Doctor, how do I stop these tension headaches? Does expanding the sinuses help?

Dear Friends

WELCOME BACK to TGIF Dr Euan :-)

Have you suffered from headaches when travelling on aeroplanes? Or even when ascending or descending high-speed elevators in high-rise buildings?

Sometimes, the pain can be acute and severe! at other times, it can be chronic, dull, throbbing in nature

If so, do have a read of this week's TGIF Dr EUAN blog post and do feel free to share with your family and friends too!

Q: Why do sinuses generate headaches?

Sometimes it IS a straightforward INFECTION such as Acute Sinusitis, with fever, headache and nasal symptoms of nasal blockage/mucus and post-nasal drip into the back of your throat!

Headache is a very common condition that affects at least 80% of the population, defined as a pain with a predominantly neuro-cranial location whose topographical extension does not correspond to the territory of distribution of single nerve trunks. It has a great range of etiological factors: a primary headache is an idiopathic form and etiological factors are not detectable (migraine, tension-type headache, cluster headache), secondary forms can have systemic or local causes. Therefore, the headache is a disease that must be well investigated and requires multi-specialist collaboration. In the context of secondary headache, some common causes, such as acute and chronic rhino-sinusitis, anatomical variations and sino-nasal lesions, requires otolaryngology evaluation. Rhinogenic Headache (RH) is a secondary form of headache, described as a facial pain syndrome in the absence of inflammatory sino-nasal disease, purulent discharge and sino-nasal polyps or masses, caused by mucosal contact points in the sino-nasal cavities.

In 1948 Wolf reported that the stimulation of the nasal septum and middle turbinate, both innervated by the anterior ethmoidal nerve, a branch of the ophthalmic division of the trigeminal nerve, caused pain in the medial canthus area of the supraorbital region.

In 2004, mucosal contact headache was added as a secondary headache disorder in the International Classification of Headache Disorders. Primary headache is often confused with RH due to their similar location and manifestation.

Therefore, before treating patients, it is important to differentiate true RH from migraine, cluster and tension-type headache and it is necessary to exclude inflammatory sinonasal diseases or masses. In the last 20 years, several authors have described the effectiveness of Endoscopic Sinus Surgery (ESS) in the treatment of RH but the role of ESS remains debated because of the difficulty of identifying the real cases of RH.

Q: How do these "RHINOGENIC headaches" arise?

Sluder, in 1997, popularized the concept of vacuum headache. He described the phenomenon as barometric pressure changes affecting narrow drainage pathways of the sinus, resulting in pain over the involved sinus without disease. According to this theory, the re-establishment of the physiological ventilation of the paranasal sinus may be decisive in handling cases of suspected vacuum rhinogenic headaches. Indeed, Bolger described all sinuses anatomical variations and described different types of middle turbinate pneumatisation.

According to Roozbahany, in the RH genesis, the most common anatomical abnormalities were middle turbinate concha bullosa and lamella bullosa, a pneumatisation of the vertical lamella of middle turbinate for their effect on the ventilation frontal sinus recess. Kuhn described a prevalence of frontal recess pneumatisation patterns in patients with no history of frontal sinus disease and recently described the benefits of balloon sinuplasty of frontal recess in patients with frontal sinus disventilation.

According to the vacuum rhinogenic headache, possible contact points or other causes involved in the alteration of frontal sinus ventilation can trap air, it will get absorbed by the mucosal sinus, and this could cause pain.

Q: What help can I get for my vacuum pressure headaches?

Well, do consult your GP or ENT Specialist if you suffer from such headaches.

There is a range of remedies available, from conservative to surgical.

For Conservative Treatments:

Symptoms may be relieved with topical decongestants, topical steroids, antibiotics, nasal saline, topical cromolyn, or mucolytics.

Steam inhalation and nasal saline irrigation may help by moistening dry secretions, reducing mucosal edema, and reducing mucous viscosity. A recent review concluded that low-volume (5 mL) nebulized saline spray was not more beneficial than intranasal steroids. Larger volume (150 mL) was marginally more efficacious than placebo.

There was no increased risk of acquiring COVID 19 infection in individuals with CRS treated with oral corticosteroids compared with those who were not treated.

For persistent headaches, consider the BALLOON SINUPLASTY option; here is a video which shows you how this method works:

Video of Balloon Sinuplasty courtesy of Easmed

For Surgical Treatments:

1. Balloon Sinuplasty

2. Septoplasty

3. Turbinoplasty, including reduction of any Concha Bullosa

4. Functional Endoscopic Sinus Surgery (FESS)

Q: When should I seek SPECIALIST help?

If your headache symptoms do not resolve with the conservative treatments, and symptoms persist for > 1 month duration, we would suggest seeking a Specialist opinion. Most commonly, the ENT Doctor will perform a NASO-ENDOSCOPIC examination in the clinic. Here is what it looks like:

Image of Dr Euan Murugasu performing a nasoendoscopy

Sometimes, it may also be necessary to undergo a CT SCAN STUDY of your sinuses, to look in detail at the anatomy of your sinuses and possible causes of the symptoms eg Concha Bullosa , sinusitis etc.

Do contact us if you would like more information on such sino-nasal surgeries or if you would like Dr Euan Murugasu to perform a nasoendoscopy for you; or to book a consultation to see us at Euan's ENT Surgery & Clinic to make an appointment or call our clinic number 6694 4282.

I hope this article has been useful, Here are some references if you are keen to find out more on the topic.

Till next time, Have a restful weekend!

References

1. Mitsikostas DD, Ashina M, Craven A, Diener HC, Goadsby PJ, Ferrari MD, Lampl C, Paemeleire K, Pascual J, Siva A, Olesen J, Osipova V, Martelletti P, EHF committee European headache federation consensus on technical investigation for primary headache disorders. J Headache Pain. 2015;17(1):5. doi: 10.1186/s10194-016-0596-y. [PMC free article] [PubMed] [CrossRef] [Google Scholar]

2. Cady RK, Schreiber CP. Sinus problems as a cause of headache refractoriness and migraine chronification. Curr Pain Headache Rep. 2009;13:319–325. doi: 10.1007/s11916-009-0051-8. [PubMed] [CrossRef] [Google Scholar]

3. Clerico DM. Sinus headaches reconsidered: referred cephalgia of rhinologic origin masquerading as refractory primary headaches. Headache. 1995;35:185–192. doi: 10.1111/j.1526-4610.1995.hed3504185.x. [PubMed] [CrossRef] [Google Scholar]

4. Stammberger H, Wolf G. Headaches and sinus disease: the endoscopic approach. Ann Otol Rhinol Laryngol Suppl. 1988;134:3–23. doi: 10.1177/00034894880970S501. [PubMed] [CrossRef] [Google Scholar]

5. Wolff HG. Headache and Other Head Pain. New York: Oxford University Press; 1948. The nasal, paranasal and aural structures as sources of headache and other pain; pp. 532–560. [Google Scholar]

6. Headache Classification Committee of the International Headache Society The international classification of headache disorders. Cephalalgia. 2004;24(suppl 1):1–160. [PubMed] [Google Scholar]

7. Chow JM. Rhinologic headaches. Otolaryngol Head Neck Surg. 1994;111:211–218. doi: 10.1177/01945998941113P109. [PubMed] [CrossRef] [Google Scholar]

8. Clerico DM, Evan K, Montgomery L. Endoscopic sinonasal surgery in the management of primary headache. Rhinology. 1997;35:98–102. [PubMed] [Google Scholar]

9. Yarmohammadi ME, Ghasemi H, Pourfarzam S, Nadoushan MS, Majd SA. Effect of turbinoplasty in concha bullosa induced rhinogenic headache, a randomized clinical trial. J Res Med Sci. 2012;17(3):229–234. [PMC free article] [PubMed] [Google Scholar]

10. Nselmo-Lima WT, de Oliveira JA, Speciali JG, Bordini C, dos Santos AC, Rocha KV. Middle turbinate headache syndrome. Headache. 1997;37:102–106. doi: 10.1046/j.1526-4610.1997.3702102.x. [PubMed] [CrossRef] [Google Scholar]

11. Mariotti LJ, Setlif RC, Ghaderi M, Voth S. Patient history and Ct findings in predicting surgical outcomes for patients with rhinogenic headache. Ear Nose Throat J. 2009;88(5):926–929. [PubMed] [Google Scholar]

12. Roozbahany NA, Nasri S. Nasal and paranasal sinus anatomical variations in patients with rhinogenic contact point headache. Auris Nasus Larynx. 2013;40:177–183. doi: 10.1016/j.anl.2012.07.007. [PubMed] [CrossRef] [Google Scholar]

13. Sanges G, Feleppa M, Gamerra M, Sorrentino G, De Luca R. Fronto-turbinalis sinus expansion and headache. Curr Pain Headache Rep. 2011;15:308–313. doi: 10.1007/s11916-011-0194-2. [PubMed] [CrossRef] [Google Scholar]

14. Marzetti A, Tedaldi M, Passali FM. The role of balloon sinuplasty in the treatment of sinus headache. Otolaryngol Pol. 2014;68(1):15–19. doi: 10.1016/j.otpol.2013.10.005. [PubMed] [CrossRef] [Google Scholar]

15. Kuhn FA, Church CA, Goldberg AN, Levine HL, Sillers MJ, Vaughan WC, Weiss RL. Balloon catheter sinusotomy: one-year follow-up-outcomes and role in functional endoscopic sinus surgery. Otolaryngol Head Neck Surg. 2008;139(3 Suppl 3):S27–S37. doi: 10.1016/j.otohns.2008.05.010. [PubMed] [CrossRef] [Google Scholar]

16. Levine HL, Sertich AP, 2nd, Hoisington DR, Weiss RL, Pritikin J. Multicenter registry of balloon catheter sinusotomy outcomes for 1,036 patients. Ann Otol Rhinol Laryngol. 2008;117(4):263–270. doi: 10.1177/000348940811700405. [PubMed] [CrossRef] [Google Scholar]

17. Greenfield H (1986) A study of referred cephalgia secondary to noxious stimulation of specific regions of nasal mucosa and sinus ostia. In: Presented as scientific exhibitions at the meeting of American Academy of Otolaryngology, San Antonio, Texas, Sept 14–18

18. Goldsmith AJ, Zahtz GD, Stegnjajic A. Middle turbinate headache syndrome. Am J Rhinol. 1993;7:17–23. doi: 10.2500/105065893781976582. [CrossRef] [Google Scholar]

19. Sluder G. Nasal neurology, headaches and eye disorders. St. Louis (MO): CV Mosby; 1927. pp. 31–67. [Google Scholar]

20. Bolger WE, Butzin CA, Parson DS. Paranasl sinus bony anatomic variations and mucosal abnormalities: CT analysis for endoscopic sinus surgery. Laryngoscope. 1991;101:56–64. doi: 10.1288/00005537-199101000-00010. [PubMed] [CrossRef] [Google Scholar]

21. Roozbahany NA, Nasri S. Nasal and paranasal sinus anatomical variations in patients with rhinogenic contact point headache. Auris Nasus Larynx. 2013;40:177–183. doi: 10.1016/j.anl.2012.07.007. [PubMed] [CrossRef] [Google Scholar]

22. Kennedy DW. Functional endoscopic approach to inflammatory sinus disease: current perspectives and technique modifications. AM J Rhinol. 1988;2:89–96. doi: 10.2500/105065888781693078. [CrossRef] [Google Scholar]