2. DEFINITION
 An Inflammatory condition involving the
paranasal sinuses and linings of the nasal
passages that lasts 12 week or longer
 This diagnosis requires objective evidence
of mucosal inflammation

3. Types of Rhinosinusitis
per Temporal Course based on Duration of Symptoms
 ACUTE : lasts up to 4 weeks, with total resolution
of symptoms
 SUBACUTE : lasts > 4 weeks but < 12 weeks
 RECURRENT ACUTE : 4 or more episodes per year, with
resolution of symptoms between attacks
 CHRONIC : 12 weeks or more of signs / symptoms
 ACUTE EXACERBATION OF CHRONIC RHINOSINUSITIS

4. Primary or secondary headache ?
 Primary :
- No other causative disorder
 Secondary :
- Headache occuring with another disorder

5. EPIDEMIOLOGY
 Headache attributed to rhinosinusitis commonly known
as sinus headache is probably one of the most prevalent
secondary headache
 Chronic rhinosinusitis is not always associated with
headache
 Headache is experienced in three out of four patients
with chronic rhinosinusitis ( Moretz , 2006)
 Chronic rhinosinusitis gives a ninefold increased of
chronic headache (Aaseth, et al. 2010)

6. • Sinusitis is overdiagnosed as a cause of headache
and facial pain
• 60 % of patients with unrecognized migraine
attrributed to their symptoms to sinusitis
• Rhinosinusitis is an uncommon cause of facial pain
• > 80% of patient with purulent secretions visible on
nasal endoscopy have no facial pain

7. CLINICAL FEATURES
• The headache associated with rhinosinusitis are usually
continuous
• Pain in maxillary sinusitis usually in the :
– Cheek
– Gums
– Maxillary teeth on affected side
• Pain in frontal sinusitis:
– frontal headache over the sinus
– the medial side of the orbital floor
– under the supra orbital ridge

8.  Frontal sinusitis can result in :
– Brain abscess
– Meningitis
– Subdural or epidural abscess
– Osteomyelitis
– Orbital edema
– Orbital cellulitis
 Ethmoid sinusitis typically produces pain in between the eyes
– Coughing, straining and lying supine can worse the pain
– Keeping the head upright lessen it
 Complication of ethmoid sinusitis: meningitis, orbital cellulitis,
cavernous sinus thrombosis

9.  Headache is always present in sphenoid sinusitis :
– Frontal
– Temporal
 Complication of sphenoid sinusitis:
– Meningitis
– Cavernous sinus thrombosis
– Subdural abscess
– Ophthalmoplegia
– Pituitary insufficiency

10. DIAGNOSIS
Headache attributed to rhinosinusitis
Diagnostic criteria: (ICHD-II / IHS 2004)
A. Frontal headache accompanied by pain in one or more regions of
the face, ears or teeth and fulfilling criteria C and D
B. Clinical, nasal endoscopic, CT and MRI imaging and/or laboratory
evidence of acute or acute on chronic rhinosinusitis
C. Headache and facial pain develop simultaneously with onset or
acute exacerbation of rhinosinusitis
D. Headache and/or facial resolution within 7 days after remission

11.  Notes:
1. Clinical evidence may include purulence in the nasal cavity,
nasal obstruction, hyposmia/anosmia
2. Chronic sinusitis is not validated as a cause of headache or
facial pain unless relapsing into an acute stage.

12. A major challenge to studying headache attributed to
sinus disease  Lack of uniform diagnostic criteria
1. The AAO-HNS Classification: Headache as one
of several criteria for diagnosis
2. The ICHD-II/IHS Classification: Requires the existence of
specific pathophysiological
condition that explain the
headache

13.  The ICHD-II does not accept chronic rhinosinusitis as a
cause of headache or facial pain unless relapsing to
an acute stage
 Several primary headache : migraine, tension-type
headache and cluster headache  misclassified as
rhinosinusitis or sinus
headache
 On the other hand, nasal and sinus related pain may
mimic migraine attacks or Tension-type headache
attacks

14. Diagnostic criteria for Rhinosinusitis and headache attributed
to rhinosinusitis
(requires 2 Major Factors, or 1 Major & 2 Minor)
Major Factors Minor Factors
― Facial Pain / Pressure – Headache
― Nasal Obstruction / Nasal – Fever
Congestion – Halitosis
― Nasal or Post-Nasal
– Fatigue
Discharge/ Purulence/
discoloured post nasal
– Dental Pain
drainage – Cough
― Hyposmia / Anosmia – Otologic symptoms
― Purulence in nasal cavity – Ear pain/pressure/fullness
on examination
The AAO-HNS Classification

15.  One of these signs of inflammation must be present and
identified in association with ongoing symptoms
consistent with chronic rhinosinusitis:
A. Discoloured nasal drainage from the nasal passages,
nasal polyps or polypoid swelling as identified on physical
examination with anterior rhinoscopy after decongestion
or nasal endoscopy
B. Oedema or erythema of middle meatus or ethmoid bulla
on nasal endoscopy

17. Migraine and tension-type headache are
often confused with Headache attributed
to rhinosinusitis because of similarity in
location of the headache

18. TREATMENT
 Patients with chronic rhinosinusitis experience
headache relief after sinus surgery
 Topic nasal corticosteroids were reported as the
second most frequent reason for headache
improvement
( Aaseth, et al. Cephalalgia 2010, 30 (2) : 152-160 )

19. SUMMARY
 Chronic sinusitis is significantly associated with chronic
headache
 Both the classification of The AAO-HNS classification
and The ICHD-II/IHS classification provide diagnostic
criteria for the diagnosis rhinosinusitis related to
headache
 Patients with chronic rhinosinusitis experience
headache relief after sinus surgery