Is it really a sinus headache?

How often do you see patients who tell you they are having a sinus headache need antibiotics. There are so many things wrong with that, not the least of which is the antibiotics part, but ….what about the cause of the headache in the first place?

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Is this headache a migraine?

2006 JAMA Rational Clinical Exam Series: Does This Patient With Headache Have a Migraine or Need Neuroimaging?

If you have a patient who has some scomoata, maybe shimmering lights that start small, get bigger, a little nausea followed by headache-  what is that? it’s a migraine. Done. But it’s not always so clear cut.

The POUNDing mnemonic can help sort this out.

  1. Is it a Pulsating head- ache?
  2. Does it last between 4 and 72 hOurs without medication?
  3. Is it Unilateral?
  4. Is there Nausea?
  5. Is the headache Disabling? Disabling headaches are those that disrupt a patient’s daily activities.

If the patient answers “yes” to 4 or more of the 5 ques- tions, the LR is 24. We like to see a positive likelihood ration of at least 10 to indicate something is useful. Twenty four: is very useful.  For 3 criteria, the LR is 3.5, not too impressive. For 1 or 2 criteria, the LR is 0.41, weak.

What about photophobia, the absence of photophobia makes migraine less likely, we know that migraines can cause debilitating photosensitiy, but interestinly, the presence f photophobia doesn’t make migraines MORE likely because in the great headache ven diagram, there is tremendous overlap in symtoms, and photophobia is one of those symptoms that many headaches share.

Sinus headaches. What’s in a name?

Sinus headache, so easy to say, it just rolls off the tongue. We say it, patients say it, but is it really a sinus headache?

Arch Intern Med. 2004 Prevalence of Migraine in Patients With a History of Self-reported or Physician-Diagnosed “Sinus” Headache.

Study Bottom Line: About 3000 patients, most carrying a diagnosis of sinus headaches. The overwhelming majority of patients met International Headache Society migraine headache criteria.

We’re not talking about patients with fever and purulent discharge. This is the patient with sinus pressure, sinus pain, even nasal congestion. So that sinus headache may not be a sinus headache after all, but a migraine with pain localized to a sinus area. But, you say, there’s overlap between sinus and migraine headaches,. That is true, but a 2008 study from Laryngoscpoe of patients seen at an ENT clinic with a previous diagnosis of sinus headache (either from a physician or themselves)  suggests that many sinus headaches do not have objective evidence of sinusitis AND get better with migraine treatment. Patients with a negative workup by exam, nasal endoscopy and CT scan were treated with triptans and the majority, over 80%,  got better. Migraine treatment made what was previously diagnosed as sinus headache better.

Maybe triptans help with sinus headaches, but maybe, and the evidence suggests this, many of what we and our patients call  sinus headaches are actually migraines.


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  1. Jenny

    Dr. Orman, Good Lecture!! To have 4 or more positive and an LR of 24, does the 4-72 hours without meds include all medications or is it referring to more migraine type meds like sumatriptan? if so, that would be hard, as most pt try at least tylenol or motrin at home. Thanks.

    1. Rob Orman

      Hi Jenny,
      I’m not completely sure what you’re asking. If it’s should one wait 4 hours after headache onset to initiate treatment, the answer is no. The earlier the better. Triptans are OK, but no better than ASA+APAP+caffeine, metaclopramide or prochlorperazine. Does that answer the question?

      1. Jenny

        sorry -- that was probably confusing the way I wrote it -- my sincere apologies -- in your pound mnemonic to help determine if its a migraine, number 2 is “Does it last between 4 and 72 hours without medication?” I feel like this is tough to obtain an answer of yes from patients as most people have at least tried motrin or tylenol (even if they did not take migraine meds) before coming to the ed with a severe headache. Thanks and sorry for the confusion.

        1. Rob Orman

          Hi Jenny,
          I think it’s a matter of research criteria versus real world medicine. I agree, the vast majority of patients are going to take some kind of med. This would technically invalidate that aspect of the POUNDing criteria. I think if the patient’s has a history of headaches lasting in that time interval, or headache has been going on over 4 hours before they come to the ED -- good enough for me. It does not follow the letter of the mnemonic, but we are working in the grey, whereas entry criteria into a study is always going to be black and white.
          Here is a link to the study that discussed the mnemonic (amongst other things)

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