|Year : 2019 | Volume
| Issue : 4 | Page : 1423-1429
Evaluation of nasal and paranasal findings in cases of migraine
Essam A Behairy1, Tarek A Abd El-Hafez1, Khaled H Afifi2, Marwa K Moustafa1
1 Department of Otorhinolaryngology, Faculty of Medicine, Menoufia University, Shibin El-Kom, Menoufia Governorate, Egypt
2 Department of Neurology, Faculty of Medicine, Menoufia University, Shibin El-Kom, Menoufia Governorate, Egypt
|Date of Submission||13-Sep-2018|
|Date of Decision||16-Nov-2018|
|Date of Acceptance||17-Nov-2018|
|Date of Web Publication||31-Dec-2019|
Marwa K Moustafa
Department of Otorhinolaryngology, Faculty of Medicine, Menoufia University, Shibin El-Kom, Menoufia Governorate
Source of Support: None, Conflict of Interest: None
The objective of this study was to evaluate nasal and paranasal findings in cases of migraine.
Migraine triggers are abundant, and anatomical nasal variations like septal spur, concha bullosa, and hypertrophied inferior turbinate may be considered as important trigger factors for migrainous headache by mucosal contact according to the trigeminovascular theory as a proposed mechanism for migraine.
Patients and methods
This was an observational cross-sectional study comparing 60 patients with migraine versus 40 normal participants with neither migraine nor nasal presentations. History was taken to define the type of migraine and its severity according to Migraine Disability Assessment Score. Computed nasal and paranasal tomography scan, diagnostic nasal endoscopy, and nasal decongestant test were done for all of them to diagnose nasal and paranasal findings in both groups and to confirm mucosal contact points in migraineurs.
There was a significant increase in overall septal, turbinate, and mucosal findings in case group compared with control group. There was a statistically significant difference between the two groups regarding septal spur, concha bullosa, and abnormal nasal mucosa, being more prevalent in the case group. The most common contact point was between the septum and middle turbinate, with a nonsignificant correlation between the type of contact point and severity of migraine.
The presence of nasal findings in migraineurs was significantly associated with triggering of migraine through contact point mechanism. The significant findings were septal spur, concha bullosa, and abnormal nasal mucosa, with the most common contact point being between the septum and middle turbinate.
Keywords: contact points, diagnostic nasal endoscopy, migraine, Migraine Disability Assessment Score, sinonasal findings
|How to cite this article:|
Behairy EA, Abd El-Hafez TA, Afifi KH, Moustafa MK. Evaluation of nasal and paranasal findings in cases of migraine. Menoufia Med J 2019;32:1423-9
|How to cite this URL:|
Behairy EA, Abd El-Hafez TA, Afifi KH, Moustafa MK. Evaluation of nasal and paranasal findings in cases of migraine. Menoufia Med J [serial online] 2019 [cited 2020 Jun 1];32:1423-9. Available from: http://www.mmj.eg.net/text.asp?2019/32/4/1423/274252
| Introduction|| |
Migraine is the second most common primary headache disorder that affects 18% of females and 6% of males (totally 12% of general population). It represents a mixture of neurologic, gastrointestinal, and autonomic manifestations, and its diagnosis is based mainly on clinical characteristics of the attacks . The trigeminovascular theory for migraine proposes that neurogenic inflammation of the meninges during the attack causes trigeminal nerve terminals activation and neuropeptides release, causing sensory stimulation of nasal cavity and sinuses, resulting in frequent symptoms in nasal mucosa during the attacks, such as runny nose, nasal congestion, and a feeling of fullness on face . Diagnostic nasal endoscopy in synergism with computed tomographic (CT) scanning of nose and paranasal sinuses has opened new scopes reaching into nasal cavity and sinus accurately. In addition, clinically undetected anatomical variations in the walls of ethmoid complex, ethmoidal infundibulum, and frontal recess may give rise to headache . The development of intense contact of opposing mucosal surfaces owing to many anatomical variations leads to hampered ciliary activity and flow of mucus drainage from ethmoid and other paranasal sinuses, and so causes of headache simulating migraine vary greatly in its nature and its criteria. In contrast, such contact points could trigger a migrainous attack through the trigeminovascular pathway. So, multidisciplinary approach is mandatory to identify these anatomical-pathological causes by diagnostic endoscopy and CT scanning to discriminate between headache of sinonasal origin and migraine . The aim of this work was to evaluate nasal and paranasal findings in established cases of migraine.
| Patients and Methods|| |
This is an observational cross-sectional study conducted at Menoufia University Outpatient Clinic of Otorhinolaryngology and Neuropsychiatry Departments during the period from November 2017 to June 2018 after approval of the ethical committee of the hospital. A written consent was taken from all patients included in the study. Sixty patients were enrolled in the study by having migraine according to International Classification of Headache Disorders (ICHD-3)  as follows: (i) at least five attacks fulfilling criteria 2–4; (ii) headache attacks lasting 4–72 h (untreated or unsuccessfully treated); (iii) headache has at least two of the following four characteristics: (a) unilateral location, (b) pulsating quality, (c) moderate or severe pain intensity, and (d) aggravation by or causing avoidance of routine physical activity (e.g. walking or climbing stairs); (iv) during headache at least one of the following: (a) nausea and/or vomiting, (b) photophobia, and (c) phonophobia; and (v) not better accounted for by another ICHD-3 diagnosis. Patients with any systemic cause for headache other than migraine or patients with diagnosis of sinusitis according to EPOS criteria  were excluded from the study. Patients with pure contact headache were excluded from the study. Contact headache was diagnosed as defined by international headache society  as an intermittent pain localized in the periorbital and medial supraorbital canthus or temporozygomatic regions, secondary to mucosal contact points in the sinonasal cavities, in the absence of inflammatory signs, hyperplastic mucosa, purulent discharge, sinonasal polyps or masses, cessation of headache within 5 min following topical use of local anesthesia at contact area, and significantly resolution of headache in less than 7 days following removal of contact points. A total of 40 normal participants with neither migraine nor sinonasal manifestations were included in the study as a control group. The participants (60 patients) of this study were assessed by history taking to evaluate migraine criteria according to ICHD-3 and to assess the degree of disability caused by migraine using Migraine Disability Assessment Score [Figure 1] , in which grade I: minimal or no disability, with score 0–5; grade II: mild disability, with score 6–10; grade III: moderate disability, with score 11–20; and grade IV: severe disability, with score more than 21. The patients were subjected to general examination, complete ENT examination, neurological examination, and diagnostic nasal endoscopy including first pass 'inferior pass', second pass, and third pass, to assess the nasal mucosa and presence of anatomical variations, including septal spur, deviated nasal septum (S-shaped, C-shaped, and focal deviation), hypertrophied inferior turbinate, concha bullosa, paradoxical middle turbinate, pneumatized agger nasi cells, pneumatized inferior turbinate, pneumatized uncinate process, supraorbital cells, medialized uncinate, Haller cells, Onodi cells, prominent bulla ethmoidalis, inter-frontal cells, supreme turbinate, and absent pneumatization of frontal sinus. The patients were also investigated by CT scan (nose and paranasal sinuses, coronal) and axial 1.5 mm cuts was taken for (soft tissue, and bone windows), as most patients were having nasal obstruction also to assess anatomical nasal variations and the state of the paranasal sinuses using Lund–Mackay score  and to exclude neurological causes of headache. Different contact points were evaluated using nasal endoscopy and CT. These points included contact points between the septum and turbinates and between the turbinates and lateral nasal wall. The relationship between these points and migraine was assessed using nasal decongestant test during a migraine attack. Two cotton pledgets soaked with lidocaine and local decongestant were inserted in the nose during endoscopic examination at the site of mucosal contact to notice the improvement of the headache severity. Our outcome was to assess the prevalence of each nasal finding in our study patients along with the prevalence of different contact points and their correlation with the severity of migraine according to Migraine Disability Assessment Score. The improvement of migraine severity with nasal decongestant test was recorded.
|Figure 1: Questionnaire for Migraine Disability Assessment Score (MIDAS).|
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Data were collected, tabulated, and statistically analyzed using an IBM personal computer with statistical package of social science, SPSS statistics, Version 20.0; IBM Corp., Armonk, New York, USA). Descriptive statistics for quantitative data were presented as mean and SD. Qualitative data were presented as numbers and percentages. Data turned up to be non-normally distributed according to Kolmogorov–Smirnov test. Mann–Whitney U-test was used to compare quantitative data of both groups. χ2-test was used to study association between two qualitative variables. Two-sided P value less than or equal to 0.05 was considered statistically significant, whereas P value less than 0.001 was considered highly significant.
| Results|| |
This study included 60 cases including 24 males and 36 females with mean age of 34.67 ± 6.9 years. Forty participants were considered as a control group including 15 males and 25 females, with mean age of 34.82 ± 6.56 years, and we found a nonsignificant difference between both groups regarding age and sex (P > 0.05). In this study, migraine without aura was the most common type (63.3%) and grade III severity was the most common grade of severity (41.7%) [Table 1].
In this study, the case group has more septal, turbinate, and mucosal findings than control group, with a significant difference (P = 0.014, 0.042, and 0.039, respectively) [Table 2]. There was a statistically significant difference between case and control groups regarding septal spur and a nonsignificant difference between both groups regarding other septal finding including focal deviation, C-shaped deviation, S-shaped deviation, and pneumatized septum [Figure 2]a and [Figure 2]c. There was a statistically significant difference between case and control groups regarding concha bullosa and a nonsignificant difference between both groups regarding other turbinate findings including hypertrophied inferior turbinate and paradoxical middle turbinate [Figure 2]a and [Figure 2]b. Other variations like pneumatized agger nasi cells, pneumatized inferior turbinate, pneumatized uncinate, supraorbital cells, medialized uncinate, Haller cells, Onodi cells, prominent bulla ethmoidalis, frontal cells, supreme turbinate, and absent pneumatization of frontal sinus were not observed in our study. There was a significant difference between case and control groups regarding nasal mucosal findings, with abnormal mucosa (pale bluish) being more prevalent in case group [Figure 2]d. There was a nonsignificant difference between case and control group regarding Lund–Mackay score [Table 3].
|Figure 2: Examples for nasal findings in patients with migraine. (a) Computed tomography of nose and paranasal sinuses, coronal cut, and bone window showing bilateral concha bullosa and septal spur (arrows). (b) Endoscopic view showing left paradoxical middle turbinate. (c) Computed tomography of nose and paranasal sinuses, coronal cut, and bone window showing pneumatized septum (arrow). (d) Endoscopic view showing contact point between right middle turbinate (MT) and nasal septum (S) along with pale bluish abnormal nasal mucosa. LW: lateral wall; PMT, paradoxical middle turbinate.|
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|Table 3: Comparison between the two groups regarding individual nasal findings|
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In this study, the distribution of different contact points among case group with septum, middle turbinate was the most common contact point (19/60) [Figure 2]d followed by middle turbinate–lateral nasal wall (13/60). There was a nonsignificant correlation between different contact points and severity of migraine with more prevalent higher grades (III and IV) of severity with septum–turbinate contact points and lower grades of severity (I and II) with turbinate–lateral nasal wall contact points [Table 4]. All patients with evident endoscopic contact improved on application of nasal decongestant test with complete resolution in 27 (55.1%) of 49 cases with contact points, reduction in the migraine severity in 13 (26.5%) of 49 cases with contact points, and no change in migraine severity in the remaining nine (18.4%) patients.
|Table 4: Different nasal contact points and their correlation with severity of migraine according to Migraine Disability Assessment Score|
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| Discussion|| |
Despite significant advances in knowledge about the pathophysiology of migraine, the percentage of the migraine population who report having been diagnosed with migraine increased only modestly over the 10-year period between 1989 and 1999. An estimated half of the 28 million individuals with migraine in the United States remain undiagnosed . Classical migraine diagnosis may be obvious. However, there are other less obvious etiologies that are more obscure in nature, for example, contact headache, and require a strong clinical suspicion to be properly diagnosed, and it is believed that contact between two different sites of nasal mucosa may lead to stimulation of the sensory portion of the trigeminal nerve, resulting in headache that is not owing to pressure within a sinus but to an abnormal contact between innervated regions of the nasal cavity . Lipton et al.  conducted a population-based survey and reached a conclusion that some patients may have had coexisting sinus headache and migraine, and misdiagnosis of migraine as sinus headache is probably common. In addition, sinus headache is often self-diagnosed incorrectly by patients. Investigations of contact point headaches date back to 1943 when McAuliffe et al.  stimulated the nasal mucosa with pressure, electricity, and adrenaline and documented the pain perceived in assigned facial dermatomes. Therefore, the role of the nasal mucosa in the generation of migraine pain gained considerable attraction ,. Stammberger and Wolf  found that mucosal contact could cause headache by substanceP (SP) which is a neuropeptide released from the nasal mucosa through receptors by chemical, caloric, and also mechanical irritants (such as pressure), and via stimulation of these polymodal receptors, SP release may cause vasodilatation, plasma extravasation, hypersecretion, and smooth muscle contraction and referred pain regarding that branches of the trigeminal nerve that innervates the dura and intracranial blood vessels. When SP is released at perivascular sites, vasodilatation, plasma extravasation, and perivascular inflammation can cause headache similar to migraine without aura . Stammberger and Wolf  also found that the concentration of SP in human nasal mucosa using the radioimmunoassay technique is higher than chronic hyperplastic mucosa or polyp tissue and the contact between mucosal surfaces in the nose would elicit more pain than chronic infection or inflammation. Behin et al.  proposed a link between mucosal contact points and migraine. They suspected intranasal contact points to act as a triggering or boosting factor. The difficulty in interpreting these studies arises from the confounding symptoms of migraines, intranasal contact point headaches, and headaches owing to chronic sinusitis . In this study, we tried to evaluate the nasal and paranasal findings, nasal anatomical variations, and contact points using both nasal endoscopy and CT scan in cases of migraine. Nasal endoscopy serves as an objective diagnostic tool in evaluation of nasal mucosa, sinonasal anatomy, and nasal pathology. In contrast, CT is another invaluable tool for managing clinical decisions, planning surgical strategies, and a method of choice for assessment of paranasal sinuses, nasal cavity, and their anatomical variants , so their roles are synergistic. In this study, the case group included 24 males and 36 females (male-to-female ratio is 6: 9) with mean age of 34.67 ± 6.9 years, which was greatly near the findings of Kelman  who studied different age groups in relations to diagnostic migraine criteria and found that 86.3% of patients were female, and the mean age was 37.7 ± 11.7 years (range: 16–80 years). Muehlberger et al.  found that 55% of the migrainous patients were females and 45% were males, with a mean age of 40.9 ± 13.84 years. In this study, migraine without aura was the most common type of migraine in the case group, and grade III severity was the most common grade of severity. Russell et al.  found the lifetime prevalence of migraine without aura was 14.7%, whereas that of migraine with aura was 7.9%. In this study, the case group had more septal, turbinal, and mucosal findings than control group, with a significant difference. Ferrero et al.  conducted a study confirming that endonasal mucosal contact is an important factor for chronic migraine, depending on CT scan of nose and paranasal sinuses and on nasal endoscopy, and that some anatomofunctional alterations of the nose, for example, deviations of the nasal septum, abnormal turbinates, especially middle or superior, with consequent areas of mucosal contact with the septum may be possible causes of headache and chronic migraine and that there may be more than one point of contact. In this study, there was a significant difference between case and control groups regarding septal spur and a nonsignificant difference between both groups regarding other septal findings, including focal deviation, C-shaped deviation, S-shaped deviation, and pneumatized septum. Our results do not match the results of Muehlberger et al.  who found that of patients in the migraine group, 80% had a septal deviation (nonmigraine patients, 71%). Of these septal deviations, 85% in patients with migraine (MPs) versus 71% in patients without migraine (NMPs) were focal. Of the MP, 6% had C-shaped or S-shaped deviations, 4% of NMPs had C-shaped septal deviations, and 8% of NMPs had S-shaped septal deviations. The incidence of septal spurs was 41% in MPs versus 35% in NMPs independent of the presence of septal deviations. Lee et al.  reviewed CT scan of a study cohort of 98 MPs showing that 75 (76.5%) of the patients had septal deviation, 34 (34.7%) patients had septal bullosa, and 33 (33.7%) patients had septal spur. In this study, there was a statistically significant difference between case and control groups regarding concha bullosa and a nonsignificant difference between both groups regarding other turbinal findings including hypertrophied inferior turbinate and paradoxical middle turbinate. Muehlberger et al.  found that concha bullosa of the middle turbinate was found in 27% MPs and 21% NMPs. Only 4% MPs had a concha bullosa of the superior turbinate and only one patient had this variant in the inferior turbinate. Lee et al.  found that 24 (24.4%) patients had superior concha bullosa, with half of those findings being bilateral. Forty-eight (50%(of the patients had middle concha bullosa and one-third of those patients had bilateral findings. Five (5.1%) patients had inferior concha bullosa and one (1%) patient had bilateral findings. There were no paradoxical turn findings in the superior turbinates in their cohort group. There were 10 (10.2%) patients with paradoxical turns in their middle turbinates and three (3.1%) patients with bilateral findings. There was one (1%) patient with a unilateral paradoxical turn in the inferior turbinate. There were 39 (39.8%) patients with enlarged inferior turbinates. In this study, there was a statistically significant difference between case and control groups regarding abnormal nasal mucosa, being more in case group. This abnormality was in the form of edematous nasal mucosa, which may be attributed to underlying pathology like allergic rhinitis. Hagains et al.  stated that mucosal edema may increase the existing pressure among the nasal structures, maintaining the process in a vicious cycle, so edema could be a manifestation and a trigger at the same time. The relationship between allergic rhinitis and migraine was investigated in a prospective study by Theodoropoulos et al.  who observed that interictal serum C-reactive protein levels declined and the severity of migraines and rhinitis decreased during sublingual immunotherapy by altering cytokine responses of T helper cells and by promoting IgG and IgA, antibodies that block the binding of IgE to mast cells. Rosario and Pinto  revealed a correlation between serum IgE levels and the severity and frequency of migraines and found that patients with higher levels of IgE had more severe headaches than those with lower levels of IgE, and these data support the hypothesis that migraine severity and disability depend on coexisting allergic rhinitis. In the pathogenesis of allergic rhinitis, allergens interact with mucosal membranes in the nasal cavity and paranasal sinuses, activating inflammatory cell response, and allergens can activate trigeminal nociceptors by releasing inflammatory chemicals from dural mast cells, triggering a migraine attack ,,. In this study, there was a nonsignificant difference between case and control group regarding Lund–Mackay score. This matches the finding of Mehle et al.  who evaluated the sinus CT scan findings in 'sinus headache' migraineurs, and compared them to nonmigraine 'sinus headache' patients and found that the mean CT scan Lund–Mackay score did not differ significantly between the migraine (2.07) and nonmigraine (2.66) cohorts. In this study, septum–middle turbinate contact point was the most common contact point followed by middle turbinate–lateral nasal wall. There was a nonsignificant correlation between the contact point and severity of migraine with more prevalent higher grades (III and IV) of severity with septum–turbinate contact points and lower grades of severity (I and II) with turbinate–lateral nasal wall contact points. Muehlberger et al.  found that 87% MPs and 79% NMPs had at least one contact point, and the most frequent one was between the middle turbinate and the septum, observed in 54% of MPs and 45% of NMPs. Although a contact point does not cause a migraine in the absence of the disease, the concomitant presence of migraine and contact points can trigger an attack, and therefore, it is necessary to differentiate or exclude a rhinological disorder in these patients. Ferrero et al.  assessed endonasal mucosal contact points in chronic migraine and found that the prevalence of septum–middle turbinate contact in case group was 36.0%, whereas the prevalence of septum–superior turbinate contact was 22.2%. The causal relationship between mucosal contact points and migraine was supported by our finding of complete improvement of migraine by nasal decongestant test in 55.1% of cases with mucosal contact points and reduction in the migraine severity in the remaining 26.5%. The limitations of this study being observational include the lack of assessment of the role of treatment of nasal pathology either medically or surgically on the improvement of migraine symptoms. This needs to be evaluated in further studies to confirm the utility of treatment of nasal disorders as a necessary step for control of migraine and to evaluate role of therapy.
| Conclusion|| |
The presence of nasal findings in migraineurs was significantly associated with triggering of migraine, which results from contact points causing the mechanical stimulation of the trigeminal pathway which is considered a common mediation for most types of facial pain and headache. The most common findings were septal spur, concha bullosa, and abnormal nasal mucosa, and the most common contact point in our study was between the septum and middle turbinate. In contrast, allergic rhinitis is an important nasal mucosal pathology which should be respected as a triggering factor for migraine.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]