Key points

Introduction

The diagnostic criteria and standard of care for the management of acute, subacute, and chronic rhinosinusitis have been largely defined. Embedded in these definitions are diagnostic imaging criteria that indicate mucosal disease within the paranasal sinuses. These mucosal findings are elementary to identify, even for a non–head and neck trained physician or radiologist. Nonetheless, other rhinogenic sources of headache and facial pain have been debated in the literature and within rhinologic circles. These rhinogenic sources include mucosal contact-point headaches, barosinusitis, recurrent barotrauma, and recurrent acute rhinosinusitis (RARS). The diagnoses for these other potential sources may be challenging for clinicians because the patient may present with a normal examination or computed tomography (CT) scan between active episodes.

In the absence of mucosal involvement, differentiating a rhinogenic from a nonrhinogenic source, such as a tension headache, migraine headache, temporomandibular joint disease, or cluster headaches through history and physical examination may be difficult. Imaging studies may only suggest a contact or obstruction point but are not hallmark to a particular rhinogenic headache diagnosis. RARS poses a diagnostic dilemma in providing objective, radiographic findings in between acute episodes that can differentiate it from an upper respiratory infection.

More complicated, and not covered in this review, are discussions regarding the potential of rhinogenic triggers that at least theoretically may elicit a classic cascade of physical events that lead to a migraine-variant–type headache.

This article focuses on CT findings associated with rhinogenic causes of headache and facial pain. These more advanced observations of CT scan variants will provide otolaryngologists with an additional tool besides clinical examination to diagnose and potentially treat rhinogenic headaches.

Introduction

The diagnostic criteria and standard of care for the management of acute, subacute, and chronic rhinosinusitis have been largely defined. Embedded in these definitions are diagnostic imaging criteria that indicate mucosal disease within the paranasal sinuses. These mucosal findings are elementary to identify, even for a non–head and neck trained physician or radiologist. Nonetheless, other rhinogenic sources of headache and facial pain have been debated in the literature and within rhinologic circles. These rhinogenic sources include mucosal contact-point headaches, barosinusitis, recurrent barotrauma, and recurrent acute rhinosinusitis (RARS). The diagnoses for these other potential sources may be challenging for clinicians because the patient may present with a normal examination or computed tomography (CT) scan between active episodes.

In the absence of mucosal involvement, differentiating a rhinogenic from a nonrhinogenic source, such as a tension headache, migraine headache, temporomandibular joint disease, or cluster headaches through history and physical examination may be difficult. Imaging studies may only suggest a contact or obstruction point but are not hallmark to a particular rhinogenic headache diagnosis. RARS poses a diagnostic dilemma in providing objective, radiographic findings in between acute episodes that can differentiate it from an upper respiratory infection.

More complicated, and not covered in this review, are discussions regarding the potential of rhinogenic triggers that at least theoretically may elicit a classic cascade of physical events that lead to a migraine-variant–type headache.

This article focuses on CT findings associated with rhinogenic causes of headache and facial pain. These more advanced observations of CT scan variants will provide otolaryngologists with an additional tool besides clinical examination to diagnose and potentially treat rhinogenic headaches.

Definitions

Traditionally, rhinogenic headaches are defined as a headache or facial pain caused by a rhinologic source, yet this definition excludes classic acute and chronic sinusitis findings such as inflammatory sinonasal disease, nasal discharge, nasal polyps, nasal mass, hyperplastic mucosa, and tumors or foreign bodies. This definition also excludes neurologic, neuromuscular, and vascular-type of headaches, including intracerebral causes, tension headaches, migraine headaches, temporomandibular joint disease, and cluster headaches. Mucosal contact-point headaches are a subset of rhinogenic headaches that are triggered by mucosal contact, most commonly from the lateral nasal wall to the septum.

According to the Rhinosinusitis Task Force, RARS is defined as 4 or more episodes of rhinosinusitis per year, but these episodes do not meet the duration criteria of more than 12 weeks to be considered chronic rhinosinusitis, and complete resolution of symptoms occurs between episodes. Barosinusitis, whether active or recurrent, results in facial pain classically caused by descent from altitude or descent when diving. When ventilation of the sinus outflow tract is inadequate or completely obstructed, a marked increase in pressure within the sinuses results in pain, and possibly mucosal inflammatory changes.

Symptom criteria

The Rhinosinusitis Task Force has differentiated RARS from acute rhinosinusitis as being characterized by 4 or more episodes of acute rhinosinusitis per year ( Table 1 ). Other potential rhinogenic triggers involving the paranasal sinus that are associated with absent or low-stage CT findings are much less defined and controversial. Nonetheless, the authors’ clinical protocol requires certain criteria be met before considering a potential rhinogenic source for the headache.

First, the region of the headache should be consistent anatomically with the paranasal sinus. This criterion includes facial pain limited to the frontalis, midface, retro-orbital, or occipital regions. Temporal and band-like headaches should not be considered, because these presentations are more consistently identifiable as tension-related or myofacial. Second, the headache or facial pain should be associated with either of the following conditions: (1) symptoms worsen with flight, diving, or change in weather; (2) symptoms improve when a topical nasal decongestants or anesthetic agent is administered; or (3) symptoms are consistently associated with congestion or rhinitis. Exclusionary symptoms include headaches with rhinitis or congestion that occur in the middle of the night, suggesting a cluster headache, or unilateral, pulsatile headaches that are more associated with migraine and migraine-variant headaches. Currently, an imaging criterion is not included, because no established hallmark or consistent radiographic abnormalities definitively identify a rhinogenic cause.