Here’s a headache question from M.

On Dec. 5th I became completely overwhelmed with fatigue. I had what felt like a sinus headache (over my eyes, on my forehead and temples). I was also congested (yellowish nasal discharge), nauseous with a sore throat, body aches and a low-grade fever. It was so awful that I could not sit up or get out of bed. It literally hurt to move my eyeballs. I also slept for 10-12 hours a night. I went to my GP on Dec. 9th and was diagnosed with a sinus infection and given a prescription for amoxicillin and allegra-D. I began feeling better within 2 days and took the meds for 7 days total (although I had missed a couple doses near the end). About 2 days after I finished of the amoxicillin I was hit again with the fatigue, headache, nausea, body aches (but no fever). Although this time I had no congestion. I thought maybe the infection was still lingering (because I missed a couple doses). So, on Dec. 24th I went to the urgent care center and was given another prescription for augmentin (2 weeks worth). I took that religiously. Again, I felt better in about 2 days. I stopped taking the allegra completely. During those 2 weeks, I went to an ENT and he had me get a CT scan of my sinuses. The CT came back clear, no infection, no blockage. After finishing the augmentin, AGAIN 2 days later, I felt the headache coming on again. I called my ENT and told him what was happening. He said I may have been having migraines, which were being relieved by the antibiotics because they are also anti-inflammatory. He suggested I see a neurologist/headache specialist for more testing. When he mentioned “anit-inflammatory,” I immediately wondered if ibuprofen would have helped just as well. I took 3 Motrin and my headache that night disappeared. I had spent over $100 in meds up to this point, only to have a $2.50 bottle of Motrin do the same trick.I have not had a headache in 2 days now AND I have not been taking any meds, including Motrin. I sometimes feel as if a headache is about to come on, but then it passes. But nothing like the episodes I just had. I have never had a migraine before in my life, so I’m not sure what one is supposed to feel like (and it does not run in my family). I have had seasonal allergies/sinusitis, but this pain was far worse. And the fatigue totally incapacitated me. Now that I think back, maybe it wasn’t so much fatigue but a desperate need to put my head down and stay there. It had a dizzying sort of effect (like when you have a high fever) that made me drowsy and very weak.

So my questions are: are my symptoms typical of a migraine? Is it likely that something more serious may be causing these symptoms? I had concerns of a possible aneurysm, brain tumor, stroke–but, if that were the case, would I be feeling better with just a few Motrin?? And I haven’t had a headache since then–I feel completely normal. I know if I see a neurologist, I will be going through some extensive (and expensive) testing. Is this really necessary right now? I really have no other medical history. I’m not allergic to anything, no other major illness or injuries, no previous surgeries. I really didn’t even have allergies up until a couple of years ago.

Dr. Joshua’s answer:

Initially, you probably had a viral infection: a cold. All the symptoms fit. The viral infection caused meningeal (tissue surrounding the brain) irritation - hence the eye movement pain and headache. It does sound like you developed sinusitis. You were given antibiotics, got better (whether the antibiotics made you better is open for debate), then possibly got recurrent sinusitis and were given another antibiotic - with a slightly wider spectrum - and got better again. However your CT scan showed no signs of sinus infection. It is possible that you did have sinusitis, and the antibiotic treatment resulted in what we call “radiological” cure, i.e. the pictures look nice after treatment. However, it’s hard to say for sure whether you had sinusitis because you didn’t have an x-ray (which would have been as good as the CT) taken before the treatments.

The Cochrane database for evidence-based medicine has this to say about antibiotics and sinusitis:

Compared to control, penicillin improved clinical cures [relative risk (RR) 1.72; 95% CI 1.00 to 2.96]. Treatment with amoxicillin did not significantly improve cure rates (RR 2.06; 95% CI 0.65 to 6.53) but there was significant variability between studies. Radiographic outcomes were improved by antibiotic treatment. Comparisons between classes of antibiotics showed no significant differences: newer non-penicillins versus penicillins (RR for cure 1.07; 95% CI 0.99 to 1.17); newer non-penicillins versus amoxicillin-clavulanate (RR for cure 1.03; 95% CI 0.96 to 1.11).For acute maxillary sinusitis confirmed radiographically or by aspiration, current evidence is limited but supports the use of penicillin or amoxicillin for 7 to 14 days. Clinicians should weigh the moderate benefits of antibiotic treatment against the potential for adverse effects.

In plain English: there is SOME evidence that antibiotic treatment is effective for a CONFIRMED (x-ray, ct, or maxillary sinus needle aspiration) acute sinusitis. Amoxicillin is not any better than regular penicillin.Your ENT doc said something very strange - that the antibiotics would relieve migraine by an anti-inflammatory mechanism. This, of course, is not true at all.

To answer your specific questions:
Initially, it does seem like you had a cold, sinusitis and that was the cause of your headaches. But then you describe some typical signs of migraine headaches: you feel a headache coming on, even before your headache actually starts, you feel nauseated, you are sensitive to smells, and sensitive to light. Ibuprofen helps. Sounds like migraine to me.

So, based on what you told me, I would guess you had a cold, sinusitis, visits to the doc, prescriptions, CT scan, and all of this contributed to added stress which provoked migraine headaches. Anyone can get migraine headaches under stressful conditions, even if they haven’t had migraines before.

So, should you go see a neurologist now? In my opinion, not necessary. You do not have headaches now, you feel “completely normal”. Your symptoms are not suggestive of brain tumor, stroke, meningitis, or aneurysm. (Actually, aneurysms, unless giant, rarely cause any symptoms at all before they rupture and cause hemorrhage).

In my opinion you’re OK to let it go for now. However, if the headaches keep bothering you in the days to come, or they keep getting worse, or if you develop any other neurological symptoms (such as double vision, limb weakness or other strange stuff, i.e. you stop feeling “completely normal”), I’d recommend you see a neurologist. A good neurologist won’t need to run all kinds of expensive tests - just a complete history and careful clinical examination is sufficient in the vast majority
of cases. Also, if you’re overly worried, a visit to the neurologist will put your mind to rest.

Dr. Joshua