Abstract
Headache is a frequent symptom of lesions in the paranasal sinuses. Although some inflammatory symptoms are suggestive of pathologies of the paranasal sinuses, occasional headache is sometimes the major presenting symptom. In a retrospective study, we examined the chart histories of 36 patients presenting for treatment at our hospital from 1 January 1992 to 30 June 2001 who were diagnosed as having pathologies of the paranasal sinuses with the primary symptom being headache. All patients had been evaluated with complete otolaryngological and neurological examinations, diagnostic nasal endoscopy, and sinus computed tomographic (CT) scans. Sinus surgery was arranged after failure in performing appropriate medical treatment. Among the 36 patients, 33 showed significant improvement after sinus operation (92%). A paranasal sinus aetiology of headache is an important factor in the differential diagnosis of chronic headache. Those patients who are clinically suspected of having headaches arising from paranasal sinus pathology should receive comprehensive otorhinolaryngological examination and evaluation. Nasal endoscopy and sinus CT scans are good diagnostic tools. Surgical management may be beneficial in those for whom medical treatment fails to resolve the problem.
Introduction
Headache is a frequent symptom of lesions in the paranasal sinuses. Although some inflammatory symptoms are suggestive of pathologies of the paranasal sinuses, occasional headache is sometimes the major presenting symptom. It is difficult to make a diagnosis in this group of patients without obvious symptoms from the paranasal sinus area. In addition, the possibility of migraine headache or autonomic symptoms associated with cluster headaches contributes to the difficulty of diagnosis. The purpose of this study was to identify the location and nature of paranasal sinus pathologies and their relationship to headache in patients presenting with headache as their primary symptom. We wanted to determine whether there was a relationship between the location of the headache and location of the paranasal sinus pathology with an aim to contribute to better differential diagnosis of paranasal sinus disease and to contribute to the discussion of the surgical management of these disorders.
Methods
Patients
From 1 January 1992 to 30 June 2001, we identified by chart review 36 patients who had been diagnosed as having paranasal sinus pathologies in those presenting headache as their primary symptom. The inclusion criteria for this patient group were as follows: (i) headache was the major presenting symptom; (ii) initial diagnosis (e.g. migraine or tension headache) did not implicate pathologies of the paranasal sinuses as the aetiological factor; (iii) patients were regularly followed in neurological out-patient clinics and received appropriate medical treatment with poor control; (iv) patients having accepted sinus surgery after failure through appropriate medical treatment. Patients who were seen during this same period of time but who were excluded were those with headache caused by acute rhinosinusitis, nasal allergies, upper respiratory tract infection, middle turbinate syndrome, and nasal anatomy abnormalities such as nasal septal deviation with spurs, concha bullosa or enlargement of the ethmoidal bulla.
Settings
Retrospective chart review was performed in a tertiary referral neurological and rhinological medical centre. Among the 36 cases, half were diagnosed at the Neurological Department and referred to a Rhinological Department. These patients met the 1998 International Headache Society (IHS) criteria. The remaining cases were diagnosed at the Rhinological Department, each patient with a previous long history of frequent visits to neurological out-patient clinics or local hospitals.
Intervention
After referral, all patients were evaluated with a complete otolaryngological physical examination, diagnostic nasal endoscopy and sinus computed tomographic (CT) scan. Past medical histories and clinical data with pain location and revised diagnosis were collected. Medical treatment was applied after diagnosis was made. Sinus surgery was arranged after medical treatment failed to produce significant improvement. The surgical methods included endoscopic sinus surgery (28), Caldwell-Luc operation (2), external frontal-ethmoidectomy (3), maxillectomy (2) and osteoplastic surgery (1).
Main outcome measures
Clinical improvement of pain duration and severity were recorded.
Results
Patient factors
From 1 January 1992 to 30 June 2001, we identified 1500 rhinological surgeries with the chief complaint of headache determined through computer data. Thirty-six cases fulfilled the inclusion criteria described above, with 24 women and 12 men (female:male ratio of 2 : 1). The mean age of the patients was 51 ± 15 years (range 19–83 years). The duration of diagnosis was 4.5 ± 1.9 months (range 1–15 months). Previous neurological diagnoses of the 36 cases included the following: migraine (n = 16), tension headache (n = 14), cluster headache (n = 3), neurosis (n = 2) and atypical facial pain (n = 1). The follow-up period was 20 ± 5 months (range 17–22 months).
Types of sinonasal lesions
The types of paranasal lesions encountered were mucocele (n = 19), chronic indolent fungal sinusitis (n = 10), chronic rhinosinusitis (n = 6), maxillary sinus carcinoma (n = 2) and superior meatus nasal polyp (n = 1) (Table 1). Regarding the involved sinuses, the sphenoid sinus (16 cases) was most frequently involved followed by the maxillary (n = 9), frontal (n = 7) and ethmoid sinuses (n = 7) (Table 2).
Causes of sinus headache
Involved sinus of sinus headache
Pain character
No patient showed rhinological symptoms. The frontal area (n = 25) was the most common painful region of sinus headache (Table 3), followed by the temporal (n = 10), occipital (n = 6), parietal (n = 5) and periorbital (n = 5) areas. The pain was throbing in 18, dull in 15, aggravating with cough in 17, sharp in 20, tearing in eight, worsening after valsalva manoeuvre in 11, and pressured in 25. Autonomic symptoms were found in 16 patients and photophobia in seven patients. Headache intensity varied from severe affecting daily life to latent dull pain. The pain duration lasted from several seconds to days. There was no specific correlation or diagnostic clue between pain characteristics/duration and paranasal sinus lesions.
Painful area of sinus headache
Treatment results
Of the 36 cases, 33 showed significant improvement regarding headache pain after sinus operation (92%); these patients reported that they had no more headaches after surgery. Symptoms for these patients improved within days after surgery. Since headache relief and time of surgery were so closely related in most of the patients, we presumed that the paranasal sinus lesions, which in general were successfully treated during surgery, were the cause of these headaches. Retrospective chart review of follow-up visit intervals were recorded. All improved cases showed no recurrence of the symptoms and thus supported the successful treatment results. The three unimproved cases included two patients with maxillary sinus carcinomas and one patient with sphenoid fungal sinusitis. The follow-up period was 20 ± 5 months (range 17–22 months).
Discussion
Diagnostic criteria
Almost 50 years ago it was proposed that various nasal and paranasal sinus pathologies could cause headaches (1). Although clinicians recognize this relationship, there have been scant data contributing to this discussion. Valuable pioneering studies showed that pressure changes could induce headache in the case of acute rhinosinusitis (2). However, headache was not reported to be a common symptom in patients with chronic rhinosinusitis. In fact, the 2004 IHS criteria state that chronic sinusitis is not valid as a cause of headache or facial pain unless it is relapsing into an acute stage (3). Besides, it should have clinical evidence including purulence in the nasal cavity, nasal obstruction, hyposmia/anosmia and/or fever, developing simultaneously with onset or acute exacerbation of acute or acute-on-chronic rhinosinusitis in supporting the diagnosis of ‘sinus headache’. However, the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) diagnostic criteria describe headache as the minor symptom of chronic rhinosinusitis (4). In addition, Stammberger and Wolf divided headache patients into three groups (5). The first group has headache specifically linked to abnormalities in the paranasal sinuses, such as inflammatory disease, neoplasm, barotraumas, or other readily identifiable causes. The second group has headache unrelated to the sinuses, such as migraines, neuralgias, ophthalmological problems and vascular problems. The third group has no clear cause for their headache, and a sinus origin could not be clearly identified; rather, causes such as contact point headache or middle turbinate syndrome were implicated. This revealed that formal diagnoses of primary headache disorder and rhinosinusitis are both symptom-based, the symptoms separating these two disorders overlapping significantly and causing confusion. To clarify this point, we retrospectively collected 36 patients with paranasal sinus pathologies presenting with headache as the primary symptom and who did not fit the 2004 IHS diagnostic criteria. We also excluded the new category of mucosal contact point headache in order to avoid confusion. In our series, the 36 patients were free of nasal symptoms and were initially diagnosed as having a headache disorder such as migraine or tension headache. We found that they needed to be differentiated more carefully and that sinus pathology needed to be included in the differential diagnosis of primary headache. Further specified IHS guidelines may be necessary in order to achieve better diagnosis and treatment results.
Disease pattern
In our study, the most common paranasal sinus pathology was mucocoele, followed by fungal sinusitis. Mucocoele is a mucous cyst in the mucus-secreting epithelium of the paranasal sinus. It occurs when sinus ostium or the compartment of the septate sinus becomes obstructed, thus causing the sinus cavity to be mucus-filled and airless. It is the most common expansile lesion of the paranasal sinuses. The expansile character promotes slow erosion of the adjacent structure and is responsible for the signs and symptoms of the pathology. The chronic indolent fungal sinusitis (fungal ball) generally does not cause headache in most populations. It will sometimes cause some pressure or a numbness sensation over the cheek area when it involves the maxillary sinus. Though not yet an established mechanism, fungal sinusitis will cause headache in a few patients, especially when the sphenoid sinus is involved.
The most common origin of induced sinus headache is the sphenoid sinus. In a review of isolated sphenoid sinus disease, the most common symptom was found to be headache, followed in decreasing order by visual changes, cranial nerve palsy and nasal symptoms (6). The onset of isolated sphenoid sinus disease is often insidious, and history and physical examinations contribute little to establishing the correct diagnosis of the sphenoid diseases. A missed or delayed diagnosis is common. Nasal endoscope, CT and magnetic resonance imaging may aid in early diagnosis of sphenoid sinus diseases (7).
Clinical approach
Symptoms
In our study, the most common location of headache was the frontal area. According to the 2004 guidelines, frontal headache accompanied by pain in one or more regions of the face, ears or teeth is characteristic of sinus headache. It is such in most cases. Among the 36 cases, 13 involved the frontal region with or without other regions. When conducting a literature review, pain was discovered as being referred to dermatomes by the first and second divisions of the trigeminal nerve. In ethmoid and frontal sinus diseases, pain is localized around the glabella, the inner canthus, between the eyes, or above the brow (8). The pain associated with the maxillary sinus may localize over the antral area with radiation to the upper teeth or forehead (8). In sphenoid sinus lesions, the pain location may be quite variable and could be over the occipital area, vertex, frontal region or behind the eyes (8). However, recent clinical studies have revealed that it is futile to attribute too much significance to headache localization resulting from sinus disease (9). In fact, the 2004 IHS criteria removed this part in the diagnosis of sinus headache. Our study supports this concept. By analysing the involved sinuses and painful region, no definite correlation was noted as in those of acute rhinosinusitis, indicating that the location of the headache is a poor predictor of localization of the primary sinus lesions. There is neither specific correlation nor diagnostic evidence between the pain characteristics/duration and paranasal sinus lesions.
It is now clear that the site of the sinus lesion is a more important determinant of pain than the extent of the lesion (10). A previous study also demonstrated that the severity of sinus diseases as revealed by CT imaging is not related to the severity of headaches (11). This was why the pain of chronic sinus headache is so variable, making diagnosis so difficult.
Physical examination
Comprehensive neurological and rhinological examinations are needed for the evaluation of primary headache. The presence of inflammatory changes, anatomical abnormalities or purulent nasal discharge suggests a secondary pathology. Sad to say, we could not find any clinical hint suggestive of sinus pathologies presenting as primary headache without any rhinological symptoms in our series. This requires further study and more attention.
Testing
A nasal endoscope can be useful in detecting nasal pathologies. Imaging studies can be used in excluding occult sinonasal lesions. There are no diagnostic tests for migraine or tension headaches. Blood tests should be considered based on specific symptoms such as fever or inflammatory diseases.
Differential diagnosis of sinus headache and primary headache
Nasal- and sinus-related pain can mimic primary headache syndromes, and it is hard to perform the differential diagnosis from either one. The sinuses and most of the anterior craniofacial structures are innervated by branches of the trigeminal sensory nerves; any kind of noxious stimulation of the sinuses and adjacent structures will trigger afferent sensory volleys into the trigeminal ganglion, which may activate a response in the trigeminal vascular system resulting in symptoms which might mimic migraine pain or other conditions such as neuralgia (9). Besides, different thinking processes in disease presentation might result in different diagnoses (9). There is no good diagnostic index of suspicion for sinus pathology when evaluating a headache patient by pain location or characteristics during pain episodes. Patients with primary headaches who do not respond to treatment may benefit from consultation with an otorhinolaryngologist. Finding one cause for headache does not exclude other simultaneous headache disorders. Further investigations of sinus headache should be peformed. A new definition of sinus headache and criteria for diagnosis should be created, instead of just stating that chronic sinusitis is not valid as a cause of headache or facial pain.
Treatment
The aim of surgery is to remove the sinus lesions and gain functional drainage. Endoscopic sinus surgery can be applied in selective cases, with preservation of mucosa functions and limited surgical trauma.
Tarabichi in 2000 reported 82 patients with radiographic and endoscopic evidence of chronic sinusitis and significant facial pain who underwent functional endoscopic sinus surgery and were available for 1-year follow-up. At 1 year, 38% of the patients had persistent facial pain despite the lack of any evidence of persistent sinusitis. He found no correlation between the severity of pain and the extent or location of mucosal disease. He concluded that causes unrelated to paranasal sinus pathology accounted for the headache in one-third of patients undergoing sinus surgery (12). Rebeiz in 2003 reported 142 patients with facial pain as one of the main presenting symptoms. Among the patient groups, 33 patients had pain as the only symptom of sinusitis. They concluded that the overall failure rate for controlled headache or facial pain was 5% (13). Therefore, it should be taken into consideration that headaches are complex issues and that headaches other than paranasal sinus pathologies can account for many of the headaches experienced by patients undergoing sinus surgery. Nevertheless, discussion and strict surgical criteria are mandatory for management of sinus headache. When pain is the only presenting symptom, surgery should be performed only in severe cases having radiological evidence of sinusitis and when the pain interferes with the patient's lifestyle or oocupation (13). The surgery should be conservative and limited to avoid massive tissue injury. Endoscopic sinus surgery fits these criteria and is suggested as the first line of surgical treatment for sinus headache.
There was very good improvement in sinus headaches as a result of surgery in our series. This is a review article; therefore, pain duration, characteristics and pattern records might have had some bias. However, the out-patient clinic follow-up records showed no recurrence of any improved cases. We concluded that headaches improved after appropriate diagnosis and surgical treatment. This revealed that suitable diagnosis is the key to treatment of this kind of patient. Surgical removal of such lesions achieves good results.
Conclusion
Paranasal sinus pathology is important in the differential diagnosis for primary headache. There is no unique clinical feature in the differential diagnosis of these diseases. Patients with primary headaches who do not respond to treatment may benefit from consultation with an otorhinolaryngologist. Surgical management can be beneficial in the treatment of sinus headaches. Further investigations of sinus headaches should be done, and a new definition of sinus headache and criteria for diagnosis should be created.