Headaches that aren't really sinus problems

For people who only have sinus pain and no other nose symptoms, it sometimes turns out that no specific sinus problem can be found to explain the pain. You may have been treated for sinus infections or allergies with little success. At some point a doctor will likely order a CT scan to look at the deep parts of the sinuses that can't be seen during an exam. In many of these people, a clear cause is never found.

When that happens, sinus pain is best treated like a headache. Too often, a specialist will say, "See, the CT scan is normal — you don't have sinus problems." I don't think that is the right way to put it. After all, if a brain MRI is normal, does that mean you don't have headaches? Of course not. The same logic applies to sinus pain. A doctor should be careful not to say things that aren't quite right or that make the patient feel like their pain is being brushed off.

The way I usually put it is: "The CT scan doesn't show any infection, blockage, or unusual shape. Antibiotics or allergy medicines probably won't help. Let's try treating this with the medicines used for headaches and see if we can get you some relief." At that point I usually try a couple of migraine medicines and refer the patient to a neurologist for a full headache workup. By this stage, most of these patients have already tried many sinus medicines anyway.

The way to explain how the sinuses can hurt without a clear physical cause is that the nerves that supply the lining of the nose and sinuses can become irritated or inflamed for reasons we don't always understand. This may be the same process that irritates the nerves around the brain lining and causes tension and migraine headaches. 

Sinus infection (sinusitis)

People often think of a sinus infection as a cause of sinus pain, and yes — it is one of the more common reasons. It's unusual for pain to be the only symptom of a sinus infection, but it does happen. If a single sinus — the one between the eyes (ethmoid), the one above the eye (frontal), or the deep one behind the nose (sphenoid) — gets blocked or infected, it can cause pain without making the nose stuffy or runny.

Clues that a blocked or infected sinus is causing the pain, even without other symptoms:

Pain on one side only
Pain that gets worse when you lean your head down low
Pain that started after a cold or sinus infection, even though the other symptoms went away
Pain that clearly gets better with antibiotics

A CT scan is usually needed to be sure of the diagnosis. Plain X-rays don't often pick up these problems. If the blockage or infection were big enough to show up on an X-ray, there would almost always also be stuffiness, blockage, or drainage. 

Jaw joint pain (TMJ — the joint where the lower jaw meets the skull, just in front of the ear)

I'm not a big fan of jumping to TMJ as the first explanation. Some doctors believe most temple or ear pain comes from the jaw joint. There are real patients with this problem, but I don't think it should be the default answer for face pain when the cause isn't clear.

Still, if you have pain right over the jaw joint, if you grind your teeth at night, or if you have had a lot of recent dental work, then it should be on the list. If chewing makes the pain worse or brings it on, or if other causes have already been ruled out, then it makes sense to look into the jaw joint as a possible source.

Jaw-joint pain is usually around the ear, the temple, or the corner of the lower jaw. It is best checked out by a dentist who has a special interest in this. It's treated with simple steps first, and then a bite splint (a small mouth guard) you can buy over the counter or get from your dentist.

A crooked wall inside the nose (deviated septum)

The bone and cartilage that divides the left and right sides of the nose is called the nasal septum. It is almost never perfectly straight. When it is very crooked, it can have sharp bony spurs that poke into the side wall of the nose — and this is not unusual. Sometimes a wide area of the septum bulges over and touches the side wall instead. Often there is no history of an injury to explain it. A crooked septum often blocks airflow, but not always.

A sharp bony spur can cause pain. The pain is usually on one side, often feels like it's on the side of the face or ear, and gets worse anytime the nose is stuffy. A simple test you can try at home: spray a decongestant nose spray (Afrin®) on the painful side. If the pain eases noticeably soon after, that supports the idea of a spur. There is even a specific name for face pain from a sharp spur — Sluder's neuralgia.

This kind of sinus pain can come and go. The usual first treatment is steroid nose sprays and the occasional use of decongestant sprays or pills. If that isn't enough, see a sinus specialist to confirm the cause and talk about next steps. A CT scan, X-ray, or a scope exam may help with the diagnosis. Long-lasting pain from a bony spur often gets better with a small surgery.  

An air pocket inside a turbinate (concha bullosa) and other shape changes

This is a fairly common normal variation. The middle turbinate (one of the scroll-shaped structures inside the nose) is normally a thin plate of bone, but in some people a small air pocket forms inside it. When that happens, the turbinate is bigger than it should be and presses against the structures next to it, which can cause pain — like trying to fit 10 pounds in a 5-pound bag.

Pain from this kind of air pocket is usually felt between the eyes. It can be on one side or both. Bigger pockets are more likely to cause pain than small ones — many small ones never cause any problem.

Other shape changes inside the nose can cause sinus pain in similar ways. They all seem to involve two structures touching that should normally have an air gap between them. A club-shaped middle turbinate, large air cells just above the nostril (agger nasi cells), and large air pockets in the area between the eyes (ethmoid bullae) are some examples.

A CT scan is needed to find an air pocket inside a turbinate and to judge how likely it is to be the cause of pain. Many smaller ones cause no problems at all. They can be treated with steroid nose sprays and decongestants, or — if symptoms are hard to control — with a small surgical procedure.

When pain is the only symptom, it may make more sense to look at other causes first. It is uncommon but not impossible for a true sinus problem to cause pain alone.

For example, pain in the upper teeth might mean a dentist visit first. Ear pain can be an ear problem or jaw-joint problem. Pain between the eyes or above the eyes is often a headache even when it feels like it's coming from the sinuses. When pain is the main or only symptom, I think getting a CT scan early is helpful so that other causes can be considered if the sinuses don't explain it.

A quick at-home test can give some clues. If two squirts of decongestant spray clearly help the pain, that points more toward a sinus cause. If the spray doesn't help, that doesn't rule out a sinus problem. This is a test, not a treatment — decongestant sprays should only be used for a few days in a row.