Clara’s Sinus Headaches

When people come to my office with “sinus headaches”, they often ask for an antibiotic and perhaps something for congestion. Pain in the forehead, behind the eyes or in the cheekbone area doesn’t always mean infection, though.

Clara was a widow in her seventies, who had experienced frequent and severe sinus headaches for years. She even had postnasal drip and a recurrent sore throat. I ordered a CT scan, which was negative; there was no sign of cancer or polyps, but also no sign of sinusitis. On this, one of many office visits, she asked for antibiotics. I agreed to prescribe something while we waited to get the scan.

When we had a follow-up visit to review the scan, I told her the films were completely normal. She told me the antibiotics had cleared all her symptoms, just like every time her previous doctor had prescribed them. How could she not have had a sinus infection when the antibiotics always made her feel better? It wasn’t long before she came back with another request for antibiotics.

The antibiotics always had to be brand name – she insisted generics made her feel badly and they never cleared her sinuses. The pharmacists would call and point out that the generic version of her favorite antibiotic was actually made by the same manufacturer as the brand name. Clara was unconvinced. She had good insurance, and all she needed me to do was check the box on the prescription and write “Brand Medically Necessary”. This is what she insisted on for her antibiotics as well as for her maintenance heart medications.

I didn’t feel comfortable with Clara’s repeated requests for antibiotics, so I sent her for a couple more CT scans over the years, and she reluctantly agreed to see an allergist and an ear, nose and throat specialist. She didn’t like either of them, and they didn’t help her. She seemed to enjoy her visits with me, and she often said that she wouldn’t know what to do without me; on the way out she would hug me good-bye.

Clara often seemed a little sad and lost. Her husband had always taken good care of her, although I wasn’t sure how happy their marriage had been. She had never involved herself with practical or financial matters. Now she was struggling with what to do with their mobile home in Florida, and she fretted about whether to sell their house, which was too large and too expensive to heat. I would try to help her find the confidence to tackle things one at a time.

We finally had a heart-to-heart talk about her headaches. I suggested we stop treating her with antibiotics, and she asked me if I thought she was just imagining them. I reassured her that I didn’t think so, but explained that you can have temporary congestion without infection.

Clara sold her home and moved into a senior citizen complex. I was busy, and didn’t notice how much time had passed. One day recently my office nurse, Autumn, grinned and said “Guess who just made an appointment to switch all her prescriptions to generics!”

Clara entered the office with an air of confidence and dressed to the nines. “You look well”, I pointed out. “I’m happy,” she beamed, and pointed out a new diamond ring. 

Clara had not been in for well over six months. She never had headaches anymore, and she thought it was time she tried the generics. I knew her problem had never been her sinuses. And I knew it wasn’t all in her head; all along it had been in her heart.

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.


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