=
TITLE: Rhinogenic
Headache
SOURCE: The University of Texas Medical Branch (UTMB Health)
Department of Otolaryngology, G=
rand
Rounds Presentation
DATE: January 30, 2010
RESIDENT PHYSICIAN: Samuel Ross Patton, M.D.
FACULTY PHYSICIAN: Patricia Maeso, M.D.<=
span
style=3D'mso-bidi-font-weight:bold'>
DISCUSSANT: Patricia Maeso, M.D.
DISCUSSANT: Bruce Leipzig,M.D.
SERIES EDITOR: Francis B. Quinn, Jr., M.D.
ARCHIVIST: Melinda Stoner Quinn, M=
SICS
"This material was prepared by resident physicians in partial
fulfillment of educational requirements established for the Postgraduate
Training Program of the UTMB Department of Otolaryngology/Head and Neck Sur=
gery
and was not intended for clinical use in its present form. It was prepared =
for
the purpose of stimulating group discussion in a conference setting. No
warranties, either express or implied, are made with respect to its accurac=
y,
completeness, or timeliness. The material does not necessarily reflect the
current or past opinions of members of the UTMB faculty and should not be u=
sed
for purposes of diagnosis or treatment without consulting appropriate
literature sources and informed professional opinion."
Editor’s Note:
graphic images may not be displayed in the Microsoft .doc/docx version.
See .PDF version.
Introduction:
Hea= dache is a common complaint otolaryngologists evaluate in practice. Therefore, it is necessary to be profic= ient in evaluating headaches of both sino-nasal and = non-sino-nasal origin alike. Rhinogenic headache is a controversial, = but distinct type of headache that has received an increased amount of attentio= n in the literature over the past twenty years. As a somewhat unsettled topic, there is very little information in textbooks regarding this subject. = This paper aims to discuss diagnostic criteria for common headaches, define rhinogenic headache, and review the literature suppor= ting and opposing the existence of rhinogenic headac= hes.
Background:
Migraine
Migraine headaches are the most common neurological il= lness diagnosed in Europe and North America. It affects 12% of women, which is double the rate in men. The exact cause of migraine headache is still unknown although vascular, neurogenic, = and other mechanisms have been proposed. Migraines are broadly divided into two separate subtypes: with and without prodromal aura.
Migraine without Aura
Com= prising 80% of all migraines, migraine without aura is a recurrent headache disorder that manifests itself as repeated headache attacks. Episodes typically last from 4-72 hours= . Pain is typically unilateral, pulsating= in quality, moderate/severe in intensity, worsened by physical activity, and associated with light or sound sensitivity. The International Headache Society, an international multidisciplina= ry organization dedicated to treating headaches has issued the following diagnostic criteria for migraine without aura:
![](3D"HA-rhino-2012-0130-_files/image001.png")
![](3D"HA-rhino-2012-0130-_files/image003.jpg")
Migraine with Aura:
Mig= raine with aura is a related, but distinct subtype of migraine with similar diagnostic criteria. In addition to recurrent headaches described above for migraine without aura, migraine with aura involves focal neurological symptoms that occur prior to or accompany a migraine. These symptoms have a gr= adual onset over a period of 5-20 minutes and last approximately one hour. To be considered a prodromal aura, the migraine headache must begin within 60 minutes of the end of aura symptoms. Migraine with aura is le= ss common, encompassing 20% of migraines. The International Headache Society has issued the below diagnostic criteria for migraine with aura:
![](3D"HA-rhino-2012-0130-_files/image005.png")
T=
ension
Headaches
Ten=
sion
headaches are the most common type of headache.
The reported prevalence varies widely between sources, but lies
somewhere between 30-78%. Similar =
to
most headaches, the exact mechanism is unknown.
Typical features of a tension headache include bilateral pain,
infrequent headache episodes, and headache duration last minutes to days.
![](3D"HA-rhino-2012-0130-_files/image007.jpg")
![](3D"HA-rhino-2012-0130-_files/image009.jpg")
Cluster
Headache
Clu= ster headaches are acute headache attacks that occur in a series (also known as a cluster period). Cluster periods l= ast from a few weeks to several months with remission periods that can last multiple years. These clustered at= tacks can be triggered by certain identifiable irritants such as alcohol, histami= ne, and nitroglycerin. Typical features include orbital, supra-orbital, or temporal pain. During a cluster period, the headache t= ends to be on the same side but can switch sides between different cluster periods. The pain from a cluster headache is frequently excruciating and patients can be debilitated during = an acute attack. Other ipsilateral symptoms also classically accompany a cluster headache including conjunctival injection, lacrimation, nasal congestion= , rhinorrhoea, forehead and facial sweating, miosis, ptosis, and eyelid edema. The mechanism is thought to involve activation of the posterior hypothalamic gray matter. Cluster headaches afflict men at 3-4 ti= mes the rate of women. The Internatio= nal Headache Society has created the following diagnostic criteria for cluster headache:
![](3D"HA-rhino-2012-0130-_files/image011.jpg")
A=
cute
Sinusitis
The American Academy of Otolaryngology/Head and Neck Surgery (AAO-HNS) has crea= ted diagnostic criteria for acute rhino-sinusitis. Diagnosis requires two major criteria or one major criteria with two minor criteria. Headache identifie= d as a minor criteria for diagnosis, although headache features are not discussed.= The diagnostic criteria issued by the AAO/HNS for acute rhino-sinusitis are listed below:
![](3D"HA-rhino-2012-0130-_files/image013.jpg")
Of note, the AAO/HNS does not recognize headache as a
feature of chronic rhino-sinusitis
Definition of Rhinogenic Heada= che:
Diagnostic criteria=
:
A. Intermittent pain localised to the periorbital and
medial canthal or temporoz=
ygomatic
regions and fulfilling criteri=
a C
and D
B. Clinical, nasal endoscopic and/or CT imaging evidence of mucosal contact
points without acute rhinosinusitis
C. Evidence that the pain can be attributed to mucosal contact based on at
least one of the
following:
1. pain corresponds to
gravitational variations in mucosal congestion as the patient
moves between uprigh=
t and
recumbent postures
2. abolition of pain wit=
hin 5
minutes after diagnostic topical application of local
anaesthesia
to the middle turbinate using placebo- or other controls1
D. Pain resolves within 7 days, and does not recur, after surgical removal =
of
mucosal contact points
Note:
1. Abolition of pain
means complete relief of pain, indicated by a score of zero on a visual
analogue scale VAS)
Comment:
A11.5.1 Mucosal c=
ontact
point headache is a new entry to the classification for which evidence =
is
limited.
Controlled trials are
recommended to validate it, using the listed criteria for patient selection=
.
Historical Perspective:
The= concept of rhinogenic headache secondary to mucosal con= tact points is not new. J.O. Roe is cre= dited with first describing them in 1888. In the 1920’s, Sluder theorized that headaches cou= ld occur from the sinuses in the absence of inflammation or infection by the creation of a vaccum in a sinus cavity. McAuliffe et. al. performed a frequently-sited study in 1943 regarding the origin of headache and facial pain. Questioning the mechanism of “sinus headache”, McAuliffe believed that headache pain originated from the nasal cavity, sino-nasal ducts, and sinus ostia rather than from the mucosal lining of the para-nasal sinuses themselves. The study included five healthy subject= s and ten patients severe facial pain that required facial nerve ablation for sym= ptomatic relief. Different areas of the nas= al cavity and para-nasal sinuses were stimulated a= metal probe, an electric current, and a 1:1000 epinephrine solution. Each subject’s fingers were dipped in s= oft red wax. When an area in the nose = was stimulated, the patient would touch the area on the face where he or she experienced pain. Patients then ra= ted the pain on a scale from 1-9+ in intensity. The sensitivity for each area stimulated was the following:
-tongue:
= -septum: 1-2+
= -turbinates 4-6+
= -naso-frontoduct: 5-7+
= -sinus ostium: 6-9+
= -sinus lining: 1-2+
In addition, he mapped areas stimulated to the locatio= n of pain experienced. The superior nas= al structures were found to correlated with headache in the front of the head, topic of the head, and between the eyes. The middle/inferior nasal structures correlated with headache experienced in the zygoma, temple, teeth, and jaw.
Mechanism of Rhinogenic Headac= he:
Wit= h the advent of endoscopic sinus surgery, a renewed interested in headache surgery began in the late 1980’s. Stammberger and Wolfe described a potential mechanism= for nasal mucosal contact point headaches in 1988. According to their theory mechanical contact between two mucosal surfaces in the nose or sinuses creates a sensory stimulus which is known as axonal reflex. Sensory nerve endin= gs primarily from V1 and V2 extend into the nasal mucosa and nearly to the cell surface. The axonal reflex results= in the release of substance P, a vasoactive neuropeptide found in unmyelinated C fibers. Substance P causes vasodilation, plasma extravasation, histamine release, and other inflammatory events. These vascular phenomenon may be responsible for migraine-like heada= che symptoms. Since V1 innervates the = dura, this mechanism may also involve referred pain described above from V2/V3.
Supporting Evidence in the Literature:
Once
described by Stammberger and Wolfe in 1988, mul=
tiple
case series (9 identified by this review) were published showing success in
operative management of rhinogenic headache.
Problems with mec= hanism of rhinogenic headache:
A n= umber of obstacles exist concerning the proposed mechanism of r= hinogenic headache. First, McAuliffe’s findi= ngs have not been reproduced since his experiment in the 1940’s. Abu-Bakra a= nd Jones re-created the experiment in 2001. Mucosal areas of the nasal cavity and para-nasal sinuses were stimulated with a metal probe, 1:1000 epi= nephrin, substance P, and placebo (cotton with sterile water). No subjects experienced referred headac= he or facial pain. The authors concluded= that nasal mucosal contact points are coincidental.
Sec= ond, there is no clear evidence that substance P is produced by mucosal contact points. Stamm= berger described that substance P is stor= ed in localized sensory C-fibers in human nasal mucosa, but did not provide a mechanism for release by mucosal contact points. Additionally, there is no evidence that mucosal contact points elsewhere in the body create pain.
Thi= rd, there is no clear evidence of a causal relationship between mucosal contact points and headache. Abu-Bakra and Jones performed a retrospective review of 9= 73 patients evaluated to determine the correlation of headache complaints and nasal mucosal contact points. They= found that the percentage of contact points was the same in both patients with and without headache. Abu-Bakra and Jones again concluded that contact points a= re coincidental.
For=
th, the
quality of evidence supporting rhinogenic heada=
che is
poor. The evidence in the literatu=
re
supporting the existence of headaches from mucosal contact points and
effectiveness of surgery in correcting them are limited largely to uncontro=
lled
cases series with short follow-up periods.
Abu-Bakra and Jones reported a small case
series of four patients who underwent surgery for rhin=
ogenic
headache. All patients experienced
improvement between 2-12 months, but 3 patients had return of symptoms by t=
wo
years. They argued that improvemen=
t in
headache after surgery could be from the placebo effec=
or a temporary alteration in sensory pathways caused by surgical trauma.
Fin= ally, diagnosis of patients who might benefit from surgery is difficulty. Mariotti et.= al. published a case series of 33 patients who underwent surgery for rhinogenic headache. Mariotti theorized that patients with a greater surface area of mucosal contact would tend to benefit the most from surgery. He created a numerical sc= oring system to rate CT scans to identify patients with the most area of mucosal contact. He study did not find an associated between surface area of contact points and patient improvement a= fter surgery.
Future Research Needs:
Sin= ce the number of treated patients in all the combined studies of rhinogenic headache is small, further research is still needed. A high quality, prospective, controlled= trial is needed to establish better diagnostic criteria. This would likely require a multi-institutional study to obtain enough subjects for adequate power.
Practice Considerations:
Tod= ay, operating on patients for rhinogenic headache r= emains very controversial and rhinogenic headaches rem= ains a diagnosis of exclusion. Before sur= gery is considered, the patient should be evaluated by other relevant specialists and treated medically for a sufficient period of time. Diagnosing headaches from mucosal conta= ct points typically requires a number of tools including CT, endoscopy, and anesthetic block testing. Patients desiring surgery should be educated about the controversial role of surgery= and the lack of definitive proof that rhinogenic headaches can be improved in the long-term with surgery.
DISCUSSANTS: Patricia Maeso, M= D & Bruce Leipzig,MD
Dr. Patricia Maeso:
=
That
was a great review of the literature of a very difficult topic. You know these patients are extremely
difficult and so I really commend you on that.
I do have some things I want to share with everybody regarding this
topic because it's one that really interests me in that it baffles me daily=
in
my practice where I really have to sit down and really think about what I'm
going to do with this patient and how I'm going to best treat them. There are multiple studies that say that
approximately 80 to 85% of patients complain of a sinus headache where you =
sort
of have some migrainous issue and we have to be=
sure
that we know those characteristics so that we don't get confused into opera=
ting
on those patients who will not get better.
Dr. Bruce Leipzig:
=
I
agree that this is a problem that is a curse.
I see it often, if not daily in my practice. Everybody's got a headache. The problem is that sinus surgery does=
not
get rid of headaches. It was very important to us in our offi=
ce in
that we were very careful to tell our sinus surgery patients that if their
headache went away it was a matter of luck, not of a matter of plan and if =
they
were having surgery for sinus headache, they ought to think through it twice
because you could certainly take care of inflammatory sinus disease and you=
can
make anyone better for a short period of time but the real relief of the
headache was just willy nilly. After seeing thousands of patients I st=
ill
can't tell you any pattern in my
experience that would give you a clue as to whose headaches are going to go
away permanently and whose wouldn't. I
will say this, though, that nearly 100% of patients got relief for a few
months. People come to a surgeon a=
nd
they want surgery. You see this a =
lot
with the tension and cluster headaches that you dealt with. I got a lot of referrals from neurologi=
sts
not because they really thought these people had sinus headaches but because
they just couldn't get them better. You
know, they're looking for someone else to take over. These patients want pain medicine and y=
ou
can't blame them because headaches=
are
really debilitating to a lot of people.
I tended to be someone who gave headaches instead of getting them but
these people are looking for medicine and if you gave them medicine you cou=
ld
often satisfy them.
Back in my training days we called these headaches
"mucosal contact headaches" or "Sluder<=
/span>
headaches". And when I was f=
irst
in practice I thought I could treat any of these easily by resecting the mi=
ddle
turbinate, which was the most common source of those contact headaches and
everybody got better for a few weeks, or a few months, but in the long run,
nobody got better. They all got th=
ese
horrible crusting problems and they became your patients for life, but they
weren't your happy patients. I thi=
nk
surgery for so-called rhinogenic headache is a =
very
contentious thing.
References
Abu-Bakra M, Jones NS. Does stimulation of nasal mucosa cause referred pain to the
face? = Clin. Otolaryngol. 2001;26:430–432
Abu-Bakra M,. Jones NS.
facial pain compared with p=
atients
without facial pain. The Journa=
l of
Laryngology & Otology. 2001;115:629–632
Behin F, Behin B,Behin D, Baredes = S. Surgical Management of Contact Point
Headaches. Headache. 2005;45:204-210.
Bektas D, Alioglu Z, Akyol N, Ural A, Bahadi= r O, Caylan R. Surgical Outcomes for
Rhinog=
enic
Contact Point Headaches. Med
Clerico DM. Pneumatized Superior Turbinate as a Cause of Referred Migraine
Headache. Laryngoscope. 1996;106: 874-879
Giacomini PG, Alessandrini M, DePadova A. Septoturbinal Surgery in Contact Point <= /p>
Headache Syndrome: Long-Term Results. The Journal of Craniomandibular Practice. 2003;21: 130-5.
The International Classification of Headache Disord= ers, 2nd edition, (Cephalalgia = 2004;
24 sup= pl 1: 1-160
Jones, Nick S. "Sinus headaches: avoiding over- a=
nd mis-diagnosis." Expert Review of
Neu= rotherapeutics 9.4 (2009): 439+. Health Reference Center Academic. Web. 7
Jan. 2012
Mariotti LJ, Setliff RC, Ghaderi M, Voth= S. Patient history and CT findings inpredicting
surgical outcomes for patie=
nts with
rhinogenic headache.
Ear Nose and Throat
Journal. 2009;88:926-9
Parsons DS, Batra PS. Func= tional Endoscopic Sinus Surgical Outcomes for Contact Point
Headaches. The Laryngoscope. 1998;108:696-702
Perry BF, Login IS, Kountakis SE. Nonrhinol= ogic Headache in a Tertiary Rhinology.
Practice. Otolaryngology-Head and Neck Surgery= . 2004;140:449-52.
Ramadan H. Non-Surgical Versus Endoscopic Sinonasal Surgery for Rhinogenic
Headah= ce. American Journal of Rhinology. 1999;13:455-7
Roe JO. The frequent dependence of persistent and so-c= alled congestive headaches upon
abnormal conditions of the = nasal passages. Med Record. 1888;34:200-204
Senocak D, Senocak M. Sinonasal Pathology and Headaches. Rhinol= ogy. 2004;42:8-14.
Stammberger H, Wolf G. Hea= daches and sinus disease: the endoscopic approach. Ann
Otol Rhinol Laryngol Suppl 1988, 134:3–23
Tosun F, Gerek M, Özkaptan Y. Nasal Surgery for Contact Point Headaches. Headache.
2000; 40:237-240
Welge-Luessen A, Hauser R,=
Schmid N, Kappos L, Probst R.
Contact Point Headaches: A = 10-Year Longitudinal Study. The Laryngo= scope
2003, 113: 2151-6.
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