# Clinical and Multivariate Predictors of Headaches Attributed to Rhinosinusitis in Pediatric Patients: A Comparative Study with Migraine and Tension-Type Headache

## TL;DR

This study finds that headaches caused by sinus issues in children are often misdiagnosed as migraines or tension headaches, but specific symptoms like nasal and hearing issues can help distinguish them.

## Contribution

The study identifies specific clinical and multivariate predictors that can help differentiate pediatric headaches attributed to rhinosinusitis from migraines and tension-type headaches.

## Key findings

- Pediatric HRS is often misdiagnosed as migraine or tension-type headache, especially in younger children.
- Nasal and auditory symptoms, allergic rhinitis, and family history of HRS are strong predictors of HRS diagnosis.
- Structured use of these predictors with otolaryngologic assessment can improve diagnostic accuracy and reduce unnecessary neuroimaging.

## Abstract

What are the main findings?

Pediatric headache attributed to rhinosinusitis (HRS) was often misdiagnosed as migraine or tension-type headache, especially in younger children.

Multivariate analysis identified distinct predictors of HRS, including nasal and auditory symptoms, allergic rhinitis, and family history of HRS.

What are the implications of the main finding?

Incorporating otolaryngologic and allergic features into diagnostic evaluation can improve accuracy and reduce misclassification.

These predictors may help clinicians avoid unnecessary neuroimaging and provide timely, targeted therapy for pediatric patients.

Background/Objectives: Headache attributed to rhinosinusitis (HRS) is uncommon in children but often misdiagnosed as migraine or tension-type headache (TTH). Overlapping phenotypes, incidental sinus findings on neuroimaging, and limited communication in younger patients complicate diagnosis and lead to inappropriate treatment. Methods: We retrospectively analyzed 3065 pediatric patients (<19 years) presenting with headache at two tertiary neurology clinics (2014–2023) with ≥1 year follow-up. Headaches were classified by ICHD-3 criteria. HRS diagnosis required radiologic sinus pathology and ≥50% improvement within 72 h of antibiotic or decongestant therapy. Demographic, clinical, neuroimaging, and family history data were collected. Symptom profiling used principal component analysis (PCA) and k-means clustering; multivariate logistic regression identified independent predictors. Results: Of 3065 patients, 32.7% had migraines, 15.5% TTH, and 4.5% HRS. Nearly one-third of HRS cases were initially misclassified. Compared with migraine and TTH, HRS patients were younger (median 9 years), more often male, and enriched in preschool age. Independent predictors included shorter duration (<1 h; OR 0.62), higher intensity (OR 2.165), nasal symptoms (OR 9.836), hearing impairment (OR 22.52), allergic rhinitis (OR 8.468), and family history of HRS (OR 32.602) (all p < 0.001). PCA showed overlap but distinct clustering: HRS was characterized by sinonasal and otologic features, whereas migraine clustered around sensory hypersensitivity. Conclusions: Pediatric HRS shows distinct predictors—young age, acute severe headache, nasal and auditory symptoms, allergic history, and family history—despite overlap with migraine and TTH. Structured use of these predictors with otolaryngologic assessment may improve diagnostic accuracy, reduce misclassification, and avoid unnecessary neuroimaging or inappropriate therapy.