Nearly everyone suffers head and or facial pain at one time or another, but when it becomes chronic or recurrent it poses a large problem. It is estimated that 7 billion dollars a year are lost on headache in the U.S. alone. The International Headache Society has a complicated classification scheme, but the two ends of the spectrum are migraine and tension headaches.
Migraine seems to have a vascular etiology. They can be subdivided by age groups and regions of the brain affected. It often has an associated aura or prodrome such as visual changes and then manifests as a unilateral pulsatile (pounding) headache with associated nausea/vomiting, photophobia (aggravated by light), and phonophobia (aggravated by noise). Patients often retreat to a quiet dark room to sleep it off. Following the headache the individual often feels listless and fatigued. Treatment is usually based on the frequency and severity of the attacks. For frequent problems patients often regularly take a prophylactic medication. New designer medications called triptans (Imitrex and Zomig) can often abort the headache if quickly administered following the aura. These headaches also seem to have a close relationship with allergies and chronic rhinosinusitis. They also run in families, affect a preponderance of females, and can correspond to hormonal changes.
Tension headaches seem to encompass the vast majority of remaining headaches. They are typically nonpulsatile, are not as debilitating as migraines and ache in a “band like” distribution around the head. They seem to be better in a recumbent position. They respond well to anti-inflammatory medications such as ibuprofen or cox-2 inhibitors (celebrex). They too can be triggered by sinus and nasal inflammation and so careful history is paramount.
Sinus headaches are increasingly recognized as a distinct entity. Facial pain, pressure, drainage, and congestion are common associated symptoms. Sinus disease can often be a chronic low grade infection that just constantly wears people out. They feel chronically fatigued because they are constantly fighting infection. Deviated nasal septums, polyps, or narrow nasal passages can predispose people to problems. Irritants and allergies can also be a cause of problems. Often immunotherapy can be successful it treating headache patients. Sinus disease will often trigger other types of headaches.
More and more we are finding the relationships between sinus and nasal disease in headaches. Every year the academy courses for the “rhinogenic” or nasally caused headache are packed with physicians hoping to learn something new for their patients. Many treatments for migraines and sinus related headaches are coming out as nasal sprays. Often we will perform an anesthetic nasal spray test to see if we can affect the head pain. We are often very pleased to find that a simple endoscopic nasal procedure can relieve some select patients of their headaches, but we must be very careful and conservative because that is not always the case. We would much rather disappoint a patient on the front end than have them be disappointed with a procedure.