Surgical Treatment of Chronic Headaches and Migraines by Ahmed M. Afifi & Ziv M. Peled & Jeffrey E. Janis

Author:Ahmed M. Afifi & Ziv M. Peled & Jeffrey E. Janis
Language: eng
Format: epub
ISBN: 9783030367947
Publisher: Springer International Publishing

Although a number of studies have linked the presence of nasal abnormalities with headache symptoms, these anatomic variants are also present in a number of patients without chronic headaches. For instance, in a study of 973 consecutive patients presenting to an outpatient rhinology clinic, Abu-Bakra et al. determined that the prevalence of nasal contact points on nasal endoscopy was the same in patients with and without facial pain, at approximately 4% in each group. They questioned if the presence of mucosal contact points in patients with chronic facial pain was purely coincidental [27]. Similarly, in a recent 2016 publication, Wang et al. demonstrated that 85.9% of 78 patients with chronic headache had at least one mucosal contact point, while 80.4% of 108 subjects without headache also had at least one contact point [28]. When these results were analyzed according to type of contact point, the authors determined that 55% of the headache group demonstrated contact between a deviated septum and lateral nasal wall, while only 40% of non-headache patients had this feature on their CT scans. Numerous other studies can also be found that document anatomic abnormalities within the nose with evidence supporting, but not proving, the causality for the patients’ headache symptoms [29, 30]. These results demonstrate that mucosal contact points have a similar prevalence in patients with and without headache. However, the presence of an abnormality on clinical or nasal endoscopic exam in a patient with a genetic predisposition for a primary headache on the ipsilateral side is more likely to be a significant finding than if the same abnormality were demonstrated in the general asymptomatic population.

Although the ICHD-3 no longer recommends any particular imaging study to establish the diagnosis of an anatomic nasal abnormality, the ICHD-2 did previously advocate for the use of either nasal endoscopy or CT to establish this criterion. The majority of studies that have evaluated surgical treatment of rhinogenic headaches utilize both studies, as the combination allows for both static and dynamic evaluation of the nasal cavity. As demonstrated above, if the nasal anatomic abnormality is static (e.g., a septal spur impinging on the turbinate or presence of expansive turbinate cells), CT imaging studies can be quite helpful to establish the diagnosis. However, these studies can also be misleading, as they often fail to identify contact points that exist only as a result of dynamic change. For example, if a patient who is predisposed to and suffers from primary headaches has a narrow airway which results in contact points during the engorgement phase, a CT scan would not show this between episodes. Therefore, most literature suggests the use of nasal endoscopy as the “gold standard” for diagnosis, as both static and dynamic changes can be identified during the onset of symptoms (see Fig. 9.2 for relevant examples).

Finally, administration of local anesthetic to the mucosa in the area of the known anatomic abnormality can serve as an easy and valuable diagnostic test. In fact, there is a significant degree of literature to suggest that a positive anesthetic test can be predictive of surgical success.

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