Transcription:

Prakash Chandran (Host): Sinus headaches; is it the sinuses or is it the nose? We’re going to find that answer out today. I’m Prakash Chandran and in this episode of Northfield Hospital & Clinics podcast series, we’ll talk about sinus headaches. Here with us to discuss is Dr. Gerard O’Halloran, an Ear, Nose and Throat doctor at Northfield Hospital. Dr. O’Halloran, thank you so much for being here today.

Gerard O’Halloran, MD (Guest): Well thank you so much for having me Prakash.

Host: Of course. So, I’m actually curious. What exactly is a sinus headache? I’ve heard of these before. I’ve had headaches, but I don’t know what the difference between a normal headache and a sinus headache is.

Dr. O’Halloran: Well, sinus headaches in a way are misnamed because most of what – the most common headache that people have that they would term a sinus headache, is really caused by crowding in the upper nose and it’s very difficult to distinguish from your sinuses. The way our nerves are wired in the nose, they run right over the sinuses on the way to our brain. So, if there’s crowding in the nose caused by congestion; it will put pressure on structures in the nose and cause a headache in the midface area, essentially where a scuba mask would sit.

Of course, you can have a true sinus headache when you have an acute sinus infection. If you have a cold followed a week later by facial pressure, pain and discolored drainage and fever; that’s acute sinusitis and that will give you a headache too, but the sinus headaches that people usually talk about are the ones that are more frequent. Every time the weather changes, or they are exposed to smoke, perfume, or first thing in the morning when they lie down, they have pain, pressure, either beneath their eyes or up in the forehead above the eyes and sometimes even in the eye.

Those are what I’m talking about and sinus headache is really the wrong term for that. The term we use in the medical journals is rhinogenic headache, rhino meaning nose. But an easier way to describe it is just a nasal headache caused by crowding in the nose.

Host: Dr. O’Halloran, I’m curious what actually causes these sinus headaches in the first place?

Dr. O’Halloran: Well, as I mentioned Prakash, it’s crowding in the upper nose and I’ll try to describe it. It’s a little difficult without a picture. But if we peeled our nose off and looked inside, there is the septum or middle wall. Our nose is like an A-frame with a wall down the middle. That’s the nasal septum. And on the side walls of the nose, the slanted parts of the A, are structures hanging off that run towards the back of our throat. They kind of look like small hotdogs that are called turbinates. Most people haven’t heard of those. The turbinates’ function is they are the heaters in the nose. If you look at a picture, they kind of look like a radiator. Air flows across them and gets heated.

The turbinates are the variable part of the nose. While most people haven’t heard of them, you’ll know you have them because is you ever have had a cold or allergies and your nose felt congested; that was caused by the turbinates swelling up and blocking the air flow through the nose. The nasal headaches that we’re talking about typically are caused by a combination of chronic swelling in the nose and the anatomy of the nose being a little off in the upper part of the A where there are two pairs of turbinates on each side of the nose. The upper ones at the narrow part of the nose, it’s more crowded there and so if the septum is off even a little bit, it might push against one of those upper turbinates so that it may not hurt all the time, or it could; but when that turbinate swells; they will have pain.

A very common scenario, probably the most common is the septum or the middle wall of the nose will be deviated or a little crooked, pushing on one of the upper turbinates and the opposite side turbinate will have had enough space to grow that it grew bigger than they should of, so then people have trouble on both sides.

People can have - these kinds of nasal headaches can be unilateral, or they’ll have it only on one side or both. I think it’s more common to have both and so, the anatomy is off, either turbinate too big or septum is off and then there’s usually some element of swelling. Chronic swelling in the nose can be caused typically by one of two things. One is allergies or allergic rhinitis. In children, it’s more common, adults less common. The other cause is called by doctors, nonallergic rhinitis. What that really means is it’s not allergies, but we don’t really know what it is.

The common triggers for these types of headaches though are where you could tell it’s a nasal headache is if you are worse whenever the turbinates are swollen. So, from colds, or allergies, or smoke, perfume, weather change. And then the turbinates are dependent on blood flow so, they are full of blood so when we lie down, they tend to get bigger. So, people with these nasal headaches are often worse either middle of the night, but more commonly first thing in the morning. And then when they are up and around, it gets a little bit better.

Sometimes the headaches are quite severe and will even progress to what seems to be a migraine.

Host: Yeah, I was just going to ask you about some of those differences. The first thing that I wanted to mention was just as you were saying, my wife sometimes this happens as soon as she lies down to go to bed or early in the morning, she has these headaches and what I’m hearing from you is that they are these nasal headaches and they do kind of cause these pains so, the triggers that I’m hearing from you are like you said, late at night, early in the morning, or even I guess being in a place where there’s a lot of allergens that cause this. I want to kind of get into some of the other triggers beyond that, that might cause a nasal headache that we can actually avoid. Is there anything else that we may want to stay away from that could cause these things?

Dr. O’Halloran: I don’t think there’s any other triggers, the nonallergic triggers are strong chemical odors or perfumes, smoke, and then some people have almost what they call a barometer nose. When the barometric pressure changes say before a storm, they will get headaches more then. The other trigger, not preventable is the menstrual cycle for women. So, a lot of women will have more headaches or only during the premenstrual or during their menstrual cycle. We presume that’s because they may retain fluid, so there’s more fluid, the turbinates are slightly more congested. These clearances in the nose, the space between turbinates and the septum is barely a millimeter so even a little bit of swelling may set them over the edge into a headache or pain.

A migraine and I’ll give you my very simplistic view is really a headache that is just so bad it sort of spreads throughout the whole brain, almost like a seizure would be. The – some migraines may be related to the nasal headaches because if they have the same triggers. So, people that have migraine headaches in the midface area, that are triggered by smoke, perfume, weather change or menstrual cycle; they may well have rhinogenic headaches. The most common population for this is women in their 20s, 30s, 40s, although this can also – they also occur in children. I just recently in the clinics saw the mother of a boy who I think is nine or ten now and I had fixed his nose. He had crowding in the upper nose. We had done surgery, a fairly limited surgery and he has only had two migraines since, and he had previously had them every day.

Host: Wow. I want to get into treatment. So, when you are experiencing these nasal headaches, what is the best way for you to treat them and when does it make sense to go see a doctor?

Dr. O’Halloran: Well, I’m happy to see anyone, anytime with these. This is an area of special interest for me. I’ve even spoken on this at the International Nose Surgery Society which as you might imagine is a super fun group. But there are really three treatments for this in my opinion. The oral decongestants will shrink turbinates, but they are not considered safe for most people as we get older because of heart attacks and stroke risk. Most of the over-the-counter – the decongestants like Sudafed. But for people who have very sporadic headaches, say you have one a week or less; using a decongestant nose spray will often work. It will just take all the swelling out of the turbinates and relieve the headache.

Now, there’s no guarantee it won’t come back when the medicine wears off and those sprays can’t be used more than two or three days in a row, but I do have patients that have sporadic headaches, not very frequent and they will use a – Afrin would be the one, oxymetazoline is the generic name. a couple of squirts of that on each side of the nose and some people, that will abort the headache.

The other – the long-term treatment for people that have them more frequently would be inhaled nasal steroid sprays, examples Flonase, Nasonex, Nasacort, Rhinocort. The nasal steroid sprays are fairly low yield on this. The area of crowding is pretty far back up in the nose and the spray doesn’t reach there very well. But if the septum is relatively straight, they at least have a shot. I always try it because there’s no downside to trying it.

The points I’d like to make about the use of the nasal sprays is and I have a video somewhere on YouTube with this; is you want to make sure your aiming it correctly. Most people, in my experience, aim the spray a little differently than I would like them to. I’m trying to hit that upper turbinate, so the correct angle would be if you started with the bottle aiming it straight to the back of your head and tilt it up a half inch or 20 degrees upward, so it’s sort of angled upward, not straight upward and then about a millimeter or a degree laterally away from the middle wall of the nose; that will aim directly at that turbinate. I usually try that for a month. If it’s going to work, it should work within a month. I think the yield on that, the people it helps is only 10 or 20%, but that’s certainly better than nothing.

The only other treatment that I’m aware of for this, would be is surgery which is correcting the anatomy of the nose. Restoring the anatomy to normal. Straightening the septum if it’s crooked, reducing the size of that upper turbinate.

Host: Another thing I wanted to ask you just as we wrap up here is like the onset of these headaches. Sometimes they seem to happen or come on very quickly and sometimes you can – it’s like a mild dim pain that happens over time. Can you kind of simply explain why that happens. Like why it’s like from zero to 100 extremely quickly in one case and then just seemingly very slow in others?

Dr. O’Halloran: Sure. All the variability, all the changes with this kind of headache, if we’re right, are all related to how much the turbinates swell. Because the anatomy, your septum and the mechanical size of the turbinates, the bone inside the turbinates, that size is fixed. So, all the changes are related to how much it swells. And the turbinates can change – the amount of swelling very quickly. Most of us, our turbinates on one side of the nose will cycle back and forth with the other where one side is always a little more swollen than the other. Most people never notice it, but the people that are crowded will because their headache will move from side to side or it will good and then bad every few hours.

But if there is something that’s a big irritator like say someone who is sensitive to smoke and happens to walk through a smoky room or near a fire; then those turbinates may swell almost instantly, and they will have sudden onset of headache.

Host: Well, definitely the one thing after this that I’m going to do is go on the internet and look up what a turbinate looks like. Because I can kind of visualize it based on your description, but I want to see exactly where they are. I can just see it’s probably close to the bridge of the nose, but it seems like those are the key things that just when they get triggered, they really cause a lot – they can cause a lot of havoc.

Dr. O’Halloran: Well that’s actually a good point. It’s really right where eyeglasses sit. The upper turbinates run straight back from there and many of the patients with these headaches will have figured out that if they apply pressure there with their fingers; they will get a tiny bit of relief because you are cutting of a little bit of the blood flow to the turbinate and it will take the swelling down just a speck, but it’s enough to get a little relief.

Host: Ah, that’s why that works. Okay and it’s so funny, I feel like we all naturally do that. We just kind of apply a little bit of pressure when we have that headache and we see this in commercials and everything and now I understand why. Thank you, Dr. O’Halloran.

Dr. O’Halloran: Oh no, no problem.

Host: Okay, fantastic. So, I think you’ve educated us really well on these sinus headaches and these nasal headaches. Is there anything else that you want to say to our audience before we wrap up today?

Dr. O’Halloran: I should probably talk a little bit more about the surgery we do for this because that’s a big leap for people and it’s good to know that it works most of the time. The surgery is essentially considered like a nasal septoplasty, about a half hour, forty minute surgery. At the same time we reduce the upper turbinate and I do about 60 of these a year for headache. I do about 150 noses a year overall. Most of the nose surgery we do is for breathing or sinus, but about 60 that I do a year for headache and I think the success rate is quite high roughly 90-95%. Some of the people will still need to use the inhaled nasal steroids to get the full benefit because they have a swelling issue, especially if they have bad allergies. But if we can correct the anatomy; most, but not all people, will get decent relief and by decent, I mean they are roughly 80-90% better or the headaches are completely gone.

Host: Okay, that’s really good to know and is there a set of guidelines that you follow in terms of recommending that surgery to someone?

Dr. O’Halloran: There’s really no guidelines for this. it’s really based on our exam. I usually will obtain a sinus CT scan to be sure there’s no sinus disease that might be involved as well and to show the anatomy. Then one of the tests we can do in the office if we can see the patients when they are having the headache is, we can look up there, find the point of contact and spray a topical numbing and decongestant medicine on it and if that alleviates the headache, that’s a pretty good sign that, that’s where it’s coming from and if we get the pressure off there, they will get better after surgery.

Host: Got it. And it sounds like the success rate, if you are able to establish that that actually works, it sounds like the success rate can be very high.

Dr. O’Halloran: Yeah, the success rate is high. I mean nothing’s perfect, but nose surgery like this does a pretty good job for most people. I’ve done several mother daughter combos even because the daughter inherited the mother’s nose and the one mother brought her kid in when she was ten and she said she’s having the same headaches that I had that you fixed, and we fixed her, and she’s done fine ever since.

Host: Okay. Well, again, thank you Dr. O’Halloran for educating us today. For more information, please visit www.northfieldhospital.org. My guest today has been Dr. Gerard O’Halloran. I’m Prakash Chandran. Thank you so much for listening.