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. An estimated seven billion dollars a year are spent on headaches in the U.S. alone. The International Headache Society has a complicated classification scheme, but the two most common are migraine and tension.
Migraines seem to have a vascular etiology and can be subdivided by age groups and regions of the brain affected. They often have an associated aura, such as a visual change, and then manifest as a pounding headache with associated nausea/vomiting, light and noise sensitivity. Patients often retreat to a quiet dark room to sleep it off.
Following a migraine, a person 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 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 when a person is in a recumbent position. They respond well to anti-inflammatory medications such as ibuprofen or cox-2 inhibitors (Celebrex/Vioxx). They too can be triggered by sinus and nasal inflammation, so careful history review 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. Often immunotherapy can be successful it treating headache patients. Sinus disease will often trigger other types of headaches.
More and more we are finding relationships between sinus and nasal disease and 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.