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C 2014 The American Laryngological,
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Rhinological and Otological Society, Inc.
Comprehensive Management of Patients Presenting to the
Otolaryngologist for Sinus Pressure, Pain, or Headache
Devyani Lal, MD; Alexis Rounds, BS; David W. Dodick, MD
Objectives/Hypothesis: To study differential diagnosis and efficacy of management strategies in patients presenting to
an otolaryngologist for sinus pressure, pain, or headache.
Study Design: Retrospective analysis at an academic medical center.
Methods: Patients were seen in the clinic (2010–2012) for sinus-related headache, pressure, pain or fullness (study
symptoms) by a rhinologist. A retrospective chart review of patients with study symptoms was conducted.
Results: Of 211 patients with study symptoms, 70.62% met American Academy of Otolaryngology–Head and Neck Surgery criteria for sinusitis or had rhinologic disease. Otolaryngic therapy alone (medical or surgical) relieved study symptoms
in 51.66%; combined neurology intervention helped another 15.17%. Nearly half of the patients (48.82%) were diagnosed
with primary headache disorders. Comorbid rhinologic-neurologic disease was present in 27.96% and odontogenic disease in
7%. Initial otolaryngology referral was likely unnecessary for 36.49% of the study patients. Sinus computed tomography (CT)
was available for 91% of 211 patients, and 80% of scans were positive. Endoscopic sinus surgery (ESS) was used in only 80/
211 patients (37.69%) and was effective in 66/211 (31.28%). ESS was most successful in patients receiving concurrent neurological intervention. The Lund-Mackay CT score did not predict outcomes from ESS. Interdisciplinary otolaryngologyneurology efforts resulted in a positive outcome for 92.4% of patients.
Conclusions: We present the first series detailing management of patients with sinus-headache pain in an otolaryngology practice. Such symptoms have multifactorial etiologies. Positive sinus CT results require cautious interpretation. ESS
should be judiciously used. Interdisciplinary care is critical for success: approximately 50% of patients benefited from otolaryngic management, 50% needed neurological treatment, and 7% required dental disease management.
Key Words: Sinus pain, sinus pressure, sinus headache, facial pain, facial pressure, facial fullness, headache, sinus
disease, sinusitis, chronic rhinosinusitis, migraine, tension headache, primary headache disorder.
Level of Evidence: 4
Laryngoscope, 125:303–310, 2015
INTRODUCTION
The management of patients with sinus pressure,
pain, fullness, or headache (study symptoms) is problematic. Although sinus headaches can result from sinusitis,
neurogenic causes, or both, this knowledge is poorly disseminated among patients and physicians.1–4 Migraines
are commonly misdiagnosed as sinusitis (sinus headache) in approximately 42% of patients.5 Rhinitis, rhinosinusitis, and migraines affect common locations, have
overlapping symptoms (nasal congestion, rhinorrhea,
facial pressure-pain-fullness, headache) and precipitating triggers (weather changes, inhaled irritants, allergies) creating diagnostic challenges.6 The estimated
From the Department of Otolaryngology (D.L., A.R.), and the
Department of Neurology (D.W.D.), Mayo Clinic, Phoenix, Arizona.
Editor’s Note: This Manuscript was accepted for publication
August 20, 2014.
Presented at the Annual Meeting of the American Academy of
Otolaryngology—Head & Neck Surgery Foundation, Vancouver, British
Columbia, Canada, September 29–October 2, 2013.
The authors have no funding, financial relationships, or conflicts
of interest to disclose.
Send correspondence to Devyani Lal, MD, Assistant Professor of
Otolaryngology, Mayo Clinic College of Medicine, Consultant, Department of Otolaryngology, Mayo Clinic, 5777 E. Mayo Boulevard, Phoenix,
AZ 85054. E-mail: [email protected]
DOI: 10.1002/lary.24926
Laryngoscope 125: February 2015
prevalence of migraines is 12%, chronic rhinitis is 24%
to 54%, and chronic rhinosinusitis (CRS) 15%.1–4 Therefore, sinonasal and migrainous disorders are also frequently comorbid.6 About 50% to 60% of migraineurs
report rhinorrhea and nasal congestion. Rhinitis and
CRS may increase migraine-associated morbidity and
increase migraine frequency nine-fold through irritation
of trigeminal nerve receptors.7,8
Symptom-based criteria can be overly sensitive in
diagnosing sinusitis.9 Although American Academy of
Otolaryngology–Head & Neck Surgery (AAO-HNS) criteria mandate objective confirmation by either nasal
endoscopy (NE) or computed tomography (CT),10 nonotolaryngologists usually do not perform NE. CT scan use is
limited due to concerns of necessity, radiation, and
cost.11 Symptom-based diagnosis of sinusitis may therefore be used for sinus pressure-pain-headache patients,
ignoring culpable neurogenic factors.1–4 The majority of
sinus-headache patients satisfy International Headache
Society criteria for migraines.5,12 The most common
cause of sinus headaches in primary care scenarios is
migraines, with 88% of 2,991 sinus-headache patients
diagnosed with migraines in one study.13 Sinusitis was
found in only 3% of 100 sinus-headache patients in a
population-based screening.6 In otolaryngology clinics,
studies selecting patients with negative NE and CT also
Lal et al.: Sinus Headache Management
303
find migraines to be the most common cause of sinus
headaches.14,15 Foroughipour et al. recently studied 58
sinus-headache patients in an otolaryngology setting
and found sinusitis in 5%.16 However, they excluded
patients diagnosed with primary headache disorders and
sinus infections in the last 6 months. A study reflecting
real-life scenarios faced by otolaryngologists in managing sinus-headache patients, often self-referred and suffering from the myriad of conditions causing such
symptoms, has not been performed.17
The objective of this work was to study differential
diagnosis and efficacy of management strategies in patients
presenting to an otolaryngologist for sinus pressure, pain, or
headache, with specific aims to study the differential diagnoses and outcomes, and compare the effectiveness of three
management strategies: upfront medical therapy, upfront
CT, and upfront neurology referral.
MATERIALS AND METHODS
This study was approved by the institutional research
board at Mayo Clinic, Phoenix, Arizona.
A retrospective electronic chart review of patients seen in
the clinic by a single rhinologist (D.L.) for sinus pressure, headache, fullness, or pain (study symptoms) between September
2010 and April 2012 was conducted. Final diagnosis, interventions, and outcomes were noted.
Positive outcome was noted by one of three criteria: 1)
subjective report of improvement in frequency or severity (or
both) of study symptoms, 2) improvement on item 10 (facial
pain- pressure) of the 22-item Sino-Nasal Outcome Test (SNOT22) questionnaire, or 3) if the former two were unavailable,
establishment of a pertinent neurogenic cause or primary headache disorder (PHD) upon neurology referral that obviated any
further otolaryngic intervention. Facial pain-pressure is scored
from zero to five points on the SNOT-22 questionnaire; we used
one point or more improvement as a positive outcome.18,19
Effectiveness was determined for management strategies.
Three strategies employed at the initial otolaryngology visit
were compared: 1) upfront medical therapy (UMT) (used for
sinusitis when highly suspected), 2) upfront sinus CT (obtained
to guide management where diagnosis was unclear), and 3)
upfront neurology referral (when sinusitis was judged unlikely
and neurogenic factors or PHD are more likely the cause of
study symptoms).
Sinusitis was diagnosed using 2007 AAO-HNS criteria.10
The presence of two major symptoms (mucopurulent drainage,
nasal obstruction/congestion, facial pressure-pain, decreased
smell) needed confirmation by NE (purulence, polyps, mass,
edema) and/or sinus CT. A positive CT was always interpreted
in the clinical context and met at least one of three criteria:
Lund-Mackay (LM) score of 4,20,21 fluid level (acute sinusitis),
or complete/near-complete opacification of more than one sinus.
Statistical analysis was performed using Microsoft Excel (2010)
software (Microsoft Corp., Redmond, WA).
RESULTS
Differential Diagnoses of Study Symptoms
The retrospective review found 211 patients managed by the rhinologist (D.L.) for study symptoms. Of
these, 72.99% (154/211) met AAO-HNS criteria for sinusitis or had rhinologic disease (69/154 positive on NE and
CT, five positive on NE, 80 with negative NE but posiLaryngoscope 125: February 2015
304
TABLE I.
Diagnoses in 211 Patients Undergoing Evaluation for Study
Symptoms (N 5 211).
Diagnoses
Value
Rhinologic disease
149 (70.62%)
Chronic rhinosinusitis
Acute sinusitis
118 (55.92%)
27 (12.80%)
Mucocele
4 (1.9%)
Odontogenic sinusitis
Septal contact point on nasal
endoscopy or CT scan (three
had localized pain to site of
contact point, and two had pain relief
with directed topical anesthesia)
Contact-point headache
Incidental septal contact point
Odontogenic disease (dental disease,
foreign body, radicular cyst,
odontogenic cysts, oroantral fistula)
Sinonasal tumor
Neurological headache or pain disorder
15 (7.11%)
26 (12.32%)
2 (0.95%)
24 (11.37%)
15 (7.11%)
2/211 (0.95%)
103/211 (48.82%)
Migraine
71 (33.65%)
Tension headache
Other chronic headache
8 (3.79%)
20 (9.48%)
Atypical facial pain
3 (1.42%)
Comorbid sinonasal-neurological
disease
59 (27.96%)
CT 5computed tomography.
tive CT). Table I lists their diagnoses. NE had a 3.25%
false-positive and 37.92% false-negative rate. True prevalence of sinonasal disease was 70.62% (149/211). CRS
was suspected in 118 (55.92%), acute sinusitis in 27
(12.80%), mucoceles in four (1.99%), tumor in two
(0.95%), and odontogenic disease in 15 (7.11%) patients.
Comorbid rhinologic-neurologic disease was present in
59 patients (27.96%). Although septal contact point was
seen in 26 patients (12.32%), contact-point headache was
diagnosed in only two (0.95%). Thirty-six of 211 patients
(17.06%) had preexisting neurological disorders, with 13
(6.16%) having been referred from neurology for sinonasal disease management. Pertinent neurological disorders were established upon neurology referral in 103
(48.82%) patients (migraine in 71 [33.65%], tension
headache in eight [3.79%], atypical facial pain in three
[1.42%], and other chronic headaches in 20 [9.48%]).
CT Characteristics
CT scan was performed or available for 91% (192/
211) of patients, of which 80.20% (154/192) were positive.
Of positive scans, 149 (96.75%) had LM scores of 4, 38
(19.79%) showed fluid levels, 15 (9.74%) had odontogenic
disease, and 90 (42.65%) had one or more completely/
near-completely opacified sinus(es) (Table II).
Management Strategies
Table III details the components of the three management strategies, UMT, upfront CT and upfront
Lal et al.: Sinus Headache Management
TABLE II.
Distribution of Patients by Lund-Mackay Score From 192 Computed Tomography Scans.
Lund-Mackay Score
Total No. of Patients
Acute Sinusitis or Acute
Exacerbation of CRS With
Fluid Level
CRS
Other Rhinologic Disease
(Tumor, Isolated Mucoceles, Contact Points)
Any Sinonasal Disease
0–3
43 (22.39 %)
0
0
5 (2.60%)
5
4–9
92 (47.92%)
30 (15.62%)
62 (32.29%)
0
92
101
Total
57 (30.69%)
192 (100%)
8 (4.17%)
38 (19.79%)
49 (25.52%)
111 (57.81%)
0
5 (2.60%)
57
154 (80.21%)
Complete or near complete opacification of one or more paranasal sinus noted in 90/192 (42.65%) patients. Lund-Mackay score of 4 was seen in 149/
192 patients.
CRS 5 chronic rhinosinusitis.
neurology referral. Figure 1 shows the actual clinical
flow of the 211 patients: 76/211 (36.01%) underwent
upfront UMT (group 1); 87/211 (41.23%) underwent
upfront sinus CT (group 2), and 48/211 (22.75%) were
referred to neurology upfront (group 3). An additional
36.49% (77/211) patients were also referred to neurology
after some otolaryngic intervention such that 112/211
patients (55.45%) were cumulatively referred. Nine
patients did not follow up, but those 103 that did were
all confirmed to have pertinent neurological disorders.
Magnetic resonance imaging (MRI) of the brain was ultimately obtained in 42.18% (89/211) of patients.
symptom improvement in 51.66% (109/211), and a combined otolaryngology-neurology approach was helpful in
an additional 15.17% (32/211). Based on any positive
response to any otolaryngic therapy, rhinologic disorder
was estimated to be culpable in causing study symptoms
in 66.82% of patients at best (141/211). Neurological disorder contributory to study symptoms was confirmed in
48.82% (103/211). Accounting unfavorable outcomes for
15 patients lost to follow-up, positive outcome (improved
symptoms/positive neurological diagnosis) was noted for
92.89% (196/211) of study subjects through an interdisciplinary approach.
Results From Therapy
Subgroup Analysis
Medical therapy (MT) targeting sinonasal disease
was used in 72.51% (153/211), either upfront (76/153;
49.67%) or subsequently (77/153; 50.33%) (Table IV). A
positive outcome was noted by one of three criteria
detailed in the Materials and Methods section. A purely
otolaryngic intervention was successful in study-
Group 1 comprised 76 patients (36% of 211 study
subjects). All 76 were given UMT targeting sinonasal
disease (selection of antibiotics, oral corticosteroids, topical corticosteroids, sinonasal irrigations, and ancillary
therapy as clinically indicated for 2–3 weeks).22 They
were then seen in follow-up. Twenty-six had study-
TABLE III.
Description of Common Management Strategy Employed.
Group
Interventions
Group 1: Upfront medical therapy
Optional/Additional
Upfront medical therapy
No further treatment
Post-treatment CT scan
Return patient visit
Further MT
ESS
Nasal endoscopy
Group 2: Upfront CT scan
Referral to neurology
CT sinus obtained after preliminary evaluation, and patient seen back in otolaryngology clinic at the same initial visit
Referral to oral surgery
Reassurance
No further treatment
MT
ESS
Referral to neurology
Group 3: Upfront neurology referral
Referral to oral surgery
No further treatment
Neurology referral
MRI Brain
MT
ESS
Referral to oral surgery
At initial visit, all patients underwent ear, nose, and throat evaluation and diagnostic nasal endoscopy.
CT 5computed tomography; ESS 5 endoscopic sinus surgery; MT 5 medical therapy for sinonasal disease.
Laryngoscope 125: February 2015
Lal et al.: Sinus Headache Management
305
Fig. 1. Flow of 211 patients presenting to the rhinology clinic with study symptoms. All patients in group 1 received upfront medical therapy
for sinusitis at initial visit. All group 2 patients underwent upfront sinus computed tomography (CT) at initial visit prior to any medical therapy being initiated. Group 3 patients underwent referral to neurology after the initial otolaryngic evaluation; some of these patients may
have concomitantly been treated for sinus disease. ENT 5ear, nose, and throat; ESS 5 endoscopic sinus surgery; MT 5 medical therapy for
sinusitis. [Color figure can be viewed in the online issue, which is available at www.laryngoscope.com.]
TABLE IV.
Outcomes From Management by Strategy Used.
Cause of Improvement in
Study Symptoms
Group 1 (Upfront MT),
n 5 76
Medical therapy
Group 2 (Upfront CT),
n 5 87
Group 3 (Upfront Neurology
Referral), n 5 48
Total, N 5 211
26/76
17/59
NA
43 (20.38%)
16 (ESS in 22)
29 (ESS in 36)
21 (ESS in 22)
42
46
21
66 (31.28%) (ESS in 80,
or 37.9%)
109 (51.66%)
Neurological intervention,
total
34/76
31/87
43/48
103 (48.82%)
Neurology referral after MT,
ESS, CT
34/76
33/87
NA
77 (36.49%)
Referral after MT
Referral after ESS
28/76 MT
6/22 ESS
0
5/36
NA
0
28 (13.27%)
11 (5.21%)
Based on CT result
ESS
Otolaryngic treatment
alone, MT and ESS
28/60
26/87
18/18
72 (34.12%)
Did not follow up
Positive outcome
0/34
76/76 (100%)*
4/87
67/87 (77%)*
5/48
42/48 (83.33%)*
9 (4.26%)
195/211 (92.41%)*
Lost to follow-up
0
10
5
15 (7.12%)
Positive outcome was noted by one of three criteria: 1) subjective report of improvement in frequency or severity (or both) of study symptoms, 2)
improvement on item 10 (facial pain-pressure) of the Sinonasal Outcome Test questionnaire by 1 point, and 3) if the former two were unavailable, establishment of a pertinent neurogenic cause upon neurology referral obviating any follow-up otolaryngic intervention.
*Accounts for patients lost to follow-up as unsuccessful outcome.
CT 5computed tomography; ESS 5 endoscopic sinus surgery; MT 5 medical therapy for sinonasal disease; NA 5 not applicable.
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Lal et al.: Sinus Headache Management
TABLE V.
Distribution of Patients by CT Scan Score and Management Strategies.
Lund-Mackay Score
Total No. of Patients
Medical Therapy for Rhinosinusitis
Endoscopic Sinus Surgery
Neurology Referral
0–3 or no CT available
62 (29.38%)
0
4/5 (80%)
45/51 (88.23%)
4–9
101
92 (43.6%)
57 (27.1%)
41/92 (44.65%)
14/57 (24.56%)
30/37 (81.08%)
32/38 (84.21%)
39/41 (95.12%)
19/20 (95%)
Total
211
55/153 (35.95%)
66/80 (80.48%)
103/112 (91.96%)*
*Nine patients did not initiate neurology referral.
CT 5computed tomography.
symptom resolution, requiring no further treatment.
Post-treatment sinus CT was available for 60 patients.
Twenty-eight patients (36.84%) showed no disease on
post-treatment CT, and were referred to neurology for
persistent study symptoms. Twenty-two patients underwent endoscopic sinus surgery (ESS) for persistent study
symptoms. Of these, 16 patients (72.7%) reported postESS improvement, and the six failures were referred to
neurology. In all, 34 Otolaryngic intervention failures
were referred to neurology in this group (44.74%), where
all were diagnosed with pertinent neurological disorders.
Though ultimately 100% (76/76) of group I patients had
positive outcomes from combined otolaryngologyneurology intervention, the initial UMT strategy was
effective for study symptoms in only 34.2% (26/76) and
all otolaryngic interventions (UMT and ESS) in only
53.16% (42/76) of this group.
Group 2 comprised 87 patients (43% of 211 study subjects) who underwent upfront CT at initial ear, nose, and
throat (ENT) visit. CT of 28 (32.2%) patients was negative,
and they were referred to neurology. Of these, two
patients did not follow up. The compliant 26 were all diagnosed with study-pertinent neurological disorders. Fiftynine patients had positive CT (67.8%) and underwent
sinonasal MT. On follow-up, 17 were successfully treated.
Six patients did not follow-up. ESS for persistent study
symptoms was performed in 36 patients, of whom 29
(80.5%) improved. Seven (19.45%) post-ESS patients with
persistent study symptoms were referred to neurology, of
whom five followed up. All 31 patients evaluated in neurology were also diagnosed with pertinent neurological
disorders. After otolaryngic treatment, improvement was
seen in 52.87% (46/87; MT 17/87; ESS 29/87) patients. No
post-ESS improvement was seen in 7/87 patients (8.04%)
making sinus disease identified on CT unnecessarily
treated. In addition, 17/59 with positive CT had successful
response to MT, and could arguably have been treated by
UMT without CT. Upfront CT, at worst, was therefore
unnecessary (19.54%) or negatively impacted (8.04%) care
in 24/87 patients (27.6%). Positive benefit in directing
early and appropriate management was initiated in 88.5%
(77/87) but executed in 72.4% (67/87) due to 11.49% (10
patients) not following up.
Group 3 comprised 48 patients (23% of 211 study
patients) who were referred to neurology upfront after otolaryngology evaluation. Forty-five patients reported with a
CT scan. Due to poor CT correlation with study symptoms
or strong suspicion of a neurological comorbidity, these
patients were referred to neurology upfront. Eighteen CT
Laryngoscope 125: February 2015
scans showed some sinonasal disease (17 with LM score
<4; one with LM score of 12) and were also given appropriate sinonasal MT. A pertinent neurological diagnosis was
established in all 43 patients who completed neurology
evaluation. Five patients did not follow up. After neurological intervention, 48.8% (21/43) of patients required no further otolaryngology intervention, but 22 (51.2%) were
referred back to otolaryngology for persistent symptoms
and sinonasal disease on MRI or CT. These 22 underwent
ESS for concomitant sinonasal disease and/or to mitigate
potential sinonasal migraine triggers, with a 95.45% (21/
22) success rate. Combined neurology-otolaryngology effort
was successful in 97.7% (42/43), and otolaryngic intervention was critical in 43.75% (21/48).
Comparing Success of Management Strategies
by Extent of Disease on CT Scan
Table V shows the distribution of patients by CT
scores in each group of management. MT was less likely
to succeed with an LM score 10 versus those in the 4
to 9 range (P 5.013). Of 92 patients with an LM score of
4 to 9, 44.65% responded to MT, in contrast to 24.56%
with an LM score 10. Neurology interventions were
equally effective across LM scores 3, 4 to 9, and 10
(P 5.41) as was ESS (P 5.93). Neurology referral was
initiated for 50/62 patients with LM scores 3.
Surgery
In the overall study cohort of 211 patients, ESS was
used in 37.91% (80/211) and effective in only 31.28% (66/
211). Carefully selected patients underwent conventional
ESS individualized by disease extent (76), balloonassisted hybrid ESS (two), and tumor resection (two). Of
these, 82.5% (66/80) showed improvement in study
symptoms at least 3 months post-ESS, but 17.5% (14/80)
noted no improvement. Success rate from ESS in alleviating study symptoms was the highest (95.45%) in those
with prior or concurrent neurology interventions. Five
patients with LM score 3 underwent surgery for mucoceles (one), fungus ball (one), tumor (one), or contactpoint headache (two), with an 80% success rate; one failure resulted from septoplasty for presumed contact-point
headache. No adverse events from ESS were noted.
DISCUSSION
Our study highlights the challenges confronting otolaryngologists treating sinus headache, pressure, and
Lal et al.: Sinus Headache Management
307
Fig. 2. A suggested algorithm to manage sinus-headache pain patients presenting to the otolaryngologist. Though an individualized
approach must be used to successfully manage each patient, three strategies based on initial ear, nose, and throat (ENT) evaluation can
be employed. The flow of patients shows that oftentimes, multidisciplinary management with active comanagement by otolaryngology and
neurology specialists is necessary. CT 5computed tomography; MRI 5 magnetic resonance imaging. *When facial or sinus pressure-painheadache is one of several prominent sinonasal symptoms, or is associated with purulent rhinorrhea or fever, sinusitis must be strongly
considered. **Stable and recurrent sinus headaches with/without limited sinonasal symptoms, especially with phonophobia-photophobiaaura, are most likely migraines. [Color figure can be viewed in the online issue, which is available at www.laryngoscope.com.]
pain, even when associated with sinonasal symptoms.
Although migraine is the most common diagnosis of
sinus headaches in the general and primary care populations,6,13 the cohort presenting to otolaryngology clinics
is distinct and has not been previously studied.17
In our large series of 211 study symptoms patients,
70.62% met AAO-HNS criteria for sinusitis or had rhinologic disease. Nearly half (48.82%) also had a primary
headache disorder. Comorbid rhinologic-neurologic disease was present in almost one-third (27.96%). Otolaryngic MT and ESS were successful in alleviating study
symptoms in 66.7% of patients at best. Upon failing otolaryngic intervention, 36.49% of the study patients were
successfully diagnosed with primary headache disorders
upon neurology referral and required no further otolaryngic management; otolaryngology evaluation was likely
superfluous in them. Neurology referral was effective in
confirming neurogenic factors in 97.7% of patients
referred. However, 6.16% of the 211 study patients had
actually been referred from neurology. An additional
10.42% were sent back to us for ESS. In these 35
patients, ESS had a success rate of 97.14%, far higher
than the 75% success rate from ESS overall. These
results reinforce the necessity for a thoughtful, interdisciplinary, otolaryngology-neurology comanagement for
sinus headache-pain-pressure patients.
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308
ESS was used in about 38% of patients, and successful in 80% of those. Success was not impacted by LM
scores, but highest in those undergoing concomitant neurological therapy. Previous studies reported that ESS
can improve headaches from CRS23 and contact points,24
but cognitive dissonance and temporary benefit have
been counter-argued.4 Of 24 contact-point patients
(11.3% patients), we attempted septoplasty on two for
presumed contact-point headaches (localized pain to site
relieved with targeted topical anesthesia on two occasions) but failed in 50%.
In comparing management strategies, UMT was
effective for only 50%. MT for sinonasal disorders was
less effective for more severe sinus disease (LM 10).
Lal et al.22 and Subramanian et al.25 also found pain
and headache to respond poorly to MT. Unsuccessful
UMT delays neurological evaluation and entails return
visits. MT can also have a placebo effect, prednisone can
treat certain PHDs, and often natural resolution of a
migraine headache is attributed to sinusitis-directed
medications.17,25,26
Upfront CT was effective in directing appropriate
therapy in 72.4% of patients in that group. In fact, CT
was utilized upfront or subsequently in managing 91%
of our patients. Earlier use of sinus CT as opposed to
UMT may be more helpful in efficient care of those who
Lal et al.: Sinus Headache Management
lack positive NE findings or overtly neurological symptoms. Leung et al.11 found upfront CT to be more costbeneficial than empiric MT for initial CRS management.
Mehle and Kremer found five of their 25 migraine
patients to have substantial sinus disease (LM scores
5), underscoring the use of CT scans and otolaryngology evaluation in migraineurs.27
However, positive CT scans must be interpreted
cautiously and in context with clinical evaluation. Mucosal changes may be entirely incidental or iatrogenic
from previous ESS, and can be seen in 15% to 30% of
asymptomatic and migrainous patients. Sinus headachepain scores also have no correlation with CT scores.27–30
Our retrospective study has several limitations. As
we did not collect pain-specific visual analog scale
scores, we used a symptomatic report of improvement or
a one-point improvement in facial pain scores on prospectively collected SNOT-22 questionnaires. This onepoint change was extrapolated from the report of 0.8 to
1 score change interpreted as meaningful change in total
SNOT-22 scores.18,19 For patients referred to neurology,
where longer-term outcome or SNOT-22 score was not
available, establishment of a pertinent neurogenic etiology was considered a positive outcome, as opposed to
complete symptom resolution. It is also not our practice
to trial migraine-specific therapy as suggested by some
authors, and therefore this approach was not studied.
Caution must be exercised in extrapolating results
from our study, which is based in a multispecialty, tertiary care practice. The prevalence of sinonasal disease,
as well as benefit of rhinologic intervention, is likely
lower in general otolaryngology and primary care practices. Our patients had easy access to headacheneurology specialists, which may not be the case in the
community. In spite of this, nine patients (4.2%) who did
follow up on neurology referral may have had deepseated beliefs in their sinus disease.
Our study illustrates the challenges associated with
managing sinus headache-pressure-pain patients. Individualized and interdisciplinary approaches, however,
were helpful for 92.% of our patients. Figure 2 outlines a
suggested algorithm for management of such patients. In
general, stable and recurrent sinus headaches with/
without limited sinonasal symptoms, especially with
phonophobia-photophobia-aura are most likely migraines.
When sinus pressure-pain-headache is one of several
prominent sinonasal symptoms, or associated with purulent rhinorrhea or fever, sinusitis must be strongly considered. NE and/or CT must always be employed for
confirming diagnosis. A headache-neurologist’s input is
invaluable for sinus headaches refractory to Otolaryngic
management, and should be considered prior to offering
recurrent antibiotic therapy or revision ESS. MRI or
referral to a headache neurologist should be also considered for new-onset or frequent (more than one per week)
headaches or associated neurological features.
CONCLUSION
Patients with sinus headache-pressure-fullness-pain
have multifactorial etiology and comorbidities. Although
Laryngoscope 125: February 2015
such patients are challenging to manage, interdisciplinary care can optimize outcomes. Half of our patients
benefited from otolaryngic therapy, 50% needed additional neurology input, and 7% required dental management. Neurological comorbidities may be culpable in
many patients with positive CT and sinusitis.
Acknowledgments
Mr. Clifton Ewbank helped with data collection.
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