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Worsening nasal obstruction lasting days to months

Patients with severe headaches and nasal obstruction lasting several hours to a couple or three days could be a migraine, sinus infection or allergies.  The other associates symptoms noted above may be helpful.  However, patients with chronic nasal or sinus disease, that is allergies, infections, or other infectious or inflammatory disorders of the nose and sinuses will usually complain of nasal symptoms for days to weeks or months in duration.  Patients that complain of sinus symptoms associated with worsening nasal obstruction may indeed have allergies or sinusitis.  Other nasal complaints are worth searching for, notably worsening yellow or green nasal discharge or decreased sense of smell.

Worsening yellow or green nasal discharge

While migraines may cause some nasal congestion and clear runny nose, true nasal or sinus conditions will cause much more noticeable changes in nasal discharge.  Patients that complain of markedly increased amounts of thick, yellow, or green nasal discharge are more likely to have nose or sinus disease, instead of (or in addition to their) migraines.  The yellow-green discharge can either be blown out the front of the nose or “snorted" down the back of the throat, but either way, patients will notice  an abnormally large amount or frequent amount of abnormal mucus production with nose or sinus diseases such as allergies or sinusitis. 

Decreased sense of smell

Patients with severe or chronic diseases of the nose and sinuses, such as allergies or sinusitis or polyps may experience a decreased sense of smell or complete loss of sense of smell.  The sense of smell arises from special neurons the very top of the nasal cavity, which is located in the midline of the nose at a level that is a little higher than the corner of the eyes.  A condition in the nose or sinuses that causes inflammation or swelling of the nasal tissues can alter the sense of smell.  Any condition associated with polyps in the nose can obstruct airflow or alter the nerve endings in this area and cause a decreased sense of smell or loss of sense of smell.

Because the sense of smell arises from such a small area in the nose, alterations in sense of smell indicate a problem that can be pinpointed to a very small area.  Migraines and almost all other headache syndromes do not cause a loss of sense of smell because they do not affect the small area in the top of the nose.  However, infections and inflammation of the nose and sinuses will affect the functioning in this area and a substantial number of patients.  So, when a patient complains of decreased sense of smell, a physician will typically focus on some disease occurring in the nose or sinuses.

An important aside is appropriate here.  That is, most patients who have a absence of sense of smell will also complain about loss of sense of taste.  It's not particularly well known that the tongue only taste sweet, sour, salty, and bitter taste.   The remainder of our  “taste experience" is actually a "smell experience".  When the olfactory neurons, which process the sense of smell, are damaged or air cannot reach them, patients will complain of decreased sense of smell and taste.  In actuality, most can taste sweet, sour, salty and bitter foods, but all of the other “taste” (which is smell really) are lost.   So patients with loss of smell often complain of loss of taste.  

Mild loss of smell might be noticed as a patient being unable to smell food cooking in the kitchen, while markedly diminished sense of smell may be noticed by an inability to smell a skunk on the road or other foul odors.

Any combination of worsening nasal obstruction, worsening nasal discharge, and decreased sense of smell

Any combination of these three symptoms makes it far more likely that there is a disease of the nose or sinuses occurring.  Remember, since headache conditions are common, there is also the possibility that a patient can have a nasal or sinus disease (such as chronic sinusitis) and some other headache syndrome as well.