Clinical Study of Rhinogenic Headache and Its Management in Adults

INTRODUCTION

Rhinogenic headaches are an important part of the secondary headache and in the diagnostic classification, it is categorized as headache as a result of acute, chronic, or recurrent rhinosinusitis or any other sinus pathologies expected to cause headache sinonasal pathology believed to cause a headache.1 Rhinogenic headaches are mainly concentrated in the nose and the pain related to headache and facial are primarily due to complex neurohumoral reflexes. Stammberger and Wolf classified the headache patients into three categories as follows,1 pain mediated by acute and chronic inflammation of sinus lining or barotrauma;2 headaches which are not due to sinus pathologies, but as a result of allergic and non-allergic rhinitis, trigeminal neuralgia, migraine or vascular pathologies;3 pain related to the sinonasal area, albeit the cause of inflammation is unknown.2 However, the pain in the third category are originated from the contacts and pressures between the nasal cavity adjacent mucosal surfaces when there is an existence of anatomical variations. Thus, these “contact points” between the nasal septum deformity along with middle turbinate variation, which causes pneumatization in the middle turbinate (concha bullosa) and nasal cavity lateral wall and it is the main etiological factor for the stimulation of such atypical pain.3

The rhinogenic headache is highly prevalent during acute rhinosinusitis.⁴ About 98% of rhinogenic headaches are mainly as a result of viral infections and sinusitis caused by bacteria accounts for 3%.⁵ Various intranasal anatomic abnormalities are associated with the cause of rhinogenic headaches. These include septal deviation and spurs, concha bullosa, enlargement of the inferior turbinate, medialized middle turbinate, uncinate bulla, medially or laterally uncinate process, paradoxically middle turbinate, and large ethmoidal bulla. Among the various anatomical variations of septal deviation, septal spur, and concha bullosa, middle turbinate pneumatization is commonly observed in the middle turbinate and accounts for 50%.⁶ The etiology of headache is a multitude and it is a challenging task for an ENT specialist for its management and in the majority of the cases, rhinogenic headaches are not addressed effectively. In this backdrop, the present study was carried out to evaluate the clinical profile of rhinogenic headache and its management strategies.

MATERIALS AND METHODS

This was a prospective study conducted among the 60 chronic headache patients attending the Department of Otorhinolaryngology, Akash Institute of Medical Sciences and Research Centre, Devanahalli, Bengaluru, Rural for a period of 2 years.

Results

The present study was conducted on 60 patients with rhinogenic headache. Out of 60 patients, 58.3% were males and 41.7% were females. Majority of the patients were in the age group between 20 years and 30 years accounting for 50%. In the age group between 31 years and 40 years, it included about 33.3% of cases. Patients within the age group between 20 and 30 displayed a male preponderance which constitutes around 57.1%. The data were shown in Table 1.

In this study, 38.3% of patients with headaches had deviated nasal septum, 28.3% had chronic rhinosinusitis, 16.7% had acute rhinosinusitis, 10% had nasal polyposis, 3.3% had allergic rhinitis, and 3.3% had concha bullosa. The data were shown in Table 2.

In this study, the cause of rhinogenic headache was more prevalent in the age group between 20 and 30 years (29 patients), followed by age group between 31 and 40 years (19 patients). The results were shown in Table 3.

Regarding the surgical distribution, out of 25 females, 20 patients underwent surgery and 5 patients had no surgical management (p = 0.001). Similarly, among the male patients out of 35 cases, 28 patients underwent surgery and 7 patients had no surgical management (p = 0.001). The data were shown in Table 4.

Among the 48 patients who underwent surgery, FESS was performed in the majority of the patients constituting 38.3%, septoplasty was performed in 36.7%, and a combination of FESS and septoplasty was done in 5%.

Among the 58.3% of patients who underwent surgical management displayed complete relief from headache, while 75% of patients who underwent conservative management had complete relief of headache. 39.6% had significant relief of headache by surgical management. Only 2.1% had no benefit from surgical management. The results were shown in Table 5.

DISCUSSION

Primary or secondary referral to otolaryngology is primarily due to pain arising from the head, face, and upper neck. The 3rd edition of the International Classification of Headache Disorders categorizes head and face pain into a primary and secondary headache. The International Headache Society (IHS) includes a category of secondary headache, which in turn includes headache attributed to acute and chronic rhinosinusitis.¹ According to Third Edition of the International Classification of Headache Disorders (ICHD-3), the headache caused by acute rhinosinusitis, its severity increases when the severity of acute rhinosinusitis is also increased. Furthermore, the headaches worsen when there is a contact pressure. Meanwhile, headache associated with chronic rhinosinusitis increases or decreases along with the degree of sinus congestion and other chronic rhinosinusitis-related symptoms in paranasal sinuses.¹

In this study, the headache is more prevalent in the age group between 21 years and 30 years. The majority of patients had headache in the age group of 21–30 years. Similar to our report in Kumar and Chawla,⁷ study 10–30 years and Kaur and Singh,⁸ study 21–30 years has been reported. In Egypt, rhinogenic patients are in the age range between 18 years and 34 years.⁹

It is noted in the literature that the rhinogenic headache needs a multidisciplinary approach. A detailed rhinoscopic, as well as endoscopic examination, is needed for appropriate diagnosis and management. According to Altin et al.,¹⁰ sinusitis, nasal polyposis, concha bullosa, and other nasal pathologies require HRCT PNS for the diagnosis and management. CT is required to rule out the pathologies that may go undetected by mere physical examination. It also helps in deciding the necessity of surgery.¹¹ All our patients were subjected to Diagnostic Nasal Endoscopy (DNE) and 51.7% of patients underwent X-ray PNS while 45% underwent HRCT PNS.

The deviated nasal septum was the main cause of headache followed by chronic rhinosinusitis in this study which is in correlation with Hammad and Gomaa.¹² They reported septal deviation causing nasal obstruction could be the cause of the rhinogenic headache and when it is corrected by surgery, improvement in headache is observed.¹² Reports show that headache is a secondary symptom due to nasal obstruction caused by a septal deviation in rates ranging between 23 and 58%.^13,14 In line with the above studies, the main cause of headache in our study deviates nasal septum (38.3%) and 28.3% had chronic rhinosinusitis.

Surgery is the mainstay in the management of rhinogenic headache. Huang et al.¹⁵ investigated 66 rhinogenic headache patients due to deviated nasal septum and concha bullosa and with Haller cells and surgical correction effectively decreased the frequency and intensity of headache. In our study, 3.3% had concha bullosa and displayed significant improvement after the surgery. A contact point when present between the septum and the lateral nasal wall it causes pressure and due to which substance P is released. It causes local reflexes like vasodilatation, plasma extravasation, hypersecretion, and perivascular inflammation resulting in a headache.¹⁰

Patients suffering from allergic rhinitis have turbinate hypertrophy, which causes increased mucosal contact points and an increase in severity of the headache.¹⁶ Sinonasal pathologies such as the concha bullosa, nasal polyposis, or a contact point between the nasal septum and the lateral nasal wall cause rhinogenic headache.¹⁰

Surgical correction helps in the improvement of not only nasal obstruction but also headache.¹³ Low and Willatt reported that out of 110 patients, 63.6% displayed complete relief of headache after the surgical correction of septal deviation.¹³ In a study done by Rai et al., 85% had relief of headache after undergoing septal surgery for DNS.¹⁷ In the USA patients, 76.2% had their headache scores improved by 50% or more and 42.9% were free of pain after undergoing septoplasty and endoscopic sinus surgery.¹⁸ In agreement with the above studies, 36.7% of our patients underwent septoplasty had a complete relief of headache.

In a study conducted among the Egypt headache patients, FESS displayed complete cure of 83.3% of the study participants.⁹ Likewise, in our study, we found 95% of patients were relieved of rhinogenic headache.

Rhinogenic headache can be managed medically or surgically depending on the etiology. Topical nasal steroids on a long-term can be used as a medical management.¹⁹ In our study, 3.3% of patients with allergic rhinitis had not shown any significant improvement after treatment with steroid nasal spray.

Peric et al.¹⁹ and Altin et al.¹⁰ reported that a follow-up of 6 months is the optimum period to assess the rhinogenic headache treatment outcome. However, a systematic review showed that a follow-up period of %3E;12 months is needed for assessing the surgical outcome in the removal of contact point as a treatment of facial pain.²⁰ The follow-up period in our study was 6 months and we believed that it was enough time for assessing the outcome of the management of rhinogenic headache, however, longer follow-up period could also be done.

CONCLUSION

Rhinogenic headaches can be treated with medical and surgical treatment. Cases of acute sinusitis, allergic rhinitis without any anatomical variations can be effectively treated by medical management. Functional endoscopic sinus surgery plays a major role in surgical management. Long-term improvement can be assessed by VAS and it also suggests that surgical management can alleviate the rhinogenic headache.

CLINICAL SIGNIFICANCE

Headache and sinus diseases have many overlapping symptoms. Headache affects the quality of life and rhinogenic headache is an important etiology of secondary headache. Diagnostic difficulties do exist and awareness of clinical signs and symptoms, detailed clinical examination from the otolaryngologist plays a pivotal role in the management. Accurate surgical technique with minimal complications is very essential to alleviate the pain associated with rhinogenic headaches and also to improve the quality of life among these patients.

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