Douglas S. Paauw, MD
December 11, 2019
A 29-year-old woman presents for evaluation of headaches. She reports that they have grown increasingly frequent over the past 12 months. She describes them as a feeling of pressure and pain in her forehead, under her eyes, and over her cheeks. Her only other complaint is "feeling stuffy," though she denies fever, cough, sneezing, or purulent nasal discharge. She reports that she "sometimes" takes ibuprofen to treat her headache but that it doesn't work well, so she usually "doesn't bother."
A Migraine Variant Often Missed
The diagnosis in this case is a variant of migraine headache—an important one that has long been misunderstood.
The classic picture is the patient who claims to experience sinus headaches two or three times a year. The typical story is, "I get congested, I take antibiotics, and 2 days later I'm better." We've all seen that patient—often on repeated occasions. These patients are typically experiencing a variant of migraine.
Let's go through the data.
The largest study involved almost 3,000 adult patients recruited from a primary care setting with a history of self-reported or physician-diagnosed "sinus" headache who reported at least six headaches during the previous 6 months. On evaluation, 88% of these patients met International Headache Society (HIS) diagnostic criteria for migraine-type headaches. The most common reported symptoms in this cohort were sinus pressure (84%), sinus pain (82%), and nasal congestion (63%).
The Sinus, Allergy and Migraine Study (SAMS), which recruited patients who believed they had sinus headaches via newspaper advertisements, came to essentially the same conclusion. Approximately 100 patients participated. Final diagnoses, based on IHS criteria, were:
- Migraine with or without aura: 52%;
- Probable migraine: 23%;
- Chronic migraine with medication overuse headache: 11%; and
- Nonclassifiable headache: 9%.
So how long does it take for a patient initially misdiagnosed with sinusitis to get a correct diagnosis of migraine? A more recent study recruited 130 adult patients with migraine who were seen in a referral practice. Just over 80% of this cohort had initially been misdiagnosed as having sinusitis, with a mean delay of migraine diagnosis of almost 8 years (range, 1-38 years). Chronic migraine was more common in this initially misdiagnosed group than in patients appropriately diagnosed at the onset. Medication overuse headache was only found in the misdiagnosed group.
If diagnosis is uncertain—could response to triptans be helpful information? A small, open-label, nonrandomized study involving 54 patients referred to a tertiary-center otolaryngology department sought to answer this question. All patients presented with multiple episodes of self- or physician-diagnosed "sinus headache." The vast majority reported having headaches that occurred daily, or multiple times per week, and that lasted hours. All received rigorous evaluation, including nasal endoscopy and CT. Those with negative results were treated with triptans.
Of the 38 patients who completed follow-up, over 80% reported significant reduction in headache pain with use of triptans; over 90% experienced significant pain relief with migraine-directed therapy. Of note, the investigators attributed the high dropout rate to patients who were reluctant to accept a diagnosis of migraine.
Keep in mind that patients with intermittent "sinus headache" do not have high fever, acute presentation, or significant sinus pain. These are the people who complain of a "sinus headache" lasting 12-48 hours several times a year. Although they are often treated with antibiotics, they typically get better with or without antibiotics and with or without decongestants.
As the US Centers for Disease Control and Prevention emphasized in the recently released 2019 antibiotic resistance report, antibiotic resistance is higher than previously estimated and is not going away. This is one group of patients that should not be contributing to overuse.
Douglas S. Paauw is the Rathmann Family Foundation Endowed Chair in Patient-Centered Clinical Education and a professor of general internal medicine at the University of Washington. He was elected to Mastership in the American College of Physicians in 2009. He is a frequent lecturer at the ACP annual meeting, yearly presenting standing-room-only lectures on drug interactions and medical myths.