Can a patient with a history of migraines and ADHD experience migraines related to congestion?

Migraine Can Present with Congestion-Like Symptoms, But This is Not "Sinus Headache"

Yes, patients with migraine—including those with ADHD—commonly experience nasal congestion and sinus pressure during migraine attacks, but these are migraine symptoms, not separate sinus-related headaches. The critical distinction is that what patients and many clinicians call "sinus headache" is actually migraine in approximately 88-90% of cases 1, 2.

The Diagnostic Confusion Between Migraine and "Sinus Headache"

The most common misdiagnosis in headache medicine is labeling migraine as "sinus headache." Research demonstrates that 88% of patients with self-described or physician-diagnosed "sinus" headache actually meet International Headache Society criteria for migraine 1. The confusion arises because:

• Sinus-area symptoms are extremely common in migraine: 84% report sinus pressure, 82% report sinus pain, and 63% report nasal congestion during migraine attacks 1
• These symptoms are part of the migraine process itself, not evidence of sinus disease 1, 2
• True bacterial sinusitis requires: purulent rhinorrhea persisting beyond 10-14 days, fever, and facial-dental pain 3

Key Diagnostic Criteria to Distinguish Migraine from Sinusitis

Apply the International Classification of Headache Disorders (ICHD-3) criteria systematically 3:

Migraine Without Aura Requires:

• At least 5 attacks lasting 4-72 hours (untreated) 3
• At least 2 of: unilateral location, pulsating quality, moderate-to-severe intensity, aggravation by routine physical activity 3
• At least 1 of: nausea/vomiting OR photophobia and phonophobia 3

True Bacterial Sinusitis Presents With:

• Persistent purulent nasal discharge beyond 10-14 days 3
• Fever and facial-dental pain (not just pressure) 3
• Mucosal erythema and purulent secretions on examination 3

Critical pitfall: The differential diagnosis of sinusitis explicitly includes "vascular headaches-migraines" 3. Headache attributed to chronic sinusitis is likely a migraine equivalent 3.

Special Considerations for Patients with ADHD

Your patient with both migraine and ADHD represents a well-documented comorbidity 4, 5:

• Migraine prevalence is significantly higher in ADHD patients: 28.3% versus 19.2% in controls (OR 1.67) 4
• The association is particularly strong in men: 22.5% versus 10.7% (OR 2.43) 4
• ADHD medications can trigger or worsen headaches: Stimulants like Vyvanse commonly cause headaches as an adverse effect 6

Management Algorithm

Step 1: Confirm Migraine Diagnosis

Ask directly: "Do you have headaches on 15 or more days per month?" 3. If yes and meeting migraine criteria on ≥8 days/month for >3 months, this is chronic migraine 3.

Step 2: Rule Out True Sinusitis

Red flags requiring imaging or ENT referral 3:

• Purulent discharge >10-14 days
• Fever
• Unilateral facial swelling or erythema
• No response to migraine-specific treatment

If no red flags and recurrent pattern: This is migraine with sinus-area symptoms, not sinusitis 1, 2.

Step 3: Optimize Migraine Treatment

For acute attacks 3, 6:

• Restart previously effective triptan (e.g., Maxalt) 6
• Limit acute medication to <10 days/month to prevent medication-overuse headache 6

For chronic migraine prevention 3:

• Topiramate has the strongest evidence for chronic migraine (Level A) 3
• Consider reducing/discontinuing stimulant medications if temporally related to headache worsening 6

Step 4: Avoid Common Pitfalls

Do not 3, 6:

• Attribute symptoms to "sinus headache" without imaging confirmation of sinusitis 7
• Treat empirically with antibiotics or decongestants when migraine criteria are met 3, 2
• Use opioids or butalbital-containing medications 6
• Delay migraine-specific treatment while pursuing sinus evaluations 1, 2

Bottom Line for Your Patient

This patient likely has chronic migraine with prominent sinus-area symptoms, not sinus-related headaches. The presence of ADHD increases migraine risk, and ADHD medications may be contributing to headache frequency 6, 4. Treat as migraine first—if symptoms persist despite optimal migraine management and you see purulent discharge >10-14 days with fever, only then consider sinusitis 3, 1.