A consensus panel of physicians who treat patients reporting sinus and facial pain strongly recommend the use of all diagnostic tools available to determine the root cause of the headache-whether it is neurological or physiological, migraine or sinus. The physicians, including two otolaryngologists, four neurologists, and two allergists writing in an article published in Otolaryngology-Head and Neck Surgery (2006; 134(3):516-523), also agreed that the wrong diagnosis can lead to inappropriate treatment or lack of treatment.
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June 2006Multidisciplinary Effort, Diverse Opinions
The consensus panel met in December 2003 to assess the current state of diagnosis and treatment for sinus headache. Although these physicians came together on the overall need for better diagnosis, they continue to have diverse opinions on the cause of these headaches.
The key point of contention is highlighted in the article. Many sinus headaches are migraines, said Michael Setzen, MD, Clinical Associate Professor of Otolaryngology at New York University School of Medicine in New York City and Chief of the Rhinology Section at North Shore University Hospital in Manhasset, NY. A significant proportion of what we now think of as sinus headaches are indeed migraine headaches, he added.
The ENT physician is obligated to rule out sinus as the cause of a headache. – Neil Bhattacharyya, MD
Headache specialists consider sinus headache to be relatively rare, even when there is demonstrable noninfectious sinus inflammation, wrote Dr. Setzen and his co-authors from the consensus panel. Otolaryngologists and allergists, who frequently evaluate patients complaining of headache and rhinogenic symptoms, recognize that sinus headache is often migraine and consider many additional pathologic disorders in the differential diagnosis of a patient experiencing recurrent episodes of sinus headache.
Dr. Setzen contends that the rhinogenic headache is more serious than what might be typically thought of as a sinus headache. He argues it may be a deviated septum with bone spurs. This condition is not routinely diagnosed and the patient is unlikely to get better without proper treatment, he added.
The Diagnostic Process
The ENT physician is obligated to rule out sinus as the cause of a headache, said Neil Bhattacharyya, MD, Associate Professor of Otology and Laryngology at Brigham and Women’s Hospital in Boston, Mass. There is wide variability in symptoms and manifestation of chronic sinusitis, he added. Everyone who has blocked sinuses will not have a headache and every headache is not a sinus headache. But the pendulum is swinging far beyond this to say that there is no such thing as a sinus headache, Dr. Bhattacharyya argues.
The take-home message for otolaryngologists is to incorporate new knowledge but continue to get a good history, an appropriate physical exam, and a determination of the likelihood of chronic rhinosinusitis, Dr. Bhattacharyya said. While he was not a member of the consensus panel, he has written several articles on the symptoms of chronic rhinosinusitis.
Drs. Setzen and Bhattacharyya agree that when a patient has symptoms that suggest a sinus related headache, the otolaryngologist should routinely do a nasal endoscopy. Even if an ENT doctor thinks the headache may be migraine, he or she should do the endoscopy to rule out sinus blockage, Dr. Bhattacharyya recommended. If blockage is detected on this test and the patient has major symptoms of rhinosinusitis such as facial pain, congestion, nasal obstruction, and headache, a CT scan is warranted, said Drs. Bhattacharyya and Setzen.
Different Diagnostic Paths
Dr. Bhattacharyya said that the controversy over headache diagnosis among treating physicians stems from a vastly different perspective on the term headache. The term is overused and too far-reaching. The symptoms of facial pain and headache are common in the general public. What the neurologist and the otolaryngologist consider a headache is vastly different, he explained.
In the recent article, Dr. Setzen and his co-authors wrote, The otolaryngologist, using the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) classification system, investigates headache as one of several symptoms and signs to diagnose a pathophysiologic condition. The neurologist or headache specialist, in contrast, comes from the opposite viewpoint, searching for a pathophysiologic condition to explain a symptom, headache.
Asignificant proportion of what we now think of as sinus headaches are indeed migraine headaches. – Michael Setzen, MD
Otolaryngologists try to define the sinus condition and the neurologists want to determine the cause of the headache, summed up Dr. Setzen. Another co-author on the consensus paper, Howard L. Levine, MD, contends that rhinosinusitis is not a sinus headache. Dr. Levine, who is an otolaryngologist and Director of the Cleveland Nasal-Sinus and Sleep Center in Cleveland, Ohio, said the overlap in symptoms of sinus and migraine headache, as well as physiological problems such as a deviated septum and the lack of clinical practice guidelines, lead many otolaryngologists to misdiagnosis.
Testing Can Confirm Diagnosis
The article outlines the two current guidelines, from AAO-HNS and the International Headache Society (HIS), for diagnosing headache and the limitations of these guidelines. Drs. Setzen and Levine noted that the definitive diagnosis for rhinosinusitis can be made by CT scan but that many physicians are not able to perform this test. As noted in the AAO-HNS guidelines, they write, the majority of symptomatic patients will be treated by primary care physicians who may lack the equipment and training necessary to perform these tests, and thus recognize that a routine diagnosis of rhinosinusitis can generally be made through history and physical examination, including anterior rhinoscopy and oropharyngeal neck examination.
Dr. Levine suggested that sinus disease can be a trigger for migraine headache and recommended new clinical research to determine this possibility. All migraine headache is caused by a neurological event and there is an entire spectrum of symptoms and possible neurological factors, he said. If the nose and its nervous system do not work properly these neurons can likely cause a migraine headache, said Dr. Levine.
As outlined, these otolaryngologists recommend the use of the nasal endoscopy and follow-up CT scan when rhinosinusitis is a definite possibility. Dr. Setzen recommended another interim step. The endoscopy does not allow the physician to see the entire nasal spectrum, but if this test does suggest sinus as the cause of headache pain, Dr. Setzen attempts to confirm the diagnosis with the application of a local anesthetic to contact points, along with a nasal constrictor. If this alleviates the headache in five minutes, it is powerful information to conclude that the contact point is the source of the headache, he explained.
Surgery a Last Resort
Because the usual treatment for chronic rhinosinusitis is surgery, these physicians recommend that all other treatment options be pursued before attempting surgery. All three warn that antibiotics currently are overused and should be limited to patients who have mucosal thickening, discolored nasal drainage, and opacification of sinuses.
Drs. Setzen and Levine recommend that a short-term course of migraine drug therapy may be initiated by the otolaryngologist. These treatments include several different triptans. They are recommended for patients who have headaches that occur less than once a week. These experts strongly discourage patients from taking over-the-counter pain medications such as ibuprofen more than two to three times per week since this overmedication can actually trigger rebound headaches.
Dr. Bhattacharyya said if the otolaryngologist rules out sinus related headache, the patient should be referred back to the neurologist. Medication for migraine headache is better managed by the neurologist who will provide long-term monitoring and follow-up for the different drug regimens, he said.
The overarching message of the consensus panel is this, said Drs. Levine and Setzen: A differential diagnosis of migraine and rhinogenic headache is necessary if a patient is to receive appropriate treatment.
©2006 The Triological Society