ROBERT HUGHES MD

NORTH COUNTRY ENT OTORHINOLARYNGOLOGY

OTOLARYNGIC ALLERGY

HEADACHE

Migraine Sinus and Allergy Tension and Stress

and countless others

Trepanning●Primitive man believed that head pain was the work of evil spirits who invaded the body of unfortunate individuals. ●If headache was caused by the invasion of evil spirits, then letting the spirits out of the skull should bring relief. ●Thus was born the surgical procedure known as trepanning which dates back ten thousand years or more.

●Such procedures were found in the South Pacific, Europe, North America and South America.

Imhotep- “the One Who Walked in Peace”

●Vizier of a Pharaoh, lived about 2900 BC;

●He is credited with many accomplishments in many fields and one of his activities seems to have been that of a successful physician.

●He is one of the first medical men whose name is on record and rose from the role of medical hero to become God of Medicine.

●He began using simple surgery instead of just magic.

Sir William Osler tells us that Imhotep was the:

!

● "..first figure of a physician to stand out clearly from the mists of antiquity." Imhotep diagnosed and treated over 200 diseases, 15 diseases of the abdomen, 11 of the bladder, 10 of the rectum, 29 of the eyes, and 18 of the skin, hair, nails and tongue. Imhotep treated tuberculosis, gallstones, appendicitis, gout and arthritis. He also performed surgery and practiced some dentistry. Imhotep extracted medicine from plants. He also knew the position and function of the vital organs and circulation of the blood system. The Encyclopedia Britannica says, "The evidence afforded by Egyptian and Greek texts support the view that Imhotep's reputation was very respected in early times. His prestige increased with the lapse of centuries and his temples in Greek times were the centers of medical teachings." 

The Two Great Names in the History of Greek Medicine

●Hippocrates-dominated the beginning of a period of remarkable scientific creativity, which lasted more than 700 years ●Galen—near the end of the period, both furthered scientific knowledge and crystallized it in an amazing volume of written works. His influence lasted for 1500 years/45 generations.

The Age of Enlightment

HEADACHETHEY CAN BE CHALLENGING

!

THEY CAN BE A CHALLENGE

The Role of Otolaryngology

Headache is a common complaint in ENT practices

ENT’s have both the Medical and Surgical expertise

Define if it is Surgical (anatomical)

Specifically Manage if Medical

Perform Allergy Management (if applicable)

My Personal OpinionSinus Headache exists as a distinct entity

!Allergic pathophysiology parallels the vascular models used for migraine HA

!Migraine/Tension/Sinus is a three way

continuum !

Anatomical abnormalities can trigger Migraines

!Confusion in diagnosis a real issue today

WORRISOME HEADACHE RED FLAGS“SNOOP”

! Older: new onset and progressive headache, especially in middle-age >50 (giant cell arteritis)

! Systemic symptoms (fever, weight loss) or ! ! Secondary risk factors (HIV, systemic cancer)

! Neurologic symptoms or abnormal signs (confusion, impaired alertness, or consciousness)

! Onset: sudden, abrupt, or split-second

! Previous headache history: first headache or different (change in attack frequency, severity, or clinical features)

How Common is Migraine?

30,000,000 Americans 20% of women

7% of men at any given time Most of us have some migraine

manifestations occasionally

Recognizing Migraine

Pounding unilateral headache Preceded by visual or other aura

Nausea, vomiting Light and sound sensitivity

Migraine DefinitionIHS Diagnostic criteria: migraine w/o aura

HA lasting for 4-72 hrs

HA w/2+ of following:

Unilateral

Pulsating

Mod/severe intensity.

Aggravated by routine physical activity.

During HA at least 1 of following

N/V

Photophobia

Phonophobia

■ IHS criteria: Migraine/aura (3 out of 4) – One or more fully reversible aura

symptoms indicates focal cerebral cortical or brainstem dysfunction.

– At least one aura symptom develops gradually over more than 4 minutes.

– No aura symptom lasts more than one hour.

– HA follows aura w/free interval of less than one hour and may begin before or w/aura.

History, PE, Neuro exam show no other organic disease.

!At least five attacks occur

What is migraine?Migraine without aura (MO)

Migraine with aura (MA)

Headache Classification Committee of IHS (1988)

At least five attacks fulfilling these criteria:

• Headache lasting 4–72 h (2–48 h in children)

At least two attacks fulfilling these criteria:

• At least three of the following: – one or more fully reversible

aura symptoms – gradually developing or

sequential aura symptoms – no one aura symptom lasts

longer than 1 h – headache shortly follows or

accompanies aura• Accompanied by at least one of: – nausea – vomiting – photophobia and/or

phonophobia

• No evidence of organic disease

• With at least two of: – unilateral location – pulsating quality – moderate/severe intensity – aggravated by activity

• No evidence of organic disease

Subtypes?Classic

Atypical

Chronic Daily HA

Cluster HA

Transformed Migraine

Medication overuse HA

Chronic Tension type HA

More subtypes?New Daily Persistent HA

Hemicranial continua

Hypnic Migraine

Paroxysmal Hemicrania

Neuralgiform HA

No Classification For SINUS HEADACHE

World prevalence of migraine:A disorder of First World

● 1-year prevalence rates

● Population-based studies

● IHS criteria (or

USA 12%

Chile 7%

Japan 8%Italy 16%

Denmark 10%France 8%†

Switzerland 13%

Rasmussen and Olesen (1994); Rasmussen (1995);Lipton et al (1994); Lavados and Tenhamm (1997); Sakai

and Igarashi (1997)†Prevalence measured over a few years

Cady (1999); Warshaw et al (1998)

Diagnosis of migraine

• Diagnosis depends on patient history • No specific tests or clinical markers

• Positive diagnosis if attack history fulfils IHS criteria for migraine

• Other pointers include: – family history of migraine – age of onset <45 – presence of aura – menstrual association

• Organic disease must be excluded

PhysiologyVasospasm – Lance

Spreading Wave of Depression – Leao Trigeminocentric

Allodynia

VasospasmI. Aura: Arteries Spasm

Visual and focal neurological symtoms Pial and Occipital small artery branches

II. Headache: Compensatory Vasodilation Pounding unilateral sick headache

III. Inflammation and muscle spasm: second pain phase

Phases of MigraineVague Prodrome: psychic change and

cravings e.g. chocolate Aura: Focal symptoms and vision

Headache: Throbbing unilateral pain Inflammation: Prolonged phase and TTH

Postdrome Migraine related stroke

Spreading Wave Brainstem controls Cortical Activity

Epileptic like phenomenon that spreads over Cortex Visual Phenomenon that spreads over surface of

brain like shimmering “C” Cheiro-oral Jacksonian phenomena

Concurrence of migraine and epilepsy Why epilepsy drugs work for migraine

Trigeminal TheorySerotonin again

Trigeminal Afferents: sensory function of face and meninges

Trigeminal efferents to vessels Cause vessel spasm and sensitivity

This theory primarily explains action of Triptans: 5-HT 1b,d agonists

Migraine Pathophysiology

Goadsby NEJM 346!:257-70,2002

MechanismNeurovascular theory.

Abnormal brainstem responses.

Trigemino-vascular system.

Calcitonin gene related peptide

Neurokinin A

Substance P

!

Extracranial arterial vasodilation.

Temporal

Pulsing pain.

Extracranial neurogenic inflammation.

Decreased inhibition of central pain transmission.

Endogenous opioids.

Allodynia TheoryMigraine is a state of hypersensitivity Light, sounds, smells, touch (head in

headache) Need for dark room

Best preventives decrease sensitivity. Anticonvulsants, tricyclics, beta and calcium

channel blockers

Each of these Theories explains some migraine phenomena

Migraine PhenomenaFocal and paroxysmal onset of symptoms

Specific visual phenomena Spreading numbness and moving visual phenomena and

sensory distortions. Nausea, vomiting “sick” headache Pounding unilateral or bilateral pain

Psychic changes Light and sound sensitivity even between attacks

Effectiveness of triptans Effect of anticonvulants

Role of serotonin

Some Dicta

Any paroxysmal headache is likely to be migraine unless proven otherwise

“Sinus” headaches and “tension” headaches are almost always migraine headaches First ever severe headache or sudden

“thunderclap” headaches may be SAH

TreatmentEffective treatment of attack

Prevention Address comorbidities

Mechanisms for treatment

CGRP NK SP

5-HT1F5-HT1D

5-HT1B

Blood vessel

Trigeminal nerve

Adapted from Goadsby (1997)

CGRP calcitonin gene related peptide

NK neurokinin A

SP substance P

triptan

CONSTRICTION

INHIBITION

Acute Attack Triptans:

sumatriptan, zolmitriptan, almotriptan, naratriptan, frovatriptan, elitriptriptan, riaztriptan

NSAID’s Fioricet

Midrin (isometheptane, chlorphenoxazone, apap OTC: Caffeine, apap, phenacitin, asa Ergots: Caffergot, DHE nasal, injected

Narcotics Depacon

Consider Combinations

Triptan + NSAID Triptan + anti-nausea

Unconventional agents Phenergan, Compazine alone or in combination. Zyprexa or atypicals We don’t have enough alternatives

Triptan worriesNot released under age 18

If you even suspect CAD don’t use or get proper exclusionary tests.

Man or woman of a certain age Smoker or other risk factors

Cerebrovascular disease or complicated migraine - contraindicated

Watch for overuse. These are rescue medicines

ProphylaxisAnticonvulsants: topiramate, valproate, Keppra,

gabapentin Tricyclics

Amitriptylene, nortriptylene, trazodone Beta Blockers

Timolol, propranolol, nadolol Calcium channel blocker – verapamil

ACE inhibitors SSRI’s

Atypicals

Preventive therapyConsider if pt has more than 3-4 episodes/month.

Reduces frequency by 40 – 60%.

Breakthrough headaches easier to abort.

Beta blockers

Amitriptyline

Calcium channel blockers

Lifestyle modification.

Biofeedback.

Botox51% migraineurs treated

had complete prophylaxis for 4.1 months.

38% had prophylaxis for 2.7 months.

Randomized trial showed significant improvement in headache frequency with multiple treatments.

Conclusions

Migraine is common but unrecognized.

Keep migraine and its variants in the differential diagnosis.

Chronic Daily Headache: When to

suspect sinus disease

“Sinus HA” Differential dx

• Acute rhinosinusitis (ARS) • nasal and facial pain, nasal congestion and purulent

nasal drainage. • Chronic rhinosinusitis (CRS)

• nasal drainage, congestion and facial pressure • Migraine

“Sinus HA” work up

• Neurologists and internists utilize the International Headache society guidelines

• Otolarynologists utilize the AAO-HNS rhinosinusitis categories and criteria • History • Examination, including endoscopic • Radiologic examination

AAO-HNS Rhinosinusitis Categories

• Acute rhinosinusitis (the patient has symptoms present for less than 4 weeks)

• Subacute rhinosinusitis (the patient has symptoms present for more than 4 weeks, but less than 12 weeks)

• Chronic rhinosinusitis (the patient has symptoms present for greater than 12 weeks)

• Recurrent acute rhinosinusitis (the patient has more than 4 acute episodes over 1 year)

• Acute exacerbation of chronic rhinosinusitis (the patient develops an acute infection, with new acute symptoms, superimposed over a chronic infection, with a constant baseline level of symptoms)

AAO-HNS Rhinosinusitis Criteria

• Major Factors • Purulence in nasal cavity on

examination • Facial pain/pressure • Nasal obstruction/blockage • Fever (acute only) • Hyposmia/anosmia • Nasal discharge/purulence • Discolored postnasal

drainage

• Minor factors • Headache • Fever (all nonacute) • Halitosis • Fatigue • Dental pain • Cough • Ear pain/pressure/fullness

Nasal/facial pain

!

• Nasal mucosa is not uniformly pain sensitive • Ostia are more sensitive

• Rhinosinusitis often affects >1 sinus; multiple pain regions = diffuse pain

Nasal/facial pain• Nasal sensation poorly

represented within the brain • Nasal sites refer pain to

surface structures

Maxillary Sinus• Maxillary division of 5th cranial

nerve (V2) • Posterior superior alveolar • Infraorbital • Anterior superior alveolar

• Stimulating the maxillary sinus ostia will produce referred pain at the posterior nasopharynx, posterior teeth, zygoma, and temple.

• Pressure within the maxillary sinus itself produces a sense of vague fullness in the face

Frontal Sinus• Ophthalmic branch of 5th

cranial nerve (V1) • Frontal recess irritation is felt

as pain in the inner canthal region, anterior zygoma, and molars.

• Local irritation within the frontal sinus itself is felt as mild pain at the same approximate frontal location.

Anterior Ethmoid• Ophthalmic division (V1) • Anterior ethmoid nerve off

nasociliary • Also supplies the anterior

septum, turbinates, ostiomeatal complex

• Pressure in the region of the anterior ethmoid cells results in fairly intense pain in the ipsilateral eye behind the inner canthus and radiates to the maxilla, canine, and bicuspid regions

Posterior Ethmoid and Sphenoid• Maxillary division (V2)

• Posterior ethmoid nerve • Posterior septum, parts of superior and

middle turbinates • Ophthalmic division (V1) • Greater superficial petrosal nerve • Pressure in the region of the posterior

ethmoid cells results in intense pain in the ipsilateral eye near the lateral canthus, the lateral nose, canine, and cuspid regions.

• Sphenoid sinus irritation produces severe deep head pain with some pain over the ipsilateral eye, upper teeth, and coronal suture region

Migaine

• Underdiagnosed condition • Physicians will label 50% of subjects meeting IHS

criteria as having migraine • Patients will label their symptoms as sinus related 90%

of the time when they actually meet the IHS criteria for migraine

• Nasal symptoms often accompany migraine which clouds the diagnosis

Migraine theory

• Sensitization of neural pathways • Sterile inflammation of intracranial vessels -

trigeminovascular system • Serotonin (5-hydroxytryptamine) receptors

• Epiphenomenon from autonomic discharge • Vascular engorgement • Other nasal symptoms

Migraine

• Usually unilateral, pulsating nature • Pain rated as moderate to severe • Lasts 4 to 72 hours • 17% of females, 6% of males • Nausea, vomiting, photophobia or phonophobia • With or without aura (visual scotoma)

Migraines - triggers!

• Stress • Menses • OCP • Infection

!

• Trauma • Vasodilators • Wine • Aged cheeses

Migraine v sinus pain

• ARS can cause facial pain per IHS and AAO-HNS • Straight-forward diagnosis • Not a source of constant/daily pain

• CRS not accepted as a cause of pain per IHS • Otolaryngologists feel CRS may be associated with

pain, but not the chief complaint

CRS and pain

• Pain described as dull and pressure-like in the bilateral periorbital areas

• Pain worst in the morning • Pain improves during the day • Pain tends to last for days • Pain not associated with nausea, vomiting,

phonophobia, and photophobia

CRS and pain

• Additional nasal symptoms present • Subjective: nasal drainage, obstruction, and

congestion • Objective: nasal inflammation and

mucopurulence • Improvement with topical anesthetics or

decongestants • CT sinus displays mucosal thickening • Pain/pressure tends to improve after surgery

What CT sinus findings are important?

• Maxillary sinus mucocele without boney erosion is not usually important

• Mucoceles in other sinuses are important • Air-fluid levels usually indicate an acute infection • Partial or complete opacification should lead one to

consider an otolaryngic exam • Location of thickening important:

• Ostiomeatal complex = confluence of sinus drainage • Peripheral thickening with patent sinuses of lesser importance

Other nasal and pain

• Mucosa to mucosa contact points • Enlarged turbinates • Paradoxically curved middle turbinate • Concha bullosa (aerated middle turbinate) • Septal spur

• Barosinusitis • Vacuum pain d/t barometric pressure changes

SURGICAL TREATMENT FOR RHINOSINUSITIS

SEPTAL SURGERY

TURBINATE SURGERY

SINUS SURGERY FOR VENTILATION AND DRAINAGE

SINUS SURGERY FOR POLYPOSIS

POLYPS

Conclusion

• “Sinus headache” may actually represent migraine

• Nasal/facial pain or headache is often associated with CRS • Careful assessment of Hx, PEX, endoscopy, CT

will help to identify • Other selected nasal anatomy may produce

chronic pain • Surgery may alleviate the pain associated with

CRS and other anatomic variants

ALLERGY MANAGEMENT OF THE CHRONIC HEADACHE PATIENT

When is immunotherapy indicated

How does one define the allergy headache patient from the surgical or the TRUE Migraine

Can CT Scans help?

Does Tension Headache require different treatment plans

Maybe we need to rethink headache

OTOLARYNGIC ALLERGY

ALLERGIC RHINOSINUSITIS

Hypersensitivity Reactions (Gell & Coombs)

Type I Immediate

(allergic rhinitis, asthma, immediate onset food reactions)

Type II Cytotoxic

(hemolytic anemia, Hashimoto’s)

Type III Immune Complex

(serum sicknesss, delayed onset food reactions, glomerulonephritis)

Type IV Delayed, Cell Mediated

(TB, poison ivy)

Type V Stimulating Antibody Reaction

(Graves’ disease)

Type VI Antibody Dependent Cell Cytoxicity

(transplant rejection)

Sinus & Allergy Health Partnership

RhinosinusitisA Collaborative Initiative of the:

American Academy of Otolaryngic Allergy American Academy of Otolaryngology- Head & Neck

Surgery American Rhinologic Society

• 250 M Americans affected • Average of 3-4 viral URIs/year • 1 Bn cases of viral RS/year • 0.5% - 2% go on to acute bacterial

maxillary disease

National Ambulatory Medical Care Survey, National Center for Health Statistics.

Acute Community-Acquired Bacterial Rhinosinusitis

Rhinosinusitis -vs- Sinusitis

The inflammatory process which causes sinusitis is also associated with inflammation

of the nasal passages

Lanza D, Kennedy D. Adult rhinosinusitis defined. Otolaryngol Head Neck Surg 1997;117(suppl):S1-S7.

Rhinitis typically precedes sinusitis • Sinusitis without rhinitis is rare • Mucus membranes of the nose and sinuses are

contiguous • Symptoms of nasal discharge and nasal obstruction are

prominent in sinusitis

Implications of Recent Knowledge

• The maxillary sinus was classically considered the major focus of the disorder

• Most maxillary sinusitis is now known to be secondary to disease in the ostiomeatal complex (OMC)

• Even minor swelling in a critical area can result in ostial obstruction and significant symptoms

Ostiomeatal Complex

Obstruction in this small area (from edema, thick secretions, polyps or a

concha bullosa) can block drainage from the anterior

ethmoid, maxillary & frontal sinuses

Normal Anatomy of Paranasal Sinuses

Paradoxic Middle Turbinate

Courtesy of H Stammberger

Nasal Septum

Middle turbinate

Obstruction of portion of

middle meatus

Factors Predisposing to Bacterial Rhinosinusitis

• Viral Upper Respiratory Infection

• Allergic Rhinitis

• Anatomic Ostiomeatal Obstruction

• Air Pollution

• Nasal Polyposis

• Medication effects

• Pregnancy

• Other Causes

Infection Allergy Nasal Obstruction/Congestion Thin, Watery Discharge Paroxysmal Sneezing Itchy, Runny Nose Seasonal or Perennial (can

increase sinusitis incidence) Other Allergic Symptoms

(conjunctivitis, otitis, laryngitis)

Rhinosinusitis -vs- Allergic Rhinitis

Nasal Obstruction/ Congestion

Thick Nasal Discharge Cough/Irritability

Pressure With Pain Toothache

Fever

Types of Rhinosinusitis: Temporal Courses

• Acute - Up to 4 wks, with total resolution of symptoms

• Subacute - Longer than 4 wks but less than 12 wks

• Recurrent Acute - 4 or more RS episodes/year, with resolution of symptoms between episodes

• Chronic - 12 weeks or more of signs and symptoms

• Acute Exacerbations of Chronic Rhinosinusitis

Lanza D, Kennedy D. Adult rhinosinusitis defined. Otolaryngol Head Neck Surg 1997;117(suppl):S1-S7.

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