Sinus Headaches Reconsidered: Referred Cephalgia of Rhinologic Origin Masquerading as Refractory Primary Headaches

Abstract

Headache associated with acute sinusitis is a well-recognized entity; the diagnosis is easily made due to the associated nasal and sinus symptoms. However, the phenomenon of referred headache from chronic sinusitis or intranasal abnormalities or both without upper respiratory symptoms is not well understood. Only recently have the nasal and sinus cavities been adequately visualized by both the human eye and radiographic techniques; a fact that may account for the historic neglect in considering this region a factor in headache etiology. Modern techniques employed in the workup of sinusitis, namely the use of rigid nasal endoscopes and coronal-plane CT scanning, have greatly enhanced the clinician's ability to evaluate and diagnose pathology in this area. This report describes a series of patients presenting with various primary headache syndromes without significant nasal or sinus symptoms who failed to respond to conventional antiheadache therapy. On nasal endoscopic and coronal CT examinations, various intranasal and sinus abnormalities were found (either anatomic variations or subclinical inflammation). Medical and/or surgical therapy addressing the sinonasal pathology resulted in improvement in every case, ranging from decreased severity of attacks to total resolution of headaches. A model explaining the possible mechanism of referred vascular-type headache from sinus and nasal origin is proposed.

Surgical Outcomes for Rhinogenic Contact Point Headaches

“…Facial pain of sinus and nasal origin in the absence of inflammatory sinonasal disease is a clinical entity that has received attention in both otorhinolaryngology and neurology societies [1,2] . In 1948, Wolff [3] showed that stimulation of the middle turbinate and the nasal septum, both innervated by the anterior ethmoidal nerve, caused pain in the medial canthus area and the supraorbital region.…”

Middle Turbinate Evacuation Conchoplasty in Management of Contact-Point Rhinogenic Headache in Children

“…In 1992, Novak and Makek [36] reported a 78.5% cure rate in a group of 299 patients; their study lacked a control group as well as definitions of a follow-up period or of improvement, and no statistical analysis was undertaken. There have been various case reports of successful outcomes and short follow-up periods [37,38]. In 1997, Clerico et al [31] have reported results from 19 patients treated surgically for refractory primary headaches during a mean follow-up period of 21 months and the success rate was 79%.…”

Perceptive analysis of nasal surgery outcomes for headache

“…11 In a study by Tosun, endoscopic endonasal surgery of 30 patients with headaches presumed to have secondary contact points found that approximately 45% of patients had relief of headache, only 10% had no improvement in headache intensity.…”