Sinus Headache — Or Is It Migraine?

1. Introduction

Why So Many People Think They Have a Sinus Headache

Facial pain, pressure, and nasal congestion are widely recognized symptoms, especially in Australia, where seasonal changes and high pollen counts exacerbate allergy and respiratory conditions. Advertising of “sinus relief” products in pharmacies and supermarkets reinforces the idea that these symptoms are always caused by sinus problems. However, medical research has revealed a much more complex reality. The trigeminal nerve (the main sensory nerve of the face) is responsible for transmitting pain from both sinus regions and migraine attacks, leading to significant overlap in how these conditions feel and present¹.

The confusion is not just academic – it affects everyday Australians. Environmental triggers common in Australia, such as wild weather swings, barometric pressure changes (drops or rises in the weight of the air), and airborne allergens, can prompt both migraine and sinus symptoms²³. This means many Australians have lived for years treating “sinus headaches” with over-the-counter medicines, only to discover that their true underlying issue was undiagnosed migraine.

The Real Story Behind That Pressure and Pain

Migraine is a neurological disorder (an illness involving nerves and the brain) characterised by recurring attacks of head pain and other symptoms — such as sensitivity to light, sound, smells, and, in some cases, nausea and vomiting. A critical discovery in the past decade is the role of calcitonin gene-related peptide (CGRP, a protein released by nerves during migraine) in causing blood vessels in the head to widen (dilate), leading to swelling, pressure and nerve-driven nasal symptoms. These effects are called neurogenic, which means the cause is from nerves, not germs or allergies⁴⁵.

Recent studies show that between 40% and 70% of people with migraine experience cranial autonomic symptoms (CAS — features driven by the involuntary nervous system, including watery eyes, runny or blocked nose, and flushing)⁶⁷. These symptoms, long thought to be exclusive to sinus disease or allergies, are now recognized as classic features of migraine. This overlap sets the scene for frequent diagnostic mistakes.

The impact is enormous. Migraine is among the top causes of disability worldwide, and in Australia alone, its annual cost is estimated at $35.7 billion when you include lost work, healthcare, and diminished quality of life³⁸.

2. What Is a Sinus Headache?

Traditional Definition

A true sinus headache is classified by the International Classification of Headache Disorders (ICHD-3) as a secondary headache — meaning it’s caused by another health problem, specifically acute rhinosinusitis (inflammation of the sinuses and nasal passages lasting fewer than 12 weeks)⁵. Unlike migraine, which is a primary disorder, sinus headache is considered a symptom of active infection. The gold-standard guideline in Europe, EPOS 2020, agrees: a diagnosis of sinus headache requires evidence of ongoing sinus infection⁹.

Associated Symptoms (Congestion, Facial Pressure, etc.)

True sinus headache is usually marked by:

• Thick (not clear), coloured nasal mucus
• Fever over 38°C (a sign the body is fighting an infection)
• Severe, constant pain over the sinuses, worsening with bending forward or lying back
• Loss or reduction of smell
• Swelling or tenderness in the face
• Halitosis (bad breath, more common with bacterial infection)
• Sore throat and cough (from mucus dripping down the back of the throat, called post-nasal drip)
• Sometimes toothache, because the roots of your upper teeth are next to the sinus cavities⁹¹⁰.

Chronic rhinosinusitis (lasting more than 12 weeks) is a different beast: it mainly causes nasal blockage, poor smell, and persistent drip, but rarely produces severe, daily headache unless a flare occurs⁹.

3. The Sinus Headache–Migraine Mix-Up

Research: Up to 90% of “Sinus Headaches” Are Actually Migraine

Perhaps the most striking finding in recent years is that up to 90% of patients diagnosed with “sinus headache” actually meet clinical criteria for migraine. This was established by two pivotal studies:

• The 2004 multicentre study by Schreiber and colleagues, which placed the misdiagnosis rate at 88% among patients presenting with “sinus headache”¹.
• The Sinus, Allergy and Migraine Study (SAMS) from Mayo Clinic, 2007, showing 86% misdiagnosis in U.S. outpatient populations².

Backing these results, a thorough 2019 meta-analysis of global trials showed misdiagnosis rates ranging from 55% to as high as 88% depending on the population studied¹¹. Meanwhile, the Global Burden of Disease Study calculates that migraine affects 1.3 billion people worldwide (including Australia), making it a vastly more frequent cause of “sinus” symptoms than true sinus infection⁸.

Importantly, the presence of cranial autonomic symptoms (CAS) like watery eyes, nasal congestion, or facial sweating is now considered common in people with migraine — averaging about 40–70% in specialist clinic samples, not just rare cases⁶⁷.

Why This Misdiagnosis Happens

Key reasons for confusion include:

• Shared pain pathways: Both sinus and migraine pain are carried by the trigeminal nerve, so the pain feels much the same.
• Cranial autonomic symptoms in migraine: Watery eyes, nasal blockage, and runny nose are present in a large proportion of people with migraine — once thought exclusive to sinusitis⁶.
• Imaging pitfalls: CT scans and MRIs often show “incidental” sinus abnormalities in 15–40% of healthy people with no symptoms¹². This can trick clinicians into blaming the sinuses.
• Over-the-counter pain relief: Many OTC “sinus” remedies actually contain simple painkillers that will temporarily help migraine, leading people to misattribute relief to sinus causes¹.

4. Migraine Symptoms That Mimic Sinus Headache

Migraine is especially confusing because it can produce symptoms that seem — to both the patient and their doctor — indistinguishable from sinus disease. Here’s how:

Nasal Congestion and Runny Nose

About 32–56% of migraine attacks feature clear nasal discharge and blockage, caused by involuntary nerve reflexes (not germs)⁶⁷.

Facial Pain and Pressure

The pain in migraine may focus over the cheeks or forehead — exactly where you’d feel a sinus headache. However, migraine pain often fluctuates, waxing and waning instead of remaining constant¹².

Tearing or Eye Redness

Classic “cranial autonomic” features — watery or red eyes — are reported in up to 45% of people with migraine, more so in specialty clinics than in the general population¹³⁶.

Fatigue and Brain Fog

A wide range of symptoms beyond headache are seen in migraine, including fatigue (feeling unusually tired) and “brain fog” (slowed thinking and trouble concentrating), especially after an attack⁵.

Glossary note: “Autonomic” refers to bodily functions controlled involuntarily, like sweating or nasal mucus production. “Neurogenic” means symptoms originate from nerve processes, rather than from infection or inflammation.

5. How True Sinusitis Headache Differs

Acute Sinusitis: Symptoms and Timeline

True sinus infection (acute rhinosinusitis) usually develops after a cold or upper respiratory illness. Symptoms peak at 7–14 days and include:

• Fever > 38°C
• Thick or coulored nasal mucus (green/yellow)
• Reduction or loss of smell
• Severe facial pain, especially when bending or chewing
• Toothache (upper jaw)
• Fast improvement (within 2–3 days) with antibiotics, if the infection is bacterial⁹¹⁰.

Chronic Sinusitis vs. Migraine

Chronic sinusitis is defined as ongoing symptoms (>12 weeks), mainly nasal blockage, poor sense of smell, and post-nasal drip, not daily headaches. Frequent, severe headaches from chronic sinusitis are rare unless there’s an acute flare-up⁹.

The 10%: When It Really Is Sinus-Related

Research reviewed by international headache societies confirms that only 10–15% of facial pain seen in GP or specialist clinics is primarily caused by sinus infection, and these cases respond rapidly to antibiotics or, rarely, a surgical procedure²¹¹.

6. Red Flags That It Might Be Migraine, Not Sinus

How can you tell if your pain is really due to migraine? Look for these clues:

• The headache comes and goes in attacks rather than being constant
• Sensitivity to light, sound, or smells
• Nausea or “aura” (aura means short-lasting visual or sensory changes before or at the onset of the headache, such as seeing zigzag patterns, blind spots, or pins-and-needles)⁵
• No fever or thick/coloured nasal discharge
• Headache improves with migraine medicines (like triptans) but not antibiotics
• A family history of migraine or childhood car sickness

4. Migraine Symptoms That Mimic Sinus Headache

Migraine is especially confusing because it can produce symptoms that seem — to both the patient and their doctor — indistinguishable from sinus disease. Here’s how:

Nasal Congestion and Runny Nose

About 32–56% of migraine attacks feature clear nasal discharge and blockage, caused by involuntary nerve reflexes (not germs)⁶⁷.

Facial Pain and Pressure

The pain in migraine may focus over the cheeks or forehead — exactly where you’d feel a sinus headache. However, migraine pain often fluctuates, waxing and waning instead of remaining constant¹².

Tearing or Eye Redness

Classic “cranial autonomic” features — watery or red eyes — are reported in up to 45% of people with migraine, more so in specialty clinics than in the general population¹³⁶.

Fatigue and Brain Fog

A wide range of symptoms beyond headache are seen in migraine, including fatigue (feeling unusually tired) and “brain fog” (slowed thinking and trouble concentrating), especially after an attack⁵.

Glossary note: “Autonomic” refers to bodily functions controlled involuntarily, like sweating or nasal mucus production. “Neurogenic” means symptoms originate from nerve processes, rather than from infection or inflammation.

5. How True Sinusitis Headache Differs

Acute Sinusitis: Symptoms and Timeline

True sinus infection (acute rhinosinusitis) usually develops after a cold or upper respiratory illness. Symptoms peak at 7–14 days and include:

• Fever > 38°C
• Thick or coulored nasal mucus (green/yellow)
• Reduction or loss of smell
• Severe facial pain, especially when bending or chewing
• Toothache (upper jaw)
• Fast improvement (within 2–3 days) with antibiotics, if the infection is bacterial⁹¹⁰.

Chronic Sinusitis vs. Migraine

Chronic sinusitis is defined as ongoing symptoms (>12 weeks), mainly nasal blockage, poor sense of smell, and post-nasal drip, not daily headaches. Frequent, severe headaches from chronic sinusitis are rare unless there’s an acute flare-up⁹.

The 10%: When It Really Is Sinus-Related

Research reviewed by international headache societies confirms that only 10–15% of facial pain seen in GP or specialist clinics is primarily caused by sinus infection, and these cases respond rapidly to antibiotics or, rarely, a surgical procedure²¹¹.

6. Red Flags That It Might Be Migraine, Not Sinus

How can you tell if your pain is really due to migraine? Look for these clues:

• The headache comes and goes in attacks rather than being constant
• Sensitivity to light, sound, or smells
• Nausea or “aura” (aura means short-lasting visual or sensory changes before or at the onset of the headache, such as seeing zigzag patterns, blind spots, or pins-and-needles)⁵
• No fever or thick/coloured nasal discharge
• Headache improves with migraine medicines (like triptans) but not antibiotics
• A family history of migraine or childhood car sickness

7. Diagnostic Pitfalls: Why Misdiagnosis Is Common

Even experienced doctors, let alone patients, often mix up sinus headache and migraine. Here’s why:

Overlapping Symptoms

Facial pain and nasal congestion can occur in both, making differentiation tricky for both doctors and patients¹.

Self-Diagnosis and OTC Treatments

Decongestants and OTC painkillers may relieve features of both sinus congestion and migraine. Many patients use these regularly without benefit, believing the sinus diagnosis is correct¹⁴.

Examples of Diagnostic Pitfalls

• A scan shows “sinus clouding,” but this is present in up to 40% of healthy adults with no sinus symptoms. Over-interpretation leads to misdiagnosis¹².
• The headache temporarily improves with common cold medications, prolonging belief in a sinus cause.
• Seasonal allergies overlap with migraine triggers, confusing the clinical picture.

Even Doctors Can Miss the Signs

Clinicians may focus on visible findings from imaging or on immediate infection symptoms, missing the underlying migraine – particularly in busy clinics⁸.

8. Consequences of Misdiagnosis

Delayed Migraine Treatment

A recent international study found an average diagnostic delay of 7.8 years for migraine misidentified as sinus headache, though some cases have been delayed for up to several decades¹⁵². This means patients may suffer for much of their adult life before receiving the right treatment.

Unnecessary Antibiotic Use

Incorrectly labelling migraine as sinus headache results in antibiotic overuse, with Australia experiencing rising antimicrobial resistance. The 2023 AURA report from the Australian Department of Health found antibiotic prescribing remains above recommended levels; causes include mistaken sinus diagnoses¹⁶.

Reduced Quality of Life

Migraine is now recognised as the leading cause of years lost to disability in those under 50 worldwide, and improper diagnosis delays effective interventions, increasing the burden for both patients and the healthcare system⁸.

9. How to Tell the Difference: A Symptom Comparison Chart

Source: Adapted from ⁵ and ⁹

10. What to Do If You Suspect Migraine

Talking to Your Doctor

Bring a detailed symptom diary (dates, times, triggers, medication effects). Mention prior treatments and how they failed to help. Ask clearly about migraine as a possible source.

Keeping a Symptom Diary

Tracking your symptoms using a headache diary or digital app like those listed here enables both you and your doctor to spot patterns and triggers, and match the timing of attacks to potential causes or medications tried.

Seeing a Headache Specialist

While your GP can guide initial treatment, frequent or disabling symptoms may necessitate specialist review. You can request a referral to a headache or neurology clinic. MBS-funded telehealth (Medicare-rebated) services are available nationwide in Australia as of August 2025, making it easier to access expert care, even outside major cities¹⁷.

11. Effective Treatments for Migraine Misdiagnosed as Sinus Headache

For more detail, see internal links:

• Migraine Treatment Options
• Acute Medications
• Migraine Prevention Strategies
• What Are Gepants?

Abortive Options

These aim to stop migraine attacks once begun:

• Triptans: Sumatriptan, rizatriptan, zolmitriptan, eletriptan, naratriptan — available on the PBS since the early 2000s for adults; pediatric use is limited, so specialist advice is recommended. Pack sizes and PBS charges vary⁶.
• Simple painkillers: Aspirin, ibuprofen, paracetamol.
• Anti-nausea medicines (also called ‘antiemetics’): Metoclopramide or domperidone, for migraine-related nausea and vomiting.
• Gepants (CGRP antagonists): Rimegepant, TGA-approved July 2023 (not PBS-listed as of August 2025)¹⁸.

Preventive Therapies

Prevention is aimed at reducing attack frequency and severity. These include:

• CGRP monoclonal antibodies (mAbs):
  • Galcanezumab: PBS-subsidised since 1 June 2021 for chronic migraine.
  • Fremanezumab: PBS since 1 August 2021.
  • Eptinezumab: PBS item 13352R since late 2024¹⁹.
  • Erenumab: TGA-approved, but not PBS-subsidised as of August 2025²⁰.
• Older preventives: Beta-blockers (propranolol), topiramate, amitriptyline, candesartan — all mainstays, often PBS-covered for eligible patients.
• For children/adolescents: Preventive options are more limited (topiramate, amitriptyline, under specialist guidance)⁵.

Non-Drug Approaches

Evidence supports lifestyle and behavioural changes:

• Sleep hygiene: Regular sleep and wake times can lower attack rates.
• Stress management: Cognitive-behavioural therapy and mindfulness have demonstrated efficacy.
• Physical exercise: Regular aerobic activity, within tolerance, is beneficial.
• Physiotherapy: Especially where neck pain is a trigger, the Watson Headache Approach (a physiotherapeutic technique) may help.
• Avoiding medication overuse: Keep triptans and painkillers to fewer than 10 days per month.

Headache Australia offers education and can connect you with experienced providers for non-drug support²¹.

12. Conclusion

Reframing What “Sinus Headache” Means

The vast majority of what Australians consider “sinus headache” is actually migraine — a treatable and well-understood neurological condition that calls for specific treatments, not antibiotics or basic painkillers. By distinguishing between migraine and true sinusitis, patients and clinicians can pursue more effective therapy, and avoid years of discomfort and disability.

The Importance of Correct Diagnosis

Early and accurate recognition of migraine prevents unnecessary antibiotics, reduces time lost to illness, and empowers you to take action with evidence-based tools. The growing range of PBS-subsidised treatments — and increased access via telehealth — are helping more Australians get relief than ever before.

Next Steps for Relief

If you suspect migraine, track your symptoms, consult your doctor, and use reliable resources like this website. Advocacy for correct diagnosis can change your outlook and quality of life.

References

1. Schreiber, C.P., Hutchinson, S., Webster, C.J., Ames, M., Richardson, M.S., & Powers, C. (2004). Prevalence of migraine in patients with a history of self-reported or physician-diagnosed “sinus” headache. Archives of Internal Medicine, 164(16), 1769–1772. https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/217302 (DOI: 10.1001/archinte.164.16.1769)
2. Eross, E.J., Dodick, D.W., & Eross, M.D. (2007). The Sinus, Allergy and Migraine Study (SAMS). Headache, 47(2), 213–224. https://headachejournal.onlinelibrary.wiley.com/doi/10.1111/j.1526-4610.2006.00688.x (DOI: 10.1111/j.1526-4610.2006.00688.x)
3. Deloitte Access Economics (2018). Migraine in Australia: country impact profile. https://www.painaustralia.org.au/static/uploads/files/deloitte-au-economics-migraine-australia-whitepaper-101018-wfsydysdysky.pdf
4. Edvinsson, L., Haanes, K.A., Warfvinge, K., & Krause, D.N. (2018). CGRP as the target of new migraine therapies—successful translation from bench to clinic. Nature Reviews Neurology, 14(6), 338–350. https://www.nature.com/articles/s41582-018-0003-1 (DOI: 10.1038/s41582-018-0003-1)
5. Headache Classification Committee of the International Headache Society (2018). The International Classification of Headache Disorders, 3rd edition (ICHD-3). Cephalalgia, 38(1), 1–211. https://ichd-3.org/ (DOI: 10.1177/0333102417738202)
6. Tiwari, A., Garg, R., & Singh, S. (2022). Cranial autonomic symptoms in migraine. Annals of Neurosciences, 29(1), 14–19. https://journals.sagepub.com/doi/10.1177/09727531221105719 (DOI: 10.1177/09727531221105719)
7. Gupta, R., & Bhatia, M.S. (2007). A report of cranial autonomic symptoms in migraineurs. Cephalalgia, 27(1), 22–28. https://pubmed.ncbi.nlm.nih.gov/17212679/ (DOI: 10.1111/j.1468-2982.2007.01246.x)
8. Global Burden of Disease Study (2019). Global, regional, and national burden of migraine and tension-type headache, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Neurology, 18(5), 459–469. https://www.thelancet.com/journals/laneur/article/PIIS1474-4422(18)30322-3/fulltext (DOI: 10.1016/S1474-4422(18)30322-3)
9. Fokkens, W.J., Lund, V.J., Hopkins, C., Hellings, P.W., Kern, R., Reitsma, S., et al. (2020). European Position Paper on Rhinosinusitis and Nasal Polyps 2020. Rhinology, 58(1), 1–464. https://research-portal.uea.ac.uk/en/publications/epos-european-position-paper-on-rhinosinusitis-and-nasal-polyps-2 (DOI: 10.4193/Rhin20.600)
10. Levine, H.L., Setzen, M., Cady, R.K., Dodick, D.W., Schreiber, C.P., Eross, E.J., & Blumenthal, H.J. (2006). An otolaryngology, neurology, allergy, and primary care consensus on diagnosis and treatment of sinus headache. Otolaryngology–Head and Neck Surgery, 134(3), 516–523. https://pubmed.ncbi.nlm.nih.gov/16500456/ (DOI: 10.1016/j.otohns.2005.11.024)
11. Rocha, D., et al. (2019). Sinus migraine: a systematic review and meta-analysis. Headache Medicine, 10(3), 134–145. https://www.headachemedicine.com.br/index.php/hm/article/download/1345/1994
12. Lim, W.K., Ramli, R., Goh, L.H., & Lee, K.T. (2013). Incidental detection of sinus mucosal abnormalities on CT. BMC Ear, Nose and Throat Disorders, 13, 4. https://pmc.ncbi.nlm.nih.gov/articles/PMC3636478/ (DOI: 10.1186/1472-6815-13-4)
13. Barbanti, P., Fabbrini, G., Pesare, M., Vanacore, N., & Cerbo, R. (2022). Cranial autonomic symptoms in migraine: characteristics and comparison with cluster headache. J Neurol Neurosurg Psychiatry, 93(6), 636–641. https://jnnp.bmj.com/content/93/6/636 (DOI: 10.1136/jnnp-2021-327805)
14. Ailani, J., Burch, R.C., & Robbins, M.S. (2021). Acute treatment of migraine: an American Headache Society consensus statement. Headache, 61(7), 1021–1039. https://headachejournal.onlinelibrary.wiley.com/doi/full/10.1111/head.14153 (DOI: 10.1111/head.14153)
15. Al-Hashel, J.Y., Ahmed, S.F., & Alroughani, R. (2013). Migraine misdiagnosis as a sinusitis, a delay that can last for years. J Headache Pain, 14, 97. https://thejournalofheadacheandpain.biomedcentral.com/articles/10.1186/1129-2377-14-97 (DOI: 10.1186/1129-2377-14-97)
16. Australian Department of Health (2023). AURA 2023: Fifth Australian report on antimicrobial use and resistance in human health. https://www.safetyandquality.gov.au/sites/default/files/2023-06/AURA_2023_-_Fifth_Australian_report_on_antimicrobial_use_and_resistance_in_human_health.pdf
17. Australian Government Department of Health (2025). Telehealth | Medicare Benefits Schedule. https://www.health.gov.au/topics/health-technologies-and-digital-health/about/telehealth
18. Therapeutic Goods Administration (2023). ARTG Entry for Rimegepant. https://www.tga.gov.au/resources/artg/392434
19. PBS Review and DUSC PRD (2024). Public Release Documents for Galcanezumab and Fremanezumab. https://www.pbs.gov.au/info/industry/listing/participants/public-release-docs/2024-06/REDACTED-Galcanezumab-and-Fremanezumab-review-DUSC-PRD-2024-06-final.PDF
20. Therapeutic Goods Administration (2025). ARTG Entry for Erenumab (not PBS as of August 2025). https://www.tga.gov.au/resources/artg/301374
21. Headache Australia (2024). About Us. https://headacheaustralia.org.au/about/