Surgical Management of Contact Point Headaches

Headache: The Journal of Head and Face Pain
Volume 45 Issue 3 Page 204 - March 2005
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The article below was presented as a poster presentation at the 46th annual meeting of American Headache Society in Vancouver on June 11, 2004.

Surgical Treatment of Patients with Refractory Migraine Headaches & Intranasal Contact Points

Behin, Fereidoon,1,2 Behin, Babak.3 From Mount Sinai Medical Center,1 New York, NY; Department of Otolaryngology, Christ Hospital,2 Jersey City, NJ; University of Medicine and Dentistry of New Jersey,3 NJ.

INTRODUCTIONOBJECTIVESMETHODSRESULTSCONCLUSIONS

INTRODUCTION

Contact point headaches are attributed to intranasal contact between opposing mucosal surfaces. Headaches result from referred pain referred trough the trigeminal nervous system. In addition, contact points may be an exacerbating factor associated with treatment refractoriness in persons with migraine.

OBJECTIVES

To assess the benefits of surgical correction in patients with refractory migraine or transformed migraine, and radiographic evidence of contact points in the sinonasal area.

METHODS

We reviewed charts of patients who underwent endoscopic sinus surgery and septoplasty for refractory migraine and intranasal contact, from October 1998 through August of 2003. Subjects eligible for surgery had:

1 €“		Refractory migraine (failed to standard pharmacological headache treatments) or refractory transformed migraine;
2		Contact points demonstrated by CT scan (Figures 1 and 2);
3 €“		Report significant headache improvement after intranasal anesthesia

Figure 1: Normal anatomy (A) and contact points (B, arrow)

The surgical procedure required general anesthesia. The area between the septum and middle turbinate and/or ethmoid sinuses and/or the superior turbinate was visualized and the contact point was identified (Figure 2).

The surgery included septoplasty, middle turbinectomy and medial ethmoidectomy. If the superior turbinate showed contact, it was either removed or lateralized

Figure 2: Contact point area surgical visualization.

Headache characteristics were assessed pre-operatively and at follow-up (6 to 60 months after surgery) using a standardized questionnaire.

RESULTS

Our sample consisted of 21 subjects (72.5% woman), 9 (42.8%) with migraine and 12 (57.2%) with transformed migraine

We compared the pre-operative baseline assessment with the last follow-up visit (6 to 60 months after surgery) (Table 1). Mean headache frequency was reduced from 17.7 (11.2) days per month to 7.7 (7.6) headache days per month (p =0.003). Mean headache severity was reduced from 7.8 (1.5) to 3.6 (3.7) (p = 0.0001).

The headache score was reduced from 138 (96.8) at baseline to 54.8 (93.7) at follow-up (p <0.01). Finally, subjects mean disability was 5.6 (2.6) at baseline and 1.8 (2.2) at follow-up (p < 0.0001).

	Baseline	Follow-up	P value
Headache frequency Mean (SD)	17.7 (11.2)	7.7 (7.6)	<0.01
Headache severity Mean (SD)	7.8 (1.5)	3.6 (3.7)	= 0.0001
Associated symptoms N (%)	21 (100%)	10 (47.6%)	<0.0001
Headache score Mean (SD)	138 (96.8)	54.8 (93.7)	<0.01
Headache related disability Mean (SD)	5.6 (2.6)	1.8(2.2)	<0.0001

Table 1: Headache characteristics before (baseline) and after (follow-up) surgical treatment.

A total of 16 subjects (76.2%) had their headache scores improved by 50% or more after surgery; 9 (42.9%) were pain free at the last follow-up. Just 3 (14.2%) had less than 25% reduction in their headache scores (Figure 4).

Figure 4: Proportion of improvement in the headache score after surgery.

CONCLUSIONS

Patients with refractory migraines and radiographic evidence of contact points with a positive response to nasal local anesthesia improved after surgical treatment.

Nasal contact points may aggravate migraine, by activating the trigeminovascular system, contributing to intractability.

Contact point surgery, by addressing the trigger point, may be an alternative to such patients.