Kim Richard Jones, M.D., Ph.D.
Adult and Pediatric Otolaryngology
Kathy Yu, M.D., M.P.H.
Adult and Pediatric Otolaryngology
Erin Blackburn, Au.D./CCC-A/F-AAA
Carolina ENT Associates 55 Vilcom Center Drive, Suite 140
Chapel Hill, NC 27514
phone: 919.942.7278
fax: 919.942.9029
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Sinusitis Headaches

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I have devoted a special section to sinus headaches because I think it is one of the most misunderstood aspects of sinus disease. In the sections below, you can read about headaches, facial pain, and what is known about their relationship to sinus disease.

Headaches

Headaches are one of the most common health complaints in America, but like a lot of things in medicine, they are still poorly understood. Not all headaches are alike; they are divided into several types, the two most common of which are discussed below:



Tension headaches

These are the most common types of headaches. The name comes from the fact that they are thought to arise from tension in the fronto-occipitalis muscle. This is a broad, flat muscle that attaches to the ridge of bone underneath the eyebrows and then travels over the top of the head to attach to the back of the skull. It is the muscle that allows us to raise our eyebrows and wrinkle our forehead. If you have a headache that is over your forehead and then radiates, or moves, to the back of your head, this is a tension headache. Conversely, if you have pain that starts in your upper shoulders or neck and then radiates to your forehead, this is also a tension headache. Tension headaches are best treated with anti-inflammatories such as ibuprofen, Tylenol, etc. Applying moist heat to the area that hurts also helps.



Migraine headaches


These are the type of headaches that are the most well-known. They are a type of vascular headache, which means they arise from changes in blood vessels. Many people know the classic symptoms of migraine, which are 1) a headache that is preceded by a change in vision, 2) a headache that is only on one side of the head, and 3) a headache that is accompanied by nausea and sensitivity to light. However, what many people don’t know is that many migraines may have only one or even none of the symptoms listed above. For example, many migraine headaches are felt on both sides of the head. Also, many patients have what are called “mixed headaches”, which combine features of both tension and migraine headaches.

Although some migraine headaches respond to anti-inflammatories, there are other drugs designed specifically for migraines that are sometimes more effective. These include newer drugs such as Imitrex and Maltrex, and older drugs such as Fiorinal and Midrin. Fiorinal contains caffeine, and it has long been noted that caffeine helps some patients with migraines. So, if your headache improves with a cup of coffee, it’s likely to be a vascular headache!

Headaches and Sinus Disease

There are three ways sinus disease has been hypothesized to cause headaches: 1) vacuum headaches, 2) inflammation of the sinus lining causing direct pain, and 3) inflammation of the sinuses triggering true tension, migraine, or mixed headache.



Vacuum headaches

The theory behind vacuum headaches is that if the opening from the sinus to the nose is blocked by swelling, infection, etc., the air trapped in the sinus will eventually get absorbed by the lining of the sinus, leaving sort of a vacuum in the sinus which could cause pain. A similar situation would be the ear pain that one experiences if one can’t clear their ears while going up in an airplane or diving. The problem with this theory is that there is little evidence to support it. First, very few people experience significant sinus pain in either of the above situations. Also, speaking from personal experience, years ago I had to give up scuba diving when I developed problems clearing my ears and sinuses, and every time I surfaced I had a bloody nose. The blood was coming from burst capillaries in my sinuses, but unlike my ears, I never experienced any pain in my sinuses. Finally, they did some experiments years ago in Germany where they purposely blocked people’s maxillary sinuses and then pressurized them to see what would happen. Despite high pressures, no patients ever experienced significant pain.



Inflammation of the Sinus Lining


Inflammation is known to cause pain in other parts of the body, and it is not unreasonable to assume the same would be true in the sinuses. However, one problem is that there have been several studies that have shown that the amount of pain that a patient is experiencing is not related to the amount of sinus inflammation as measured by CT scan. Also, in my own experience, some of the patients that have the worst amount of inflammation do not complain of pain at all. Finally, anti-inflammatory drugs do not seem to be particularly effective in many patients who ascribe their pain to their sinuses.



Sinus Inflammation Triggering Headaches


There has been little research examining this theory, but based on my own experience, this is the most likely explanation for sinus disease causing facial or headache pain. Many of the patients that I see that complain the most about headaches or facial pain have a strong history of either tension or migraine headaches. It is known that headaches of both types can be triggered by a wide variety of situations, and it may be that certain individuals are highly sensitive and the presence of sinus disease may act as a “trigger” to initiate other processes that result in a headache.

If It's Not Your Sinuses,
What Is Causing Your Headaches and Facial Pain?


In many cases, patients who present with pain complaints have sinus CT scans that show little, if any, sinus disease. There are a number of studies that convincingly show that these patients’ pain, rather than coming from their sinuses, may come from one of the common types of headaches or some other neurological disorder. For those whose pain consists primarily of headaches, a study was presented last year that showed that more than 90% of these patients may be suffering from some type of migraine. For patients with primarily facial pain, a study from England demonstrated that many of these patients have what is called “midfacial pain syndrome”. This is a neurological disorder of unknown cause that often responds to medications such as amytriptyline or Neurontin.

For patients that have pain and do have sinus disease on their CT scan, the problem becomes more complicated. First, many studies have shown that if you took 100 people off the street that had no symptoms of sinus disease and performed a sinus CT on them, about 35% would have some amount of sinus inflammation. Thus, having a positive sinus scan does not necessarily indicate that a patient has true sinus disease. In addition, I have seen a number of patients who were told by their ENT doctor that they had an abnormal CT scan and needed surgery. When I examined the scan, it was completely and totally normal. So, you can’t always trust what your doctor tells you, either.

So, although every patient is different, here are a few pointers: First, if chronic headache or facial pain is your main complaint, and it is not accompanied by other symptoms of sinus disease such as chronic nasal obstruction postnasal drainage, etc., it is unlikely to be caused by sinus disease. You may want to get another opinion from a headache specialist such as a neurologist. Second, be very, very careful if sinus or nasal surgery is recommended to treat your pain. Finally, if after all of the above, you still are considering sinus surgery, get a second opinion, preferably from an ENT doctor not in the same town as the one recommending surgery.
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