Unilateral Headache Starting from the Nasal Region: Likely Migraine with Cranial Autonomic Features
This presentation is most consistent with migraine with cranial autonomic symptoms, not "sinus headache," which is a common misdiagnosis among migraineurs. 1
Most Likely Diagnosis
The recurring left-sided headache originating from the left nasal region strongly suggests migraine with activation of the trigeminal-autonomic reflex, which produces nasal and periorbital symptoms that patients often misattribute to sinus problems. 1
Key Clinical Features Supporting Migraine:
- Unilateral location (left-sided predominance) 1
- Nasal region origin indicating trigeminal nerve involvement 1
- Recurrent pattern (on and off) consistent with episodic migraine 2
- Approximately 62% of migraineurs experience cranial autonomic symptoms like nasal congestion, rhinorrhea, or facial pressure 1
Critical Red Flags to Exclude
Before accepting a primary headache diagnosis, assess for these concerning features that would mandate immediate imaging:
Immediate Neuroimaging Required If:
- New onset in patient over age 50 3, 4
- Sudden "thunderclap" onset (worst headache of life) 4, 5
- Progressive worsening pattern 5, 6
- Any abnormal neurologic examination findings 4, 5
- Headache triggered by Valsalva, cough, or exertion 5
- Associated systemic symptoms (fever, weight loss, vision changes) 5
- History of cancer, HIV, or immunosuppression 5
Diagnostic Approach
Essential History Elements:
- Headache frequency (if >2 days/week, preventive therapy indicated) 7
- Medication use including over-the-counter analgesics (>10-15 days/month suggests medication-overuse headache) 7, 3
- Associated symptoms: nausea, photophobia, phonophobia, nasal congestion, tearing 1, 2
- Temporal pattern: morning headaches resolving after waking suggest sleep apnea 3
- Triggers: stress, foods, sleep changes, hormonal factors 2
Physical Examination Priorities:
- Complete neurologic examination (any abnormality requires MRI) 4, 5
- Fundoscopic examination for papilledema 1
- Temporal artery palpation if age >50 (temporal arteritis consideration) 3, 4
- Sinus percussion (though true sinusitis rarely causes isolated recurrent headache) 1
Imaging Recommendations
Neuroimaging is NOT routinely indicated for recurrent headaches with normal neurologic examination and no red flags. 1
When to Image:
- MRI brain is preferred modality if imaging is indicated 5
- CT brain only if acute hemorrhage or trauma suspected 5
- Yield of imaging in primary headache with normal exam is extremely low: tumors 0.8%, vascular malformations 0.2% 4
Management Strategy
Acute Treatment:
- Limit acute medication use to <10-15 days per month to prevent medication-overuse headache 7
- Avoid medications containing barbiturates, caffeine, butalbital, or opioids (highest rebound risk) 7
- NSAIDs carry lower risk when used <15 days/month 7
Preventive Therapy Indications:
- Headaches occurring >2 days per week 7
- Frequent use of acute medications 7, 2
- Significant disability or quality of life impairment 2
Essential Monitoring:
- Headache diary to track frequency, triggers, and medication use 7, 2
- Regular follow-up to assess treatment response and prevent medication overuse 2
Common Pitfall
The most critical error is misdiagnosing migraine with cranial autonomic symptoms as "sinus headache." This leads to inappropriate antibiotic use, unnecessary sinus imaging, and delayed appropriate migraine treatment. 1 True bacterial sinusitis causing headache typically presents with purulent nasal discharge, facial tenderness, fever, and does not follow a recurrent episodic pattern. 1