|Year : 2018 | Volume
| Issue : 1 | Page : 51-56
Contact point headache: Diagnosis and management in a tertiary care center in Northeast India
Upasana Lungun Rai, Puyam Sobita Devi, Ningombam Jiten Singh, Nicola C Lyngdoh, Th Sudhiranjan, Nirmala Nongthombam
Department of Otorhinolaryngology, Regional Institute of Medical Sciences, Imphal, Manipur, India
|Date of Web Publication||18-Jun-2018|
Puyam Sobita Devi
Associate Professor, Department of ENT, RIMS, Imphal - 795 004, Manipur
Source of Support: None, Conflict of Interest: None
Background and Objectives: Headache in the absence of infection or inflammation and other causes may be related with some anatomical abnormalities of nose called contact point headache. Our objective was to study endoscopic and radiological nasal findings of contact point headache and their outcomes after surgery in patients attending department of otorhinolaryngology, tertiary care teaching hospital/center in Northeast India.
Study Design: A prospective study.
Materials and Methods: A total of fifty patients attending ear, nose, and throat outpatient department and diagnosed as contact point headache were selected after a detailed history of symptoms through questionnaires, diagnostic nasal endoscopy, computed tomography scan, and a positive xylocaine-adrenaline test. All the patients underwent surgery. Pre- and post-operative pain score (visual analog score [VAS]), mean frequency of pain, and mean duration of each attack were noted for comparison. Data collected were analyzed using appropriate tools.
Results: A total of thirty males and twenty females were included in the study. At the end of 12-month follow-up, pain score (VAS) reduced from 7.47 with standard deviation (SD) of ± 1.6–0.2 with SD of ± 0.59 postsurgery and the mean frequency of pain reduced from 9.10 with SD of ± 2.86–0.22 with SD of ± 0.67. Both were statistically significant.
Conclusion: Contact point headache is a common cause of headache in Northeast India and surgery is effective in a carefully selected cases.
Keywords: Contact point headache, middle turbinate headache, septoplasty
|How to cite this article:|
Rai UL, Devi PS, Singh NJ, Lyngdoh NC, Sudhiranjan T, Nongthombam N. Contact point headache: Diagnosis and management in a tertiary care center in Northeast India. J Med Soc 2018;32:51-6
|How to cite this URL:|
Rai UL, Devi PS, Singh NJ, Lyngdoh NC, Sudhiranjan T, Nongthombam N. Contact point headache: Diagnosis and management in a tertiary care center in Northeast India. J Med Soc [serial online] 2018 [cited 2020 May 28];32:51-6. Available from: http://www.jmedsoc.org/text.asp?2018/32/1/51/234654
| Introduction|| |
Headache is the most common disorder encountered by physicians in clinic in both adult and child. It can be a symptom of a number of different conditions of the head and neck and can result from a wide range of causes both benign and serious conditions. Usually, headaches associated with facial pain are treated as “sinus” headache; hence receive inappropriate treatment. Headaches secondary to sinonasal anatomic abnormalities need identification of contact points as a cause for the incapacitating problem and surgical procedures are undertaken to relieve these anatomic abnormalities.
Rhinogenic headache is defined as headache or facial pain secondary to mucosal contact points in the nasal cavity in the absence of inflammatory sinonasal disease, purulent discharge, nasal polyps, nasal mass, or hyperplastic mucosa. Many literatures have described it as rhinologic headache, rhinopathic, sinogenic, middle turbinate headache, nasal spur headache, four finger headache, sinus headache, contact point headache, Sluder's neuralgia, and anterior ethmoidal neuralgia.
In the year 1988, Stammberger and Wolf gave the cause of rhinogenic headache as mechanical contact between two mucosal surfaces, which creates a sensory stimulus resulting in release of substance P that is responsible for migraine-like headache symptoms.,
Diagnosis of contact point headaches is confirmed by nasal endoscopic examination and noncontrast computed tomography (CT) of nose and paranasal sinuses in patients complaining of headaches not relieved by medications and whose usual findings are septal deviation contacting nasal wall, middle turbinate, inferior turbinate, concha bullosa, pneumatized superior turbinate, and any other visualized mucosal contact point. Relieving the contact point by surgical methods is considered the ideal treatment method.
This study was conducted to evaluate the surgical outcome of patients diagnosed as having contact point headaches.
| Materials and Methods|| |
The study was done from October 2013 to September 2015 in the department of otorhinolaryngology of tertiary care teaching hospital/center in Northeast India after taking approval from the Ethical Committee of the Institute.
Patients presenting with headache in the outpatient department (OPD) and diagnosed as nasal mucosal contact point headache according to The International Classification of Headache Disorders (ICHD-2) criterion were enrolled for the study after taking consent. Inclusion criteria included headache >2 months, pain or pressure feeling over the nasal bridge, glabella, or forehead as the main complaint without any apparent sinus disease clinically or radiologically and failure of standard medical therapy for headache, with normal ophthalmologic, neurologic, dental, and systemic findings. Nasal contact point was demonstrated either endoscopically or radiologically or both and relief of headache with local anesthesia packing. All were above 15 years and below 50 years. Patients presenting with primary headaches or having other known causes of headaches, acute/chronic rhinosinusitis, patients already undergone sinonasal surgery, those not willing or fit for surgery, and those lost in follow-up were excluded from the study.
A total of fifty patients were included in the study. A detailed history of symptoms through questionnaires, diagnostic nasal endoscopy to identify mucosal contact points, CT scan of the nose and paranasal for evaluation of contact points, and pain evaluation with visual analog score (VAS) were taken. Xylocaine plus adrenaline test was performed on the study cases attending OPD during the attack of headache: Ribbon gauzes soaked in a mixture xylocaine (4%) and adrenaline (1:200,000) solution were placed at contact points intranasally under endoscopic guidance. Those who were relieved of pain after 5–10 min were pronounced positive and were selected for surgery. Informed and written consents were taken from the patients for surgery. A preoperative pain intensity score (VAS), average number of headache attacks per month, and the mean duration of each attack were calculated for future evaluation and outcome comparison.
The patients underwent endoscopic nasosinus surgery, wherein the contact points and ostiomeatal complex obstructions were relieved under general anesthesia. The surgical procedure was according to each patient's specific anatomic variations, though septoplasty was the standard procedure followed to correct any deviation or thickening of the septum in the area of presumed triggering contact point. Postoperatively, nasal packing was done with merocel, which was removed after 48 h. Perioperative antibiotics were given 2 days before surgery and continued until the 7th postoperative day. Endoscopic cleansing of the nasal cavity was done on the 3rd and 14th postoperative days. Regular saline nasal douching was given for 1 month. For patients with associated allergic rhinitis, fluticasone nasal spray once daily was advised to continue for 12 months. Nasal endoscopy findings and pain intensity score (VAS), average number of headache attacks per month, and the mean duration of each attack of the patients were noted on follow-up at the end of 3 months, 6 months, 9 months, and 12 months.
Data collected were processed in the IBM-SPSS-version 20.0 program (Chicago, Illinois, US). Both descriptive and analytical statistics were calculated. Friedman test was calculated to find the significance of the finding. P < 0.05 was taken as significant for this study.
| Results|| |
A total of thirty males and twenty females within the age group of 15–50 years were included in the study. Maximum cases were seen in the age group of 15–35 years. Majority of the headache was located in the frontal region (82%) followed by periorbital (34%), nasal (32%), malar (4%), entire head (4%), and occipital (2%). Almost all patients had multiple locations of the headache. Duration of headache ranged from 1 year to more than 10 years with the mean duration of 6.41 years and standard deviation (SD) of ± 3.25. Ten patients had 2–4 attacks/month, 26 patients reported of having 5–8 attacks/month, while more than eight attacks/month, and daily headaches were seen in seven patients, respectively. In 38 patients, duration of each attack lasted for 2–12 h, while six patients reported to have headache lasting for 12–24 h and four patients for more than 24 h. Pulsatile headache and photophobia were complained in 11 and 9 patients, respectively.
All the enrolled patients had positive xylocaine-adrenaline test preoperatively. Preoperative nasal endoscopy revealed anatomic abnormality of septum and the lateral wall in all patients [Picture 1]. Contact point between septum and middle turbinate were present in 34 patients (68%) followed by septum and inferior turbinate and spur and inferior turbinate in six each (12% each) [Picture 2] and between spur and middle turbinate in five (10%) as shown in [Figure 1].
Preoperative CT of nose and paranasal sinuses revealed contact point between septum and middle turbinate in 34 patients (68%) followed by septum and inferior turbinate and spur and inferior turbinate in six each (12% each) [Picture 3] and [Picture 4] and between spur and middle turbinate in five (10%). Concha bullosa was present in ten (20%) cases as shown in [Figure 2].
After diagnosis, endoseptoplasty was carried out in all fifty patients. In addition, turbinoplasty was done in 19 patients.
Comparison of pain scores: In comparison, preoperative average pain score (VAS) was 7.47 with SD of ± 1.6. Average postoperative pain score at 12 months after surgery declined to 0.2 with SD of ± 0.59 which is also statistically significant (P = 0.001) as shown in [Table 1].
|Table 1: Comparison of pain scores before surgery and follow-up till 12 months|
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Comparison of frequency of pain: At the end of 12 months follow-up, the mean frequency of pain reduced from 9.24 preoperatively to 0.22 which is also statistically significant (P = 0.001) as shown in [Table 2].
|Table 2: Comparison of frequency of pain before surgery and follow-up till 12 months|
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Preoperative and postoperative duration of headache: preoperatively, 38 patients suffered for 2–12 h, while six patients reported to have headache lasting for 12–24 h and four patients for more than 24 h. Postoperatively at 12 months, only five patients suffered headache in the group of 2–12 h, while no patients reported headache in the group of 12–24 h and more than 24 h group in [Table 3].
Preoperative and postoperative frequency of headache: Preoperatively ten patients had 2–4 attacks/month, 26 patients reported of having 5–8 attacks/month, while seven patients had more than eight attacks/month and another seven had daily headaches. Postsurgery frequency drastically reduced to 2–4 attacks/month at the end of 12 months in only five patients, rest all were symptom free indicating major success of the treatment through surgery as shown in [Figure 3].
Location of pain
Preoperatively, frontal headache was seen in 41 patients (82%) followed by periorbital (34%), nasal region (32%), malar (4%), entire head (4%), and occipital (2%). A number of patients had multiple locations of the headache. Location gradually decreased with subsequent visits after surgery as depicted in [Figure 4].
|Figure 4: Location of pain preoperative and during postoperative follow-up (can be multiple sites)|
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Comparison of pre- and post-operative nasal endoscopic findings: Postoperative contact point was seen in five cases which might justify pain persistence in these patients as shown in [Table 4].
|Table 4: Comparison of preoperative and postoperative nasal endoscopic findings|
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| Discussion|| |
Rhinogenic-related headache has been recognized since 1888 by Roe  and it has been a controversial topic. In the year 1980, Morgenstein and Krieger described middle turbinate headache syndrome caused by the vasoactive-engorged middle turbinate that compresses against an often deviating nasal septum. Diagnosis of such contact point headache necessitates a multidisciplinary approach. Diagnostic endoscopy of the nasal passages and CT of the nasal and paranasal region are complementary procedures. Therefore, before initiating treatment, correct diagnosis is mandatory for beneficial results.
All patients enrolled in the study were diagnosed preoperatively according to the criteria set by ICHD through xylocaine-adrenaline test and endoscopically and radiologically. In our study, all the fifty patients were tested positive for xylocaine-adrenaline test. Other studies used cocaine, tetracaine for anesthetic test., In the study done by Mohebbi et al., 12 out of 17 patients responded positively to tetracaine test unlike my study.
In our study, nasal endoscopy positive contact points were noted in all the cases between the deviated nasal septum and middle turbinate; septum and inferior turbinate; spur, middle turbinate, and inferior turbinate. More than one contact points were detected in ten cases. The findings of nasal endoscopy were almost similar to the CT findings; in addition, concha bullosa of middle turbinate was detected in ten patients. The most consistent findings in the study were contact between the septum and middle turbinate (68%). Similar finding of anatomical variations of middle turbinate as major causes of mucosal contact points was seen in a study done by Tosun et al. in Turkey. Another study by Harley et al. pointed anatomic abnormalities commonly at fault include deviation of nasal septum, septal spurring, and hypertrophied turbinates. However, Mohebbi et al. reported only 53% of positive CT scan findings. Wolff and Stammberger postulated intranasal mucosal contact as a cause of headaches by releasing neuropeptides, especially substance P, calcitonin gene-related peptide, and neurokinin A. These chemical mediators are well-recognized nocioceptive fibers in the central nervous system and the trigeminovascular system. This strongly supports our finding of positive contact point in patients with long-term headache.
In our study, headache duration of the patients ranged from 1 year to more than 10 years with an average duration of 6.41 years which is comparable with other studies done by Behin et al., Clerico et al., and Mohebbi et al., with the mean duration of headache for 8 years, 6.1 years, and 5.5 years, respectively. Majority of the headache were located in the frontal (82%) followed by periorbital (34%), nasal (32%), malar (4%), entire head (4%), and occipital (2%). Behin et al. also described pain location at frontal region and periorbital area. In the study done by Clerico et al., 74% reported pain in the supraorbital region, 37% in periorbital region, and 26% had maxillary pain. Location of pain can be explained by referred pain through the first and second branches of trigeminal nerve.,,
In our study, 31 patients underwent endoseptoplasty alone. In the rest, endoseptoplasty was combined with turbinoplasty. Several studies have undergone similar surgical procedures as a treatment modality. Septoplasty (mostly) with turbinoplasty (as needed) in the form of middle turbinectomy were done in almost all studies.,,,,,,
Various studies have shown good success rates of surgical management of contact point headaches. Ramadan  reported a 60% improvement rate, while Parsons and Batra  reported a 91% improvement in the symptoms after the surgery. Clerico et al. showed that 76% of their patients reported a decrease of 50% in pain after the operation. Likewise, Cho et al. reported a success rate of 82% in their study. Morganstein and Kreiger showed a success rate of 89% with surgery. In our study, a success rate of 90% was achieved with surgical intervention.
The postoperative pain intensity and frequency and duration of attacks were fully investigated for 12 months. Several studies ,,, have used visual analog scale to score pain as done in our study. Preoperatively, average pain score was 7.47 with SD of ± 0.6 on the scale of 0–10 (VAS), which declined to 0.2 postoperatively indicating major pain relief. Patient pain responses to surgical corrective treatment were statistically significant (P ≤ 0.001*'). Only five patients complained of headache at the end of follow-up, this may attribute to the persistence of contact points after surgery. Comparison of frequency of pain preoperatively and postoperatively shows marked reduction of pain frequency after corrective treatment, which is statistically significant (P ≤ 0.001*'). Similarly, Clerico et al. reported 15 patients (79%) of their study to have achieved improvement in headache severity or frequency, whose average preoperative pain severity was 7.2 (0–10 scale) and postoperative average pain severity was 3.1. In addition, preoperative headache frequency on average of 6.3 headache days/week reduced to on an average of 3.2 days/week postoperatively which was statistically significant (P< 0.001). In another study done by Nayak and Ramaswamy, pain score reduced postoperatively by 91% making 58% of them to be improved and 33% as resolved case. Likewise, Mohebbi et al. achieved an overall success rate of 83% in improving pain. Ramadan  reported 60% improvement. Parsons and Batra  reported 91% improvement in the intensity of headache after surgery. Chow achieved 82% success in alleviating the pain. Morgenstein and Krieger showed 89% success rate with surgical management of contact point headache. Behin et al., showed 83% complete relief and another 8% had at least 67% improvement giving a success rate of 92%. All these results are comparable with our study.
| Conclusion|| |
Contact point as one of the causes of headache can be identified with the use of endoscopy and CT imaging. Surgical correction of obvious anatomic abnormalities in carefully selected patients can significantly improve several important clinical outcomes from abolishing headache completely to decreasing its intensity and frequency in patients with contact point headaches.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4]