Can Functional Nasal Surgery Treat Chronic Headaches? A Systematic Review

Centripetal endoscopic sinus surgery in rhinogenic headache

OBJECTIVES

The aim of this manuscript is to analyse a diagnostic protocol to select correctly patients with Rhinogenic Headache Contact Point (RH) and to investigate the effect of surgical treatment and medical therapy in pain relief.

METHODS

A prospective no-randomized study selected adult patients with headache and nasal alteration at CT exam or endoscopic vision with positive response to test with nasal spray with corticosteroids and antihistamine or/and local anesthesia test to the contact points. MIDAS score, intensity score, daily duration of symptoms, frequency of headache in the last month were collected in patients who performed surgery and in patients who performed medical therapy.

RESULTS

Following the inclusion, 415 patients were selected for this study. 302 patients performed nasal surgery (septoplasty, turbinoplasty and/or endoscopic surgery with centripetal technique), 113 performed medical therapy. There was a statistically significant improvement in MIDAS score, intensity score, daily duration of symptoms, frequency of headache in the last month in patients who performed surgery and in patients who performed medical therapy. Regarding the comparison between patients who performed surgery (Group A) and patients who performed only medical therapy for RH (Group B), better outcomes were obtained by Group A. Considering the daily life handicap index, the lowest handicap was obtained in Group A.

CONCLUSION

This study demonstrates that surgery, using in some cases centripetal technique, gives an improvement statistically significant than medical therapy in RH. The use of nasal spray with corticosteroids and with anti-histamine is a good method in the diagnosis of RH, especially in patients with anatomical variants such as concha bullosa, agger nasi cells and Haller cells.

A longitudinal prospective study of septoplasty impact on headache and allergic rhinitis in patients with septal deviation

OBJECTIVE

To measure the severity of allergic rhinitis (AR) and different types of headaches in patients with septal deviation before and after septoplasty.

METHODS

This multicentre, prospective, longitudinal, observational study enrolled patients with deviated nasal septum, nasal symptoms and headaches associated with persistent AR lasting at least 2 months without resolution. The nasal obstruction evaluation (NOSE) scale, immunoglobulin-E (Ig-E) levels and visual analogue scale (VAS) for headache pain severity were evaluated before and after septoplasty using Wilcoxon signed-rank test.

RESULTS

A total of 196 patients were enrolled in the study (102 males; 94 females). A total of 134 patients (68%) were diagnosed with severe AR and 166 (85%) experienced headaches with AR. The majority (100 of 166 patients; 60%) had sinusoidal headaches, while 25% (42 of 166 patients) reported a combination of sinusoidal headache and migraine and 14% (24 of 166 patients) experienced migraines. A comparison of preoperative and postoperative Ig-E levels, NOSE and VAS scores demonstrated that septoplasty significantly improved AR symptoms and headaches. Although there were significant improvements in headaches overall post-septoplasty, only the sinusoidal components improved, while migraine remained unaffected.

CONCLUSION

Septoplasty improved AR and sinusoidal headaches in patients with septal deviation, but migraines remained unaffected.

Effectiveness of the Treatment of Rhinogenic Headache Caused by Intranasal Contact

OBJECTIVES

The aim of the study is to evaluate the effectiveness of the surgical and nonsurgical treatment of headache caused by contact points (CPs) between the nasal septum and inferior or middle turbinate.

METHODS

The research was designed as a prospective clinical case-series study. The patients with CP headaches were offered to choose between 2 treatment options, surgery and medical treatment. Two groups of surgically treated patients (surgery groups 1 and 2, depending on whether there is a contact between nasal septum and inferior turbinate or middle turbinate) were evaluated and compared for headache intensity and frequency. Headache intensity was measured using a visual analog scale value from 0 to 10; the frequency of headache was expressed as the number of days during 1 month with a headache (before surgery, 1 month, and 6 months after surgery). A comparison was also made between surgically and nonsurgically treated patients.

RESULTS

We found more intensive and frequent headache in patients who had CP between the nasal septum and the middle turbinate (P = .038 and P = .003, respectively). A significant reduction in headache intensity and frequency was found in both groups of surgically treated patients 6 months after surgery; however, this reduction was more significant in patients with mucosal contact between nasal septum and middle turbinate. The nonsurgical treatment made a significant reduction of headache intensity and frequency at 1-month follow-up (P = .012 and P = .031, respectively), but not at 6-month follow-up (P = .114 and P = .088, respectively).

CONCLUSION

Surgery gave a statistically significant reduction in the intensity and frequency of headache, which was assessed 6 months after surgery. Surgery was found as superior to nonsurgical treatment in the therapy of CP headache.

Trigeminal Function in Sino-Nasal Health and Disease

The upper airway (nasal passages, paranasal sinuses, pharynx, and glottis) provides the sentinel portion of the human respiratory tract, with the combined senses of olfaction (cranial nerve I) and trigeminal sensation (cranial nerve V) signaling the quality of inspired air. Trigeminal function also complements the sense of taste (in turn mediated by cranial nerves VII, IX and X), and participates in the genesis of taste aversions. The ability of trigeminal stimulation in the upper aero-digestive tract to trigger a variety of respiratory and behavioral reflexes has long been recognized. In this context, the last three decades has seen a proliferation of observations at a molecular level regarding the mechanisms of olfaction, irritation, and gustation. Concurrently, an ever-widening network of physiological interactions between olfaction, taste, and trigeminal function has been uncovered. The objective of this review is to summarize the relatively recent expansion of research in this sub-field of sensory science, and to explore the clinical and therapeutic implications thereof.

The Effects of Intervening With Synonasal Changes on Headaches in Migraine Patients Using Endonasal Surgery

OBJECTIVE

Some anatomical changes might trigger headaches in people who have migraine, and that surgical applications eliminating the structural problems in treatment-resistant migraine patients are effective in pain treatment.

METHODS

A total of 36 patients, who did not respond to different treatment options without aura migraine and chronic migraine that were showing synonasal and anatomical changes in synonasal nasal endoscopy and/or paranasal sinus CT screening, responding insufficiently and/or approximately one year period also did not respond to different treatment options, were included in this study between June 2016 and September 2019.

RESULTS

The relation between migraine episodes and synonasal symptoms was found to be statistically significant. A significant difference was detected between nasal congestion and obstruction, postnasal discharge, and runny nose in patients with attacks compared to patients without attacks. The difference between mean pain severity values was statistically significant when compared to preoperative values (3.0(3.0∼4.0)) and post-operative values (1.0(0∼1.0)). When the pain severity after the operation (1.0(1.0∼2.75)) was compared with the severity of pain before the operation (5.0 (3.0∼5.0)), it was determined that there was a significant decrease in pain severity in patients diagnosed with chronic migraine, the difference between the mean pain severity values was statistically significant, and the prevalence of pain decreased at a significant level after the operation.

CONCLUSION

The results of the present study indicate that the elimination of synonasal structural changes, which were hypothesized to trigger pain in migraine patients, could have a pain-reducing effect on the frequency and severity of the pain.

Trigger-Site Deactivation Surgery for Nerve Compression Headaches

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Identify patients who are candidates for headache surgery. 2. Counsel the patient preoperatively with regard to success rates, recovery, and complications. 3. Develop a surgical plan for primary and secondary nerve decompression. 4. Understand the surgical anatomy at all trigger sites. 5. Select appropriate International Classification of Diseases, Tenth Revision, and CPT codes.

SUMMARY

Headache surgery encompasses release of extracranial peripheral sensory nerves at seven sites. Keys to successful surgery include correct patient selection, detailed patient counseling, and meticulous surgical technique. This article is a practical step-by-step guide, from preoperative assessment to surgery and postoperative recovery. International Classification of Diseases, Tenth Revision, and CPT codes, in addition to complications and salvage procedures, are discussed. Intraoperative photographs, videos, and screening questionnaires are provided.

The Paramedian Forehead Flap: A Retrospective Clinical Model for Understanding the Connection Between Supraorbital and Supratrochlear Nerve Pathology and Headaches

Background:

In the later stages of a paramedian forehead flap (PMFF) surgery, the supratrochlear (STN) and branches of the supraorbital nerve (SON) are transected during flap inset above the supraorbital rim. This can lead to either a nerve release if the compression point was previously distal to the transection point or a new nerve compression through neuroma or scar tissue formation. We inferred that PMFF could be a model for understanding the correlation between STN/SON pathology and migraines headaches (MH). We hypothesized that patients undergoing PMFF would experience either a change in severity or an onset of a new headache (HA) or MH.

Methods:

One hundred ninety-nine patients who underwent a PMFF at a tertiary medical centre were identified and contacted by phone. Patients were asked about the presence of MH or HA before and after the procedure. If a patient reported a perioperative history of MH/HA, their pre- and postoperative MH/HA characteristics were recorded.

Results:

Of the 199 patients contacted, 74 reported no perioperative HA/MH history and 14 reported a perioperative history of HA/MH. Of these 14 patients, 5 had stable HA/MH pre- and post-surgery, and 9 reported a change in HA/MH post-surgery. In this subset of 9 patients, 3 reported change in HA/MH quality post-surgery, 1 reported HA/MH resolution post-surgery, and 5 reported new onset HA/MH post-surgery.

Conclusion:

Sixty-four percent of patients with perioperative HA/MH experienced a change in headache quality following surgery. These results suggest a potential connection between SON and STN pathology and HA/MH pathophysiology; further work is warranted.

Etiology of 'Sinus Headache'-Moving the Focus from Rhinology to Neurology. A Systematic Review

'Sinus headache and/or facial pain' (SH) is a common complaint encountered by otorhinolaryngologists, neurologists and general practitioners. However, several studies suggested that the majority of those cases may be attributed to primary headaches (i.e., migraine and tension-type headache (TTH). The purpose of this review is to evaluate the etiology of SH. The first part includes cross-sectional studies analyzing the prevalence of respective diagnoses in subjects with SH. The majority of these publications indicate that migraine and TTH are the most prevalent causes of SH, although most of these studies were conducted in a clinical setting. The second part of this review included treatment trials in subjects with SH. The findings from this part of the review show that SH without rhinosinusitis responds well to pharmacotherapy targeted at primary headaches. This observation further supports a neurologic etiology of the majority of SH cases.

Headache and rhinosinusitis: A review

PURPOSE OF REVIEW

To explain our current understanding of headache attributed to rhinosinusitis, an often inappropriately diagnosed secondary headache.

RECENT FINDINGS

Recent studies have shown that headache attributed to rhinosinusitis is often over-diagnosed in patients who actually have primary headache disorders, most commonly migraine. Failure to recognize and treat rhinosinusitis, however, can have devastating consequences. Abnormalities of the sinuses may also be treatable by surgical means, which may provide headache relief in appropriately selected patients.

SUMMARY

It is important for the practicing physician to understand how rhinosinusitis fits into the differential diagnosis of headache, both to avoid overdiagnosis in patients with primary headache, and to avoid underdiagnosis in patients with serious sinus disease.

A Comprehensive Review of Surgical Treatment of Migraine Surgery Safety and Efficacy

BACKGROUND

Recent clinical experience with migraine surgery has demonstrated both the safety and the efficacy of operative decompression of the peripheral nerves in the face, head, and neck for the alleviation of migraine symptoms. Because of the perceived novelty of these procedures, and the paranoia surrounding a theoretical loss of clinical territory, neurologists have condemned the field of migraine surgery. The Patient Safety Subcommittee of the American Society of Plastic Surgeons ventured to investigate the published safety track record of migraine surgery in the existing body of literature.

METHODS

A comprehensive review of the relevant published literature was performed. The relevant databases and literature libraries were reviewed from the date of their inception through early 2018. These articles were reviewed and their findings analyzed.

RESULTS

Thirty-nine published articles were found that demonstrated a substantial, extensively replicated body of data that demonstrate a significant reduction in migraine headache symptoms and frequency (even complete elimination of headache pain) following trigger-site surgery.

CONCLUSIONS

Migraine surgery is a valid method of treatment for migraine sufferers when performed by experienced plastic surgeons following a methodical protocol. These operations are associated with a high level of safety. The safety and efficacy of migraine surgery should be recognized by plastic surgeons, insurance companies, and the neurology societies.