punctured
05-02-2009, 06:43 PM
I recently stumbled upon surprising causes of intractable headaches that no one had mentioned to me. They may interest people who are exploring alternative explanations for chronic headaches that you suspect are due to CSF leaks but perhaps are not.
These rare or unusual headaches come from your nose or sinus, even if there're no sniffles or stuffiness (although such symptoms may be present as well).
And, just as with chronic CSF leak headaches, we're not talking mainstream medicine here. It's really unlikely that anyone reading this post would have such a headache!
Still I could't find any write-up covering these headaches, so I delved into writing this little piece with all the gusto of an amateur.
Main Points
Here are the main points to remember.
These kinds of headache have long been taught in medical school to not exist or to be too marginal for consideration. Your neurologist will probably not suspect them. And your ENT may likely not do so either.
The symptoms are often described as deep seated pressure pain or sharp pain, behind nose or face, between or near temples, intermittent or chronic, one-sided or two-sided, worsening with leaning over, and sometimes worsening with lying down and sometimes improving with lying down. And then symptoms seem to spread out to the front, sides and back of head, etc, etc. I couldn't find any consistent descriptions of the kinds of pains involved so it doesn't matter so much I think that I've lumped both the nose and the sinus headaches together. A professional may be able sort 'em out.
These headaches can be diagnosed with CT scans, endoscopy or a very simple knock-the-nose-out test that takes of couple of minutes to carry out.
The treatment consists of nasal sprays, decongestants, antibiotics or surgery.
Let's look at some of this in more detail.
Real or not?
You may wonder why you haven't heard about this before, why none of the many doctors you have seen didn't stop a sec to think about this. One reason is that headachologists have long been guided by the International Headache Society Manual for Headache Diagnosis (1988). This report quite emphatically states that chronic sinus infection and trouble with your nose's anatomy won't make your head hurt:
Other conditions which may cause headache such as nasal passage abnormality due to septal deflection, hypertrophic turbinate and atrophic sinus membranes are not sufficiently validated as causes of headache. Chronic sinusitis is not validated as a cause of headache unless relapsing into an acute phase.
BUT... in a more recent edition of the headache classification the neurologists opened the door ajar for such headaches. Still it's certainly not something that'll carry a "high degree of suspicion" with most. Apparently, many ENTs have been trained in a similar spirit.
Nowadays, there are however more and more ENT docs who do recognize such headaches although these conditions are still considered rare by most. I plucked this out (Grand Rounds Presentation, UTMB, Dept. of Otolaryngology, Word document (http://www.utmb.edu/otoref/Grnds/HA-facial-pain-2001-0131/HA-facial-pain-2001.doc)):
Patients with headaches of sinus origin do not necessarily present with the typical sinusitis history. The physical examination and plain radiographs may be negative as well. When in question, the combination of rigid nasal endoscopy and CT scanning provide the most complete information regarding sinus anatomy and disease. Multiple authors have reported good successes with sinus surgery targeted at these points of mucosal contact and anatomical variation for the treatment of chronic headache presumed to arise from the nose and sinuses.
So what are these aches called?
The disorders that now may be real after all are:
chronic sinus headaches without acute sinus symptoms
contact point headaches due to warped anatomy such as septal deviation, septal spurs, turbinate hypertrophy, and more...
Diagnosis
Apparently a sinus CT scan is necessary for diagnosing chronic sinusitis but as the previous quote implied it won't always be sufficient. Allergist W. S. Tichenor, M. D. writes:
A CT scan is usually accurate in evaluating for sinusitis, but it can also be difficult to interpret or underinterpreted.
That's where the endoscope enters the picture. It's a flexible (sometimes rigid) thin optical instrument that the doctor inserts into your nostril in order to look around in the nasal vault. It goes with out saying that this has to be done twice.
So occult infections, anatomical troublemakers, and other problems may be found only this way.
Sinus infections may afflict the "forgotten sinus": the sphenoid, which are two hollows deep inside your head, right under the brain. Such an infection can be detected only on a CT or MRI scan because the endoscope won't reach into this area.
As for the contact point headaches there is an interesting diagnostic feature associated with the endoscopy procedure: in general, to make you squirm less the ENT doc will first anesthetize your nose with a puff of magic spray or with a cotton pledget. And if you bring an contact point headache to the appointment, then your symptoms should disappear or at least decrease significantly very shortly after. Also for this diagnosis, the ENT would like to see anatomical contact points such as septal spurs or crowded quarters in your nose.
Obviously, a contact point headache may be difficult to diagnose. Both you and your doctor may be afraid of overinterpreting the relief accomplished by the anesthesia. Or maybe the anesthesia was not applied to the right parts of your nose so that you didn't experience the relief. For these reasons, some doctors prefer to repeat the knock-the-nose-out test several times. Usually of course there will be no relief from the anesthesia --- because you don't have a contact point headache.
In practice: getting evaluated
From what I read and what I've experienced: just going to a nearby ENT office is not likely going to result in a serious attempt of ruling in or out the kinds of subtle nose or sinus problems described above. The doctor will quickly look in your ears and in your throat. Before your tongue regains its normal curvature, the ENT will be out of the door announcing through the hallway that there's nothing wrong with you.
Several metropolitan areas feature ENT practices that offer diagnosis and treatment of contact point headaches. Some claims you'll find sound to good to be true. "We do not manage headaches; We cure headaches". So, I don't know how to proceed in practice perhaps except for calling around and asking "Does Dr. X treat contact point headaches?" Or ask your neurologist for recommendations.
Please be skeptical if you venture into this area of headache medicine. Still, it seems to be me that a CT scan + an endoscopic upper airways examination (done with headache) may warrant to be on your list of things to do if you've dealt with an intractable headache for a longer period. But that's actually not what some doctors would recommend, mind you.
Traditional view of unusual facial pains
This alternative is familiar to many. I include it because it helps understand where the doctor may be coming from; I guess it's the best diagnosis and treatment in many cases. (Grand Rounds Presentation, UTMB, Dept. of Otolaryngology)
Atypical facial pain is a diagnosis of exclusion for pain not meeting the diagnostic criteria of other facial pain syndromes. Mongini refers to the term atypical facial pain as outdated and includes its description in psychogenic facial pain. Indeed, the description of the pain may be inconsistent with bilateral pain that often changes locations over weeks to months. The pain is not triggered and not electrical in quality. Intensity fluctuates but the patient is rarely pain-free. Pain is typically located in the face and seldom spreads to the cranium in contradistinction to TTH. It is more common in women aged 30 to 50 years old. Sixty to 70% of these patients have significant psychiatric findings, usually depression, somatization or adjustment disorders, therefore psychiatric evaluation is indicated. Treatment is with antidepressants, beginning with low dose amitriptyline at bedtime and increasing the dose until pain and sleep are improved.
Want to know more?
There isn't much out there, no patient information sites or discussion groups as far as I've been able to determine. Try searching for concepts mentioned here. For contact point headaches, a current US study is underwayRhinogenic Headache Improvement After Nasal Operation (http://clinicaltrials.gov/ct2/show/NCT00580307)
-----------------------
The quotes above from UTMB (University of Texas Medical Branch), Department of Otolaryngology came with disclaimers:
No warranties, either express or implied, are made with respect to its accuracy, completeness, or timeliness. The material does not necessarily reflect the current or past opinions of members of the UTMB faculty and should not be used for purposes of diagnosis or treatment without consulting appropriate literature sources and informed professional opinion.
These rare or unusual headaches come from your nose or sinus, even if there're no sniffles or stuffiness (although such symptoms may be present as well).
And, just as with chronic CSF leak headaches, we're not talking mainstream medicine here. It's really unlikely that anyone reading this post would have such a headache!
Still I could't find any write-up covering these headaches, so I delved into writing this little piece with all the gusto of an amateur.
Main Points
Here are the main points to remember.
These kinds of headache have long been taught in medical school to not exist or to be too marginal for consideration. Your neurologist will probably not suspect them. And your ENT may likely not do so either.
The symptoms are often described as deep seated pressure pain or sharp pain, behind nose or face, between or near temples, intermittent or chronic, one-sided or two-sided, worsening with leaning over, and sometimes worsening with lying down and sometimes improving with lying down. And then symptoms seem to spread out to the front, sides and back of head, etc, etc. I couldn't find any consistent descriptions of the kinds of pains involved so it doesn't matter so much I think that I've lumped both the nose and the sinus headaches together. A professional may be able sort 'em out.
These headaches can be diagnosed with CT scans, endoscopy or a very simple knock-the-nose-out test that takes of couple of minutes to carry out.
The treatment consists of nasal sprays, decongestants, antibiotics or surgery.
Let's look at some of this in more detail.
Real or not?
You may wonder why you haven't heard about this before, why none of the many doctors you have seen didn't stop a sec to think about this. One reason is that headachologists have long been guided by the International Headache Society Manual for Headache Diagnosis (1988). This report quite emphatically states that chronic sinus infection and trouble with your nose's anatomy won't make your head hurt:
Other conditions which may cause headache such as nasal passage abnormality due to septal deflection, hypertrophic turbinate and atrophic sinus membranes are not sufficiently validated as causes of headache. Chronic sinusitis is not validated as a cause of headache unless relapsing into an acute phase.
BUT... in a more recent edition of the headache classification the neurologists opened the door ajar for such headaches. Still it's certainly not something that'll carry a "high degree of suspicion" with most. Apparently, many ENTs have been trained in a similar spirit.
Nowadays, there are however more and more ENT docs who do recognize such headaches although these conditions are still considered rare by most. I plucked this out (Grand Rounds Presentation, UTMB, Dept. of Otolaryngology, Word document (http://www.utmb.edu/otoref/Grnds/HA-facial-pain-2001-0131/HA-facial-pain-2001.doc)):
Patients with headaches of sinus origin do not necessarily present with the typical sinusitis history. The physical examination and plain radiographs may be negative as well. When in question, the combination of rigid nasal endoscopy and CT scanning provide the most complete information regarding sinus anatomy and disease. Multiple authors have reported good successes with sinus surgery targeted at these points of mucosal contact and anatomical variation for the treatment of chronic headache presumed to arise from the nose and sinuses.
So what are these aches called?
The disorders that now may be real after all are:
chronic sinus headaches without acute sinus symptoms
contact point headaches due to warped anatomy such as septal deviation, septal spurs, turbinate hypertrophy, and more...
Diagnosis
Apparently a sinus CT scan is necessary for diagnosing chronic sinusitis but as the previous quote implied it won't always be sufficient. Allergist W. S. Tichenor, M. D. writes:
A CT scan is usually accurate in evaluating for sinusitis, but it can also be difficult to interpret or underinterpreted.
That's where the endoscope enters the picture. It's a flexible (sometimes rigid) thin optical instrument that the doctor inserts into your nostril in order to look around in the nasal vault. It goes with out saying that this has to be done twice.
So occult infections, anatomical troublemakers, and other problems may be found only this way.
Sinus infections may afflict the "forgotten sinus": the sphenoid, which are two hollows deep inside your head, right under the brain. Such an infection can be detected only on a CT or MRI scan because the endoscope won't reach into this area.
As for the contact point headaches there is an interesting diagnostic feature associated with the endoscopy procedure: in general, to make you squirm less the ENT doc will first anesthetize your nose with a puff of magic spray or with a cotton pledget. And if you bring an contact point headache to the appointment, then your symptoms should disappear or at least decrease significantly very shortly after. Also for this diagnosis, the ENT would like to see anatomical contact points such as septal spurs or crowded quarters in your nose.
Obviously, a contact point headache may be difficult to diagnose. Both you and your doctor may be afraid of overinterpreting the relief accomplished by the anesthesia. Or maybe the anesthesia was not applied to the right parts of your nose so that you didn't experience the relief. For these reasons, some doctors prefer to repeat the knock-the-nose-out test several times. Usually of course there will be no relief from the anesthesia --- because you don't have a contact point headache.
In practice: getting evaluated
From what I read and what I've experienced: just going to a nearby ENT office is not likely going to result in a serious attempt of ruling in or out the kinds of subtle nose or sinus problems described above. The doctor will quickly look in your ears and in your throat. Before your tongue regains its normal curvature, the ENT will be out of the door announcing through the hallway that there's nothing wrong with you.
Several metropolitan areas feature ENT practices that offer diagnosis and treatment of contact point headaches. Some claims you'll find sound to good to be true. "We do not manage headaches; We cure headaches". So, I don't know how to proceed in practice perhaps except for calling around and asking "Does Dr. X treat contact point headaches?" Or ask your neurologist for recommendations.
Please be skeptical if you venture into this area of headache medicine. Still, it seems to be me that a CT scan + an endoscopic upper airways examination (done with headache) may warrant to be on your list of things to do if you've dealt with an intractable headache for a longer period. But that's actually not what some doctors would recommend, mind you.
Traditional view of unusual facial pains
This alternative is familiar to many. I include it because it helps understand where the doctor may be coming from; I guess it's the best diagnosis and treatment in many cases. (Grand Rounds Presentation, UTMB, Dept. of Otolaryngology)
Atypical facial pain is a diagnosis of exclusion for pain not meeting the diagnostic criteria of other facial pain syndromes. Mongini refers to the term atypical facial pain as outdated and includes its description in psychogenic facial pain. Indeed, the description of the pain may be inconsistent with bilateral pain that often changes locations over weeks to months. The pain is not triggered and not electrical in quality. Intensity fluctuates but the patient is rarely pain-free. Pain is typically located in the face and seldom spreads to the cranium in contradistinction to TTH. It is more common in women aged 30 to 50 years old. Sixty to 70% of these patients have significant psychiatric findings, usually depression, somatization or adjustment disorders, therefore psychiatric evaluation is indicated. Treatment is with antidepressants, beginning with low dose amitriptyline at bedtime and increasing the dose until pain and sleep are improved.
Want to know more?
There isn't much out there, no patient information sites or discussion groups as far as I've been able to determine. Try searching for concepts mentioned here. For contact point headaches, a current US study is underwayRhinogenic Headache Improvement After Nasal Operation (http://clinicaltrials.gov/ct2/show/NCT00580307)
-----------------------
The quotes above from UTMB (University of Texas Medical Branch), Department of Otolaryngology came with disclaimers:
No warranties, either express or implied, are made with respect to its accuracy, completeness, or timeliness. The material does not necessarily reflect the current or past opinions of members of the UTMB faculty and should not be used for purposes of diagnosis or treatment without consulting appropriate literature sources and informed professional opinion.