Sinus Headache or Migraine? What to Record for Two Weeks

Facial pressure, a blocked nose, pain that gets worse when you lean over the dishwasher. It looks like sinuses. In a study of 2,991 people with self-described or physician-diagnosed “sinus” headache, 88% met the criteria for migraine.

That figure is worth sitting with, because it means the single most likely explanation for a recurring sinus headache is that it is not a sinus headache. And the reason the mistake is so easy to make is that migraine genuinely produces the symptoms everyone treats as proof of sinus trouble.

Why migraine looks like a sinus problem

The nerve that carries migraine pain across your face also runs a reflex loop to the glands and blood vessels in your nose and eyes. When it fires, you get congestion, a runny nose, watery eyes, and a heavy pressure across the cheeks and forehead. These are called cranial autonomic symptoms, and they are a recognised feature of migraine rather than a sign of anything infected.

So the checklist most people apply — pressure over the sinuses, stuffy nose, worse when I bend down, comes with weather changes — describes both conditions about equally well. Every item on it is a symptom the two share. Tension headache is the third label in the same pile, and separating migraine from tension headache takes a fortnight of records rather than a judgement made during one bad afternoon.

The one sign to stop relying on

Pain that worsens when you bend forward is the sign nearly everyone treats as decisive. It isn’t. Bending, coughing and straining aggravate acute sinusitis, and aggravation by routine physical activity is part of the definition of migraine — it is one of the features clinicians count when deciding whether a headache is migrainous at all.

If the test you’re using is satisfied by both answers, it isn’t a test. Drop it and record the four things below instead.

Four things worth recording

Do this for two weeks, or for two attacks, whichever comes first. Written down at the time — the memory of last month’s headache is not evidence.

Discharge and fever. Clear, watery discharge with watering eyes fits the autonomic reflex above. Thick, discoloured discharge with a raised temperature fits an infection — though colour on its own is a weak sign, and a clinician weighs it alongside how long it has run, whether it is one-sided, and whether you improved and then got worse again. Note it honestly on the day and let them do the weighing.

The recurrence interval. Acute rhinosinusitis is an illness: it starts, it runs a course, it resolves. It does not arrive politely three times a month for six years. Write the date at the top of every episode and look at the gaps after two months. A regular monthly rhythm is a much stronger signal than anything about the pain itself, and if the interval tracks your cycle then the hormonal question is the one to answer next.

Nausea, light and sound. Feeling sick, wanting the lights off, wanting the television down. These are close to definitional for migraine and distinctly unusual in a sinus infection. People underreport them because after years of calling it a sinus headache they’ve stopped noticing that they always draw the curtains. Record them as yes or no per attack, not from memory.

What it responded to, and how fast. A decongestant, a paracetamol, a triptan, a dark room, sleep. Include the time you took it and the time things changed. A headache that reliably lifts within two hours of a triptan is telling you something specific, and it is also how the trial definitions classify a day when the other features are ambiguous.

Weather deserves a note of its own, because it’s the trigger both explanations claim. Pressure changes are blamed for sinus pain and for migraine alike, and the evidence for the migraine side is genuinely mixed — what the barometric-pressure research does and doesn’t show is worth reading before you conclude anything from a stormy fortnight.

Why the label matters more than it sounds

If it is migraine and it’s being treated as sinusitis, three things follow.

You get repeated courses of antibiotics that cannot help. You lean on decongestants and over-the-counter painkillers, and frequent use of those brings its own problem — medication overuse headache starts at ten days a month for some drug classes and fifteen for others, which is a threshold many people cross without knowing it exists. And you never get offered the treatments that work for migraine, because nobody in the room is calling it migraine.

The years lost this way are the ordinary story rather than the unusual one. People arrive at a headache clinic in their forties having had “sinus headaches” since university.

Take the record, not the theory

You don’t have to arrive at a diagnosis yourself, and you shouldn’t try to — that conversation belongs with a clinician who can examine you. What changes the conversation is turning up with two weeks of dated entries rather than a description.

Two attacks, each with a start time, the symptoms present, what you took and what happened, is enough to move things along. Writing it in a way a doctor can use in ninety seconds is a skill in itself, and describing the pain in the terms they listen for covers the vocabulary. Migraine Journal records symptoms per attack including nausea and light sensitivity, so the yes-or-no columns are already there rather than being something you have to remember to add.

If there’s fever, swelling around the eye, or a headache unlike anything you’ve had before, that’s not a fortnight-of-recording situation. Get it looked at now.