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Abstract & Commentary
Synopsis: Headaches commonly attributed to sinus are very likely to be migraines.
Source: Schreiber CP, et al. Arch Intern Med. 2004;164(16):1769-1772.
Recruiting 2991 patients from 452 North American primary care practices, Schreiber and colleagues set out to document headache symptoms and severity, degree of disability, and medication efficacy. The primary end point was the percentage of patients who reported a sinus headache (either self-report or physician-diagnosed), but met International Headache Society (IHS) criteria for migraine headache. The eligibility criteria were: between ages 18 to 65, and at least 6 sinus headaches within the 6 months preceding screening. Patients who had a diagnosis of migraine headache or use of triptans, had x-ray confirmation of sinusitis within the preceding 6 months, or had headache with fever and purulent nasal or nasopharyngeal discharge were excluded. The patients were 77% female, 85% white, and average age was 39.3 years.
At screening, 2396 patients (80.1%) fulfilled IHS criteria for migraine, with or without aura. The vast majority of patients (97%) rated their headaches as moderate or severe. The average disability rating was very severe. Over two-thirds expressed dissatisfaction with their current medication (nonnarcotic analgesics, nonsteroidal anti-inflammatory drugs, decongestants, and antihistamines).
Comment by Allan J. Wilke, MD
This is not the first report of misclassification of headache. This study used the IHS criteria to diagnose migraine headaches, and the 6-item Headache Impact Test (HIT-6) to evaluate disability from headache. The IHS criteria were first published in 1988, and a second edition was published this year. The 2004 IHS criteria for migraine, without aura (AKA common migraine, hemicrania simplex), are:
a. At least 5 attacks fulfilling criteria b-d
b. Headache attacks lasting 4-72 hours (untreated or unsuccessfully treated)
c. Headache has at least 2 of the following characteristics:
1. unilateral location
2. pulsating quality
3. moderate or severe pain intensity
4. aggravation by, or causing avoidance of, routine physical activity (eg, walking or climbing stairs)
d. During headache at least 1 of the following:
1. nausea and/or vomiting
2. photophobia and phonophobia
e. Not attributed to another disorder
The criteria for migraine with aura are similar, except, of course, for the additional criteria for aura. The astute reader will note there is no mention of sinus or eye symptoms, eg, no rhinorrhea, no nasal congestion, no sinus pain or pressure, nor any lacrimation. It should not be surprising that these symptoms could occur with a migraine. After all, we accept unilateral rhinorrhea, congestion, and lacrimation as part of cluster headache. Additionally, Schreiber et al provide a plausible explanation for these symptoms that invokes the innervation of the sinuses. The trigeminal nerve, along with sympathetic and parasympathetic fibers, constitute the nerve supply. The trigeminal nerve is known to be involved with migraine pathogenesis, and can stimulate sympathetic and parasympathetic nerves.
The IHS does recognize headache attributed to rhinosinusitis (AKA sinus headache). The criteria for it are:
a. Frontal headache accompanied by pain in 1 or more regions of the face, ears, or teeth, and fulfilling criteria c and d
b. Clinical, nasal endoscopic, CT and/or MRI imaging, and/or laboratory evidence of acute or acute-on-chronic rhinosinusitis
c. Headache and facial pain develop simultaneously with the onset, or acute exacerbation, of rhinosinusitis
d. Headache and/or facial pain resolve within 7 days after remission, or successful treatment of acute or acute-on-chronic rhinosinusitis
It also addresses the confusion of migraine without aura accompanied by facial pain and nasal congestion with headache attributed to rhinosinusitis, and makes the point that you need purulent nasal discharge to diagnose the latter.
Is this simply a case of calling a rose by another name? I don’t think so. We have at our disposal medications (the triptans, the ergotamines, dihydroergotamine) that are very good at treating migraine. However, treating a migraine headache accompanied by nasal symptoms with medications appropriate to a sinus infection is less likely to help our patients.
Caveat: GlaxoSmithKline, who has a vested interest in our prescribing certain triptans, supported this study.
Dr. Wilke, Associate Professor of Family Medicine, Medical College of Ohio, Toledo, OH, is Associate Editor of Internal Medicine Alert.
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