Chapter 21 Rhinogenic Migraine Headaches
Pearls
• 60% of migraineurs have rhinogenic trigger sites.
• 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).
• 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.
• 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.
• 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.1–11 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.
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.12–20
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).21
