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Table of Contents
Year : 2022  |  Volume : 6  |  Issue : 3  |  Page : 65-69

Rhinogenic contact point headache – A review

Department of Otorhinolaryngology and Head and Neck Surgery, IMS and SUM Hospital, Siksha “O” Anusandhan University, Bhubaneswar, Odisha, India

Date of Submission14-Jan-2022
Date of Decision18-Jan-2022
Date of Acceptance21-Jan-2022
Date of Web Publication25-Aug-2022

Correspondence Address:
Dr. Santosh Kumar Swain
Department of Otorhinolaryngology and Head and Neck Surgery, IMS and SUM Hospital, Siksha “O” Anusandhan University, K8, Kalinga Nagar, Bhubaneswar - 751 003, Odisha
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mtsm.mtsm_1_22

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Headache is a universal symptom in the course of everyone's life. There are myriads of causes for headache ranging from simple migraine, tension headache, refractory errors in the eye, temporomandibular joint arthralgia, and myofascial spasm to severe form of headache by brain tumors. The anatomical variations in the nasal cavity result in mucosal contact between the opposing surface and cause rhinogenic contact point headache (RCPH). RCPH is a new type of headache in medical literature. The pathogenesis of the RCPH is still the subject of controversy. Nose has diverse anatomical variations. Deviated nasal septum or spur, middle turbinate concha bullosa, and enlarged bulla ethmoidalis are the common anatomical variation in the nasal cavity which can cause RCPH. Diagnostic nasal endoscopy and computed tomography scan are helpful to confirm the mucosal contact points inside the nasal cavity. The precise excision of the contact points with the help of endoscopic approach in patients of RCPH is very effective. Clinicians should not ignore the anatomical variation of the nasal cavity during management of the headache. There is not much literature for RCPH indicating that this clinical entity is neglected. This review article presents an overview of the current aspect of RCPH.

Keywords: Deviated nasal septum, intranasal mucosal contact point, middle turbinate concha bullosa, rhinogenic contact point headache, spur

How to cite this article:
Swain SK. Rhinogenic contact point headache – A review. Matrix Sci Med 2022;6:65-9

How to cite this URL:
Swain SK. Rhinogenic contact point headache – A review. Matrix Sci Med [serial online] 2022 [cited 2022 Oct 3];6:65-9. Available from: https://www.matrixscimed.org/text.asp?2022/6/3/65/354525

  Introduction Top

Headache is a very common clinical manifestation among human beings. The incidence of headache in a lifetime is approximately 90%.[1] Patients often attend otolaryngology clinic for sinus headache. The common presentations of the sinus headache are facial pain or pressure over the maxillary, frontal, ethmoid sinuses, mandibular or maxillary pain, facial spasm, temporal pain, or otalgia.[2] Rhinogenic contact point headache (RCPH) is a secondary headache newly added in the International Classification of Headache Disorder-2.[3] RCPH is described as intermittent pain confined to the periorbital and medial canthal or temporozygomatic areas, associated with intranasal mucosal contact points confirmed by diagnostic nasal endoscopy or computed tomography (CT) scan and supported by limited evidence.[3] However, there has been controversy regarding mucosal contact point headaches since its introduction in literature. Many studies on RCPH emphasized mucosal contact between the nasal septum and middle turbinate or inferior turbinate of the nasal cavity. This review article aims to discuss the details of history, epidemiology, etiopathology, clinical presentations, diagnosis, and current treatment of RCPH.

  Methods of Literature Search Top

Multiple systematic methods were used to find current research publications on RCPH. We started by searching the Scopus, PubMed, Medline, and Google Scholar databases online. A search strategy using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was developed. This search strategy recognized the abstracts of published articles, while other research articles were discovered manually from the citations. Randomized controlled studies, observational studies, comparative studies, case series, and case reports were evaluated for eligibility. There were total numbers of articles 96 (42 original articles, 28 case series, and 26 case reports) [Figure 1]. This paper focuses only on RCPH. This paper examines the history, epidemiology, etiopathogenesis, clinical manifestations, diagnosis, and treatment of RCPH. This analysis provides a foundation for future prospective trials of intranasal mucosal contact point and its manifestations as RCPH. It will also serve as a catalyst for additional study into RCPH and its manifestations on along with early diagnosis and treatment.
Figure 1: Flowchart for literature search

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  History Top

McAuliffe et al. in 1943 explicated that the stimulation of certain anatomical areas of the nasal cavity can lead to trigeminal nerve stimulation and release of the substance P (SP) which cause headache in the absence of sinonasal inflammatory diseases.[4] Later on, Zechner used the word RCPH as the cause of headache due to intranasal mucosal contact point.[5] Headache classification subcommittee of the International Headache Society included the RCPH among the secondary sinonasal causes for headache in 2004.[6] Stamberger and Wolf described the role of the SP in etiopathogenesis of RCPH.[7]

  Epidemiology Top

Headache may be classified into primary and secondary types where primary headache does not have any specific etiology and include migraine, tension headache, and cluster headache. Secondary headache is due to trauma, infections, neoplasm, vascular lesions, and metabolic diseases.[8] Anatomical variations of the nasal cavity can result in mucosal contact and headache. Intranasal contact points are seen in approximately 4% of the noses.[9] Deviated nasal septum (DNS) is the most common anatomical variation of the nasal cavity which causes headache (in approximately 35.18%).[10] Spur is the second most common cause for RCPH followed by middle turbinate concha bullosa, inferior turbinate hypertrophy, enlarged ethmoidal bulla, enlarged pneumatized superior turbinate, medialized middle turbinate, and nasal septal bullosa.[10] The most common site for RCPH is frontal area followed by glabellar region.[1] Occipital region is the rare location for headache in RCPH.

  Etiopathology Top

Headache patients are classified into three groups such as (1) headache due to sinonasal pathology like inflammatory diseases or barotraumas; (2) headache not related to sinus causes like seasonal allergies, migraine, neuralgic pain, and vascular headache; and (3) headache where sinus origin cannot be identified.[11] The third category is concerned for clinicians where nasal mucosal contact point results in referred pain in the face or head. The pathophysiology for RCPH is still a subject of debate. A study suggested that anatomical variations such as concha bullosa or inferior turbinate hypertrophy cause contact of the mucosa to the nasal septum and result in pain.[12] One report showed that contact between the superior turbinate and septum can cause headache.[13] Bulla ethmoidalis is the largest anterior ethmoidal cell area. When it is larger than usual, it may push the vertical lamella of the middle turbinate and cause contact with the septum. In rare cases, it may be so large that it will contact with septum by itself. This situation can cause RCPH. Mechanical irritant such as pressure effect on the mucosal surface of the nasal cavity may cause release of the neuropeptides through central orthodromic impulse and peripheral local, antidromic impulse. The released neuropeptides such as SP and calcitonin gene-related peptide (CGRP) result in vasodilatation and mucosal edema in the nasal cavity, which again aggravate the pressure effects at the contact area. The neuropeptides released from the central nervous system cause pain sensation which usually mimic to the migraine without aura. The duration and onset of the pain are usually similar to the beginning and duration of the nasal cycle.[14] SP, neurokinin, and CGRP are seen in nociceptive fibers at the central nervous system and also in the trigeminovascular system. Hence, the contact area between the opposing mucosal layers in the nasal cavity may result in secondary headache. SP plays a vital role in etiopathogenesis of the RCPH. Release of SP results in vasodilatation, plasma extravasations, and perivascular inflammation and manifests headache similar to migraine without aura.[15] The mucosal layers of the nasal cavity usually have higher concentration of SP than chronic hyperplastic mucosa or polypoidal tissues. This is the explanation for headache due to intranasal contact points in the absence of rhinosinusitis.[16] There is also controversy in intranasal contact points and headache. Regarding fact that intranasal mucosal contact points may be found in the person who does not have a headache where the causal association between the mucosal contact points and headache is still not easily established. The debate over RCPH in the scientific community has long history.

  Clinical Presentations Top

In everyone's life, headache is a common symptom. Headache is often associated with various severities. There are different characteristics of headache associated with different etiologies such as migraine, vascular headache, temporomandibular joint dysfunction, ophthalmological condition, intracranial lesions, dental abscess, and head-and-neck tumors.[17] One study showed that the pain in mucosal contact point headache is localized to the frontal region.[18] Headache and facial pain by sinus and nasal origin in the absence of the inflammatory sinonasal pathology favors the diagnosis of the RCPH. In the current clinical practice, headache due to RCPH has received attention in both otorhinolaryngology and neurology. There are different types of intranasal anatomical variations resulting in mucosal contact points in the nasal cavity that result in RCPH. The characteristics of headache in RCPH differ as per the type of intranasal anatomical variations. Many clinicians are not well versed with anatomical variations of the nasal cavity and its impact on headache. One study documented that DNS and spur cause referred headache in the absence of the inflammation.[19] The DNS may be cartilaginous deviation, bony deviation, bony spur, and high septal deviation. The significant referred headache is seen in sharp septal spur. Concha bullosa is hypertrophied pneumatized middle turbinate and rarely found in superior. The mucosal contact between concha bullosa and nasal septum or other mucosal surfaces of the nasal cavity can cause referred pain at periorbital or ocular pain via anterior ethmoidal nerve, a branch of ophthalmic division of the fifth cranial nerve.[19] The contact point between hypertrophied superior turbinate and upper part of the septum can cause RCPH. The hypertrophied superior turbinate often causes pain over the forehead and medial and lateral canthus.[20] Sometimes, medialized middle turbinate results in mucosal contact with nasal septum. Bulla ethmoidalis is the large hypertrophied anterior ethmoidal cell.[21] Hypertrophied bulla ethmoidalis may push the middle turbinate and cause a contact with nasal septum. The headache due to sinusitis can be distinguished by a way such as pain in the sinusitis is worsened by tilting the head forward and performing Valsalva maneuvers.[22] The sinusitis is often over diagnosed as a cause of headache as a belief that pain over the paranasal sinuses must be associated to the sinuses. However, it is important to differentiate the sinus pain from severe headache which responds poorly to the medication, usually confined to the frontal and periorbital region of the face. However, the clinical history, endoscopic examination, and imaging do not indicate the presence of diseases of the mucous membranes in the nasal cavity and paranasal sinuses.[23] The headache is usually dull ache and associated with a sense of pressure, which oscillates in intensity and localization or pulsates as per the nasal cycle.[23] Sometimes, the intranasal mucosal contact point causes referred otalgia through trigeminal nerve.[24]

  Investigation Top

The diagnosis of RCPH needs a multidisciplinary approach. The diagnosis of the RCPH is often misdiagnosed. This clinical entity may not be suspected during preliminary evaluation. Patients with headache in the absence of inflammation of the sinonasal area should be examined by a neurologist, ophthalmologist, dentist, and internist to rule out other causes. Diagnostic nasal endoscopy and CT scan of the nose and paranasal [Figure 2] sinuses are helpful to confirm the intranasal contact points and also to rule our sinusitis.[25] The patency is better assessed by endoscopic evaluation along the exact site of the intranasal mucosal contact points. CT scan of the paranasal sinuses is helpful to identify the pathological findings which cannot be seen by endoscopic examination and helpful to decide the type of surgery.[26] CT scan is helpful to decide the exact location of contact pints and necessity before the surgery.[26] The nasal resistance can be assessed by anterior rhinomanometry. The intensity of headache is usually evaluated by using visual analog score. The headache severity is graded on a scale of 0–10 points, where 0 indicates trouble free and 10 indicates worst thinkable troublesome. To reverse such contact point, anterior ethmoidectomy and lateralization of the middle turbinate is required. In RCPH, anterior rhinoscopy is helpful to rule out sinusitis such as purulent nasal discharge, postnasal drip, and foul smelling from nasal cavity. Application of local anesthetics at the contact point relieves the headache which confirms the diagnosis of the RCPH. In one study of 30 patients with RCPH, application of local anesthetic agents, 43% showed complete recovery, 47% showed partial improvement, and 10% showed no improvement.[27] After diagnostic nasal endoscopy and CT scan of the paranasal sinuses, it is important to do a lidocaine test. This lidocaine test help not only the diagnosis of this type of headache but also useful as an indicator of the success of the surgical excision of the intranasal mucosal contact points.[28] There is another nasal shrinkage test where nasal decongestant with topical anesthetic agents is applied at the intranasal contact points of the nasal cavity.[14]
Figure 2: Computed tomography scan of the nose and paranasal sinuses showing left side spur with mucosal contact to inferior turbinate

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  Treatment Top

Headache is a common clinical symptom for which patients need medical attention. Headache is considered a major factor for disability in the community. RCPH is an important etiology for secondary headache which can be treated by surgical or medical therapy. The treatment of RCPH requires multidisciplinary approaches for early diagnosis and treatment. Topical nasal decongestant or steroids can relieve the RCPH, however, the long-term relieve needs surgical interventions.[29] The topical nasal steroid improves the patency of the nasal cavity on short-term basis.[30] Endoscopic surgery is an ideal technique to relieve mucosal contact point headache.[29] Endoscopic surgical treatment offers superior visualization of the intranasal mucosal contact points, which is important for limited resection of the mucosal contacts and allows for a more controlled and precise surgery with minimal injury to the adjacent mucosa. The surgery is usually performed under general anesthesia. Septoplasty or spurectomy is helpful to correct the nasal septum deviation and relive contact between the turbinate and septum. Middle turbinate can be lateralized to avoid the mucosal contact and also it exposes the superior turbinate and superior meatus. The superior turbinate can be lateralized to remove the mucosal contact between the superior turbinate and nasal septum. Optimum care should be taken for injuring the olfactory area during the surgical procedure. If the mucosal contact is present in both sides of nostrils, the surgery on the other side should be done at the same time after completion of one side. Endoscopic lateral lamellectomy is the treatment of choice for middle turbinate concha bullosa.[31] However, there is chance of recurrence of mucosal contact points inside the nasal cavity after surgery with formation of synechia leading to frontal sinus disease as a complication.[32] Before introduction of the endoscopic sinus surgery, complete excision of the middle turbinate was done for treating the middle turbinate concha bullosa. Sometimes, the medialized middle turbinate contacts with septum and causes RCPH. Creating a space between the septum and middle turbinate is required for reversing the contact points between the medialized middle turbinate and septum. Following surgery, diagnostic nasal endoscopy, and pain intensity score, average number of headache attacks per months and average duration of headache in each attack should be documented at follow-up visit. Headache is usually resolved in less than a week following removal of the mucosal contact point of the nasal cavity.[33] One study with 66 patients of RCPH due to middle turbinate concha bullosa and DNS and enlarged ethmoidal bulla showed resolution of the headache after excision of the contact points.[34] Chow showed a reduction of the frequency and severity of the headache in approximately 82% of the patients with RCPH after surgical excision of the intranasal mucosal contact points.[35] Another study of RCPH showed reduction of the frequency and severity of the headache after endoscopic excision of the intranasal mucosal contact points in approximately 91% of the cases.[36] A systematic review of the literature with 973 patients of mucosal contact points in nasal cavity showed no facial pain in majority of patients.[17] Hence, the authors concluded that the presence of the mucosal contact point is not a good predictor of facial pain. They also observed that removal of the contact point rarely causes complete elimination of the headache. The improvement of the postoperative symptoms after excision of the mucosal contact points may be explained by cognitive dissonance or neuroplasticity.[17]

  Conclusion Top

RCPH is a well-represented clinical entity. RCPH is often considered an exclusion of diagnosis. The correct identification of the intranasal mucosal contact points can act as specific trigger points and responsible for RCPH. Nasal cavity has a diverse anatomical variation. DNS and septal spur are common anatomical variations of the nose resulting contact point headache followed by middle turbinate concha bullosa and bulla ethmoidalis. Proper investigation is helpful for effective and appropriate treatment. Diagnostic nasal endoscopy and CT scan of the nose and paranasal sinuses are important tools for diagnosis of anatomical variations inside the nasal cavity causing RCPH. Endoscopic surgical approach is highly useful for elimination of the mucosal contact points and symptomatic relief of the headache.

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  References Top

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