Pearls
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60% of migraineurs have rhinogenic trigger sites.
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Migraine headache pain originating from the nose and septum is usually located behind the eyes, is sensitive to hormonal and atmospheric pressure changes, is more prevalent in the morning and can wake the patient up at night, is associated with rhinorrhea and is exploding in nature (starts from deeper structures and travels superficially).
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The most common pathology found intranasally is a reverse C-shaped septal deviation with a spur and contact between the turbinates and septum, and presence of a concha bullosa of the middle turbinate, which is often found to be significantly larger and thicker than usual.
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Perinasal CT images may reveal septal deviation with spur, contact between the septum and turbinates, concha bullosa, septa bullosa, and Haller’s cell, with or without a varying degree of sinusitis.
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The surgical treatment will include septoplasty, turbinectomy, and decompression of concha bullosa, septa bullosa or Haller’s cell.
Over 30 million Americans, approximately 12% of the population, including 18% of females and 6% of males, suffer from migraine headaches. The cost of migraine headache treatment is an enormous economic burden on our society and a combination of the cost of medications and loss of time from work exceeds $13 billion. A large proportion of patients who experience migraine headaches have an active nasal trigger site. In our experience, 60% of patients with migraine headaches endure rhinogenic migraines. The understanding of this condition and the utilization of maneuvers to deactivate the relevant trigger is extremely rewarding for rhinoplasty patient and surgeon alike. It is very important to elicit information about the presence of migraine headaches by asking pertinent questions of patients requesting rhinoplasty. Many such patients do not volunteer the fact that they experience migraine headaches since they do not recognize the association.
It is crucial to have a neurologist make the diagnosis of migraine headaches. The differential diagnosis by a neurologist is important, since all the conditions that cause meningeal inflammation and irritation mimic migraine headache and the consequences of a wrong diagnosis can be devastating. Additionally, some patients experience rebound headaches, which will not be addressed by the surgery.
While medical control of migraine headaches is often successful, there is no medical treatment that eliminates symptoms after cessation of the effects of the pharmaceutical products. On the other hand, it has been demonstrated by the author’s group and others that surgery can produce lasting results without the need for medication in patients who experience a complete elimination of the headaches, and better management and less need for medication in those who observe improvement.
Symptoms of Rhinogenic Migraine Headaches
In patients who have rhinogenic trigger sites ( Box 21.1 ), the pain starts from behind the eyes, it is commonly triggered by weather changes, the patient often wakes up with the pain in the morning or in the middle of night, and the nose frequently runs on the affected side. Menstrual-period-related migraine headaches are also usually triggered from the nose, since the turbinates are highly sensitive to hormone fluctuations. The pain is usually described as exploding (starts from the deeper structures and extends to the surface).
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Pain starts from behind the eye
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Triggered by weather changes
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Pain commonly awakens the sufferer in the morning or middle of the night
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Rhinorrhea on the affected side
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Pain described as exploding
Internal Nose Examination
Examination of inner nasal structures may reveal varying degrees of septal deviation. The most common presentation is a reverse C-shape deviation, with the curve facing the patient’s right. There is often contact between the turbinates and the septum, with a large septal spur. Nasoendoscopy can further confirm these findings, and also reveal enlargement of the turbinates. Such patients sometimes respond favorably to the use of decongestants.
Radiological Findings
The best imaging for identification of intranasal pathology findings that contribute to rhinogenic migraine headaches is a computed tomography (CT) scan including sagittal and coronal views of the septum, turbinates, and paranasal sinuses. Commonly, these images demonstrate significant septal deviation and often a sharp spur protruding into the inferior and middle turbinate or even reaching the lateral nasal wall ( Figures 21.1, 21.2 ). The middle, superior or inferior turbinates could be in contact with the septum. Additionally, the images may demonstrate the presence of concha bullosa, paradoxical curl of the middle turbinate ( Figure 21.3 ), septa bullosa ( Figure 21.4 ), or Haller’s cell.
