Sinus headaches do, another way to interpret these observations is to just say that most people with self-diagnosed sinus headaches have no sinus disease. Migraine, having no biomarker, is often the place where these headaches land.
There are many effective treatments for sinusitis.
According to the literature (eg. Fouroughipour et al, 2011), there is an immense amount of over-prescribing of antibiotics for sinus "infections", in persons who often have migraine or tension headaches. Similarly, there is an immense number of patients with migraine or tension headache who are "treated" with nasal septoplasty.
Surgical treatment for sinus disease has evolved over the past 30 years into a procedure that is mainly done with endoscopes (Phillips et al, 2007). This procedure, often called "FESS" for functional endoscopic sinus surgery, allows surgeons to drain plugged up sinuses without doing any as much "cutting". The development of sophisticated instruments has resulted in a huge spike in the number of physicians offering to perform this procedure. It is often effective in restoring patients to near normalcy (Rurik et al, 2014).