|
Headache is a frequent symptom of sinusitis, and often the one that brings a patient to my office for treatment. Take, for example, my patient Larry, a company president who flew across the country at least once a week for business. He was plagued by frequent sinus headaches coincident with air flight. Despite long-term antibiotics, decongestants, and nasal sprays, he had persistent pain around the left side of his face and around his left eye. A CAT scan x-ray revealed a severe left-sided nasal septal deviation with narrow areas of sinus drainage and inflammation in the left maxillary sinus (cheek) and the left ethmoid sinus (around the eye). After surgery to correct the deviated septum and to widen his sinus openings, he was free of headaches.
There are some patients who, like Larry, have actual "sinus headaches" that respond favorably to treatment of the sinus disease. In fact, most patients who come to me with a history of headaches claim to have "sinus trouble." In reality, only a minority of these individuals actually has headaches that are nasal or sinus in origin. However, most patients with chronic sinus infections do have some degree of headache or facial pain, which must be addressed. It is important to try to differentiate if your headache is sinus in origin or due to another cause, since treatment for different types of headaches varies greatly. Any discussion of sinus disease would be incomplete without the common causes and treatments of headaches, and thus this article will explore both the sinus and the non-sinus headache.
An acute sinus infection may be accompanied by a headache. In these patients, a common cold or nasal allergy progresses to increasing congestion, fever, and pain in the area of the involved sinus. This headache increases in severity when coughing or bending over. The pain tends to be dull rather than piercing or knifelike. I often find that patients are not bothered by their nasal symptoms as much as by their headaches and facial pain.
As we have discussed earlier, adults have four pairs of sinuses. The frontal sinuses are located over the eyes, with pain presenting in the forehead when these sinuses are infected. Infection of the ethmoid sinuses, located in the deeper recesses of the nose rather than in the front of the face, causes pain between and behind the eyes. The deepest pair of sinuses, named the sphenoid sinuses, results in pain referred to the back of the head. This is a rare occurrence. The maxillary sinuses are located in the middle third of the face, below the eyes and to the side of the nose. These are the most frequently infected sinuses, with pain across the face or in the upper teeth on the affected side.
You should begin to suspect that you have an acute infection of the sinuses when a headache develops in the course of what seems to be only a cold. Acute sinusitis requires treatment by a physician, and usually includes an antibiotic and a decongestant.
Headache may also be a feature of chronic sinusitis. Usually characterized as a dull ache or feeling of fullness, this pressure starts after an individual is up and about in the morning, then lasts until late in the afternoon. It is triggered when congestion of the nasal lining results in contact between adjacent structures in the nose and sinuses. This leads to closing off of a normally patent sinus opening (ostium). When the opening to a sinus is blocked, the air within the sinus is absorbed and cannot be replaced because of the blockage. This results in a negative pressure within the sinus compared with the outside barometric pressure. This pressure, plus any accumulated secretions within the sinus, accounts for sinus headaches. Diagnosis usually requires examination and an x-ray study of the sinuses.
Many common things cause changes in air pressure, with resultant sinus swelling and possible headache. Going up and down in an airplane subjects you to quick changes in atmospheric pressure. This is why flying can lead to sinus (or even ear) trouble in the predisposed individual -- one who has an underlying anatomic narrowing. Even if you typically have no problems when flying, if you have an upper respiratory infection and decide to fly anyway, you may end up with a full-blown sinus infection because of the combination of nasal swelling from your cold and pressure changes in the airplane. Taking both an oral and a topical decongestant before takeoff may ameliorate this problem. Scuba diving, with its increased pressure underwater, can similarly lead to sinus swelling and infection.
Another common sinus headache patient I see is typified by Allen, a computer programmer who was debilitated whenever there was a drastic change in the weather. It reached the point where he was better at predicting the forecast than the local TV weatherman. While some might think Allen is crazy, this phenomenon actually has a scientific basis: With changes in atmospheric humidity, pressure changes within the sinuses can cause infection and headache.
Headaches may be among the first symptoms of hypertension, or high blood pressure. This headache is often located at the back of the head and is usually noted upon arising in the morning. The pain is throbbing or pulsating. This headache is worsened by exercise, straining, or stooping, since these activities raise blood pressure. A diagnosis can usually be made by checking the blood pressure, which is measured as two numbers: The systolic pressure is listed above the diastolic pressure. A normal reading might be 120/80 (systolic/diastolic). The number 120 (millimeters of mercury) is the systolic pressure, which may vary with activity, exertion, or nervousness. In the diagnosis of hypertension, the diastolic number (in this example 80) is especially important. A diastolic pressure exceeding 100-110 mm (millimeters) of mercury is usually present if hypertension is the true cause of the current headaches. For most patients, treatment consists of medication to lower the pressure, and a low-salt diet and weight reduction when indicated. Evaluation and treatment for high blood pressure are by an internist, family physician, or cardiologist.
Brain tumor is a rare cause of headache, but it is often a major concern of the headache patient. Recent onset of headache or a change in the character of a current head-ache (especially in those older than age 40) suggests the possibility of a brain tumor. The headache associated with a brain tumor tends to be constant and usually dull in nature rather than severe or knifelike. This headache is made worse by coughing, sneezing, or straining as during a bowel movement, since these all raise the fluid pressure in the brain (also known as cerebral spinal fluid). It may interfere with sleeping and awaken the patient. Pain is typically worse in the morning. If a headache is accompanied by vomiting, blurred vision, lethargy, fainting, dizziness, or personality change, then it becomes mandatory to search for a brain tumor. In most chronic headache patients where a diagnosis is not apparent, CAT scan (Computerized Axial Tomography) of the brain or an MRI (Magnetic Resonance Imaging) study will be requested by the physician in order to visualize the brain and identify a possible lesion or growth.
Eye problems are also a rare cause of headache. The discomfort is usually just above the eyes. When headache is related to eye strain, the symptoms are often first noted late in the afternoon (rather than in the morning), after you have been using your eyes all day. Examples of patients who are at increased risk to have headaches secondary to eye strain are college students with long hours of studying, people who sit in front of a computer screen all day, and individuals who drive all day. If you have pressure in or about the eyes, examination by an eye specialist is advised. It is important to check for increased eye or intraocular pressure, which can be seen with glaucoma. More important, there can be errors of refraction (or sight), which may indicate a need for glasses or for a change in your current prescription. There are also some specific inflammations of the eye, for example, optic neuritis, which may result in ocular pain. Remember that some migraine headaches are associated with visual symptoms at their onset.
Head pain with dental origin may be apparent when it occurs in the teeth, especially in the lowers. When biting or chewing causes pain, or any tooth is sensitive to cold food or liquid, you should probably see your dentist. Pain in an upper tooth is usually a dental problem but may also be a sign of disease in an adjacent maxillary (cheek) sinus. The patient with a lingering upper respiratory infection who develops pain in an upper tooth may need sinus rather than dental treatment. Too often I have seen one or more upper teeth extracted in a vain effort to relieve pain that originated in the sinus, or which was a manifestation of trigeminal neuralgia.
Somewhat less obvious is the pain that accompanies temporomandibular joint (TMJ) dysfunction. These are the joints where the mandible (jaw) hinges in front of each ear. Abnormal function of these joints may result in ear or jaw pain that is aggravated by chewing or yawning. Additional symptoms include a clicking or popping noise in the involved joints. There may be fullness in the ear or limitation of motion when opening the mouth wide. Patients with TMJ problems often present a history of grinding their teeth, behavior frequently triggered by underlying stress. TMJ disorders commonly occur in people who are missing some back teeth and in those with malocclusion (overbite or underbite).
The use of a night-guard dental splint may be helpful in relieving temporomandibular joint discomfort, especially in anyone who grinds his teeth. Self-help measures include application of heat via a heating pad or hot compresses to the upper jaw to relax adjacent muscles that may be in spasm. A diet of soft food should be implemented and gum chewing should be stopped. If needed, anti-inflammatory medications, such as aspirin or ibuprofen, can be used. Dental rehabilitation may include correction of an abnormal bite or fitting of a partial or full denture to replace missing teeth. Your general dentist or a TMJ specialist can help you with this.
This general term refers to pain that occurs when a nerve fires abnormally, producing pain in the area supplied by the nerve. Neuralgia may occur in almost any part of the body. For the purposes of our discussion of headaches, a condition called trigeminal neuralgia will be considered, since this is the primary neuralgia that involves the face and head. This painful disorder is also known as tic douloureux.
The trigeminal -- the prefix "tri-" referring to its three divisions -- nerve supplies sensation to most of the face. The upper division supplies sensation to the forehead area; the middle division, to that part of the face between the eyes and lips; the third division, from the lips to the chin.
The pain of trigeminal neuralgia is severe, sharp, occurs in paroxysms, and lasts only a few minutes. It may occur in any part of the face depending on which division of the trigeminal nerve is firing abnormally. The most common location is in the middle part of the face, adjacent to the nose or cheek.
These patients usually exhibit a trigger zone, with the pain triggered by irritating a certain spot. Trigger factors may include chewing, shaving, brushing the teeth, or even blowing the nose. Thus, individuals may develop a fear that one of these actions may precipitate a paroxysm of pain. Beginning usually in mid- or late life, the attacks tend to become more severe and more frequent. Examination and x-rays are unrevealing, with a diagnosis being made by history alone.
Most trigeminal patients can be managed by prescription medication, but some of the drugs have potent side effects (one drug most commonly used for tic douloureux is an antiseizure medication). As with most recurrent headaches, strong analgesics and narcotics should be avoided, since drug dependency or even addiction is a real possibility. Many of these patients require surgery to destroy the nerve pathway responsible for the neuralgia. This destruction may be by cutting, or by injection with alcohol or boiling water. Additionally, a blood vessel that is pushing on the nerve can be decompressed. Neurosurgical consultation is advised for those patients who continue to have attacks after an adequate trial with medication. However, since neuralgia patients have symptoms of facial pain similar to that caused by sinus or dental infection, it is important for your doctor to be able to differentiate between these, since treatment varies.
A common type of head pain is myalgia. This muscular discomfort builds gradually, reaches a maximum, and then recedes gradually. It is often brought on by sudden temperature change, especially chills, drafts, or air-conditioning. The muscles affected are often those at the back of the neck. The involved area is tender to touch, with pain often migrating from one area to another. Treatments include application of heat (especially moist heat), use of medication, improved circulation to the affected area, and occasionally muscle relaxants.
A small number of allergy patients has headache as a primary symptom. You should suspect that allergy is the cause of your headache if it occurs only upon exposure to a certain environment or only after eating a certain food. An example of this allergic headache would be a person who develops headache when exposed to highly scented cosmetics. Cigarette smoke can also be a significant trigger of an allergic headache. When the headache is due to an inhalant, i.e., something breathed in, there is usually nasal congestion and blockage, watery eyes, or other signs of allergy. Food allergies are less obvious. You will have to keep a food diary and note the time of onset of each headache. A pattern may become apparent, with each headache preceded by ingestion of the same offending food. Common food allergens include milk, eggs, wheat, nuts, pork, chocolate, or shellfish.
Avoiding the offending substance is the ideal way to prevent food allergies, but often this is not practical with inhaled substances that may be around you daily or during certain seasons. The use of an antihistamine is helpful. These work by blocking the action of histamine, the substance responsible for allergy symptoms, such as itching, sneezing, watery eyes, and runny nose. Antihistamines that can be purchased without a prescription include Tavist-1, Benadryl, and Chlor-Trimeton. If an antihistamine relieves your headache, suspect allergy as the cause. If an allergic headache is accompanied by nasal congestion, consider an antihistamine-decongestant medication. Examples of this combination include Benadryl Allergy/Sinus caplets, which also contains acetominophen (Tylenol) for pain relief; Dimetapp, Contact; Tavist-D; and Drixoral Allergy/Sinus. |
