Question: I have a migraine every morning. I’ve had it for several months now. I’ve always had them, but not like this. I’ve noticed if I blow my nose in the middle of the night or right before bed then I wake up in the night with a...

This is part of our Case Studies in Headache Series which can be found in the National Headache Foundation's newsletter, the NHF Head Lines. By Philip Bain, M.D. Wilkinson Medical Clinic Hartland, Wisconsin THE CASE C.B. is a 45-year-old female who presented to her new primary care physician recently to establish care. She has been quite healthy except for recurrent sinus headaches. These headaches began approximately 15 years ago and, at least initially, nearly always responded to antibiotics. She had an agreement with her previous healthcare provider that when her sinuses acted up, he would call in a prescription for a course of antibiotics. After taking the antibiotics for 2-3 days, her headaches would almost always go away. The headaches were located over the forehead and cheeks. She rarely noted fevers or chills, but would often have clear nasal discharge and nasal congestion. Her stomach was also upset, which she attributed to post nasal drainage. The episodes would occur 8-9 times per year and, at times, were so bad that she would have to miss work because of the pain. Because of her frequent episodes, she had been referred to an ENT physician. He ordered a CT scan of her sinuses which showed mild inflammation of the lining of the sinuses as well as a deviated septum. C.B. underwent two separate surgeries to correct the septal deviation and to improve the drainage from the sinus passages. The headaches improved after the first surgery, but then gradually returned to their previous pattern. C.B. saw numerous other healthcare providers over the years for these sinus headaches and even tried such therapies as acupuncture, chiropractic, cranial sacral therapy, and a TMJ splint. She presented to her new primary care physician frustrated and resigned to suffer from these recurrent headaches. This case represents a classic example of a patient with a long history of headaches, incorrectly attributed to recurrent sinus infections. The likelier cause of her headaches is migraine without aura. This is an important presentation of migraine to recognize because it is too often misdiagnosed, but very treatable. It can be very difficult for patients to accept that their headaches are migraine and not sinus-related. This can lead to years of inappropriate treatment and needless suffering.