What could cause a headache centered around the nose or forehead and how should it be managed?

Headache Centered Around the Nose or Forehead

Most patients presenting with "nose headache" or "sinus headache" actually have migraine or tension-type headache, not sinusitis—true rhinosinusitis headache requires purulent nasal discharge plus either nasal obstruction or facial pain lasting >10 days or worsening after initial improvement. 1, 2

Diagnostic Approach: Distinguishing True Sinusitis from Primary Headache

Key Differentiating Features

For Acute Bacterial Rhinosinusitis (ABRS):

• Required criteria: Purulent (colored, thick) nasal drainage PLUS nasal obstruction OR facial pain/pressure/fullness 3, 2
• Timing patterns: Either symptoms persisting ≥10 days without improvement OR worsening within 10 days after initially getting better ("double sickening") 3
• Additional features: Unilateral predominance, fever >38°C, severe localized pain, elevated inflammatory markers 3
• Critical pitfall: Facial pain alone without purulent discharge is insufficient for sinusitis diagnosis 2

For Migraine (the most common misdiagnosis):

• Duration: 4-72 hours per episode 4
• Character: Unilateral, throbbing/pulsatile, moderate-to-severe intensity, worsens with routine activity 1, 4
• Associated symptoms: Nausea/vomiting OR photophobia and phonophobia 4, 2
• Important note: Up to 62% of pediatric migraineurs have nasal congestion or rhinorrhea from trigeminal-autonomic activation, mimicking sinusitis 3

For Tension-Type Headache:

• Character: Bilateral, pressing/tightening (non-pulsatile), mild-to-moderate intensity 1, 2
• Key negative features: No worsening with routine activity, no nausea/vomiting 2

Physical Examination Essentials

• Check for: Purulent nasal discharge on examination, sinus tenderness on palpation, mucosal erythema, fever 1
• Complete neurologic exam: Rule out focal deficits, papilledema, cranial nerve abnormalities 1
• Nasal endoscopy findings: When performed during symptomatic episodes, the vast majority of "sinus headache" patients show no evidence of sinus infection 5

Management Algorithm

If Viral Rhinosinusitis (symptoms <10 days, not worsening):

Symptomatic treatment only—no antibiotics:

• Pain relief: Acetaminophen or NSAIDs 3, 1
• Nasal symptoms: Intranasal corticosteroids, nasal saline irrigation 3
• Decongestants: Oral pseudoephedrine for 3-5 days maximum to avoid rebound congestion 1

If Acute Bacterial Rhinosinusitis (meets criteria above):

• First-line antibiotic: Amoxicillin-clavulanate for 7-10 days 1, 2
• Most patients respond: Recurrent bacterial sinusitis (>2 episodes/year) is rare and warrants immune workup 5

If Primary Headache Disorder Suspected:

For migraine features:

• Acute treatment: Trial of triptans—a positive response confirms diagnosis 1, 4, 2
• Chronic migraine prevention (≥15 days/month): OnabotulinumtoxinA (FDA-approved), topiramate, or amitriptyline 1, 4, 2

For tension-type headache:

• Trial of amitriptyline for prophylaxis 1, 2

Critical Red Flags Requiring Immediate Evaluation

• Orbital complications: Proptosis, visual changes, abnormal eye movements, periorbital swelling/erythema 2
• Intracranial complications: Severe headache, altered mental status, neck stiffness 2
• Giant cell arteritis (age >50): New-onset unilateral temporal/facial pain—check ESR and CRP emergently 4
• Progressive symptoms: Unilateral symptoms, focal neurologic signs, sensory disturbances warrant MRI 4

Common Diagnostic Pitfalls to Avoid

1. Do not diagnose sinusitis based on facial pain location alone—frontal or facial pain is far more commonly migraine or tension-type headache 5, 6
2. Chronic sinusitis does not cause headache unless it relapses into acute bacterial infection with obstruction 5
3. Imaging is not needed for typical viral rhinosinusitis or when clinical criteria for ABRS are already met 3
4. Do not prescribe antibiotics for symptoms <10 days unless severe or clearly worsening 1, 2
5. Sinus surgery has no role for isolated facial pain without documented inflammation and failed medical therapy 4, 2

When to Refer

• Neurology referral: If diagnosis remains unclear after initial evaluation, or if primary headache disorder requires specialized management 4
• ENT referral: For recurrent bacterial sinusitis (>2 episodes/year), complications, or failed medical therapy with documented inflammation 5