S4:Ep13 – Facial Pain in Migraine


Voice-over: Welcome to Spotlight on Migraine, hosted by the Association of Migraine Disorders. Join us for fresh perspectives by medical experts and advocates as we explore the spectrum of migraine and dig deeper into this complex disease. This episode is brought to you, in part, by our generous sponsors, Lundbeck and Amgen. 

Sinus headache or migraine. People who frequently visit their doctor for recurrent sinus infections or sinus headache may be living with migraine disease. In this episode, Dr. Philip Zald describes the patterns of facial pain and pressure that may be caused by migraine, common comorbidities, and how an otolaryngologist or ENT doctor can help with the care of a migraine patient.

Philip Zald, MD: My name’s Phil Zald, I’m an otolaryngologist, and I practice community-based comprehensive otolaryngology in Oregon. Today, I’m going to talk to you about facial pain in migraine from an otolaryngology perspective.

The objective of today’s talk is to discuss patterns of facial pain, pressure, or fullness that may be caused by migraine. We’ll talk about common sinonasal symptoms and comorbidities in migraine. We aim to increase awareness of the midfacial variant presentation of migraine and associated symptoms. And we’ll review the diagnosis and management of migraine from an otolaryngology perspective.

So when we look at these two images, take a look at them, tell me what you see, or tell yourself what you see. And keep that in mind, and we’ll come back to that at the end of the presentation.

So what is a sinus headache? I frequently see patients who come to me with undifferentiated sinus headaches. They tell me they have sinus infections frequently. They have sinus issues, sinus problems. Many times these patients experience allergies. It turns out that the term sinus headache lacks medical diagnostic specificity and may mean different things to different people. 

So in 2007, there was a study called the SAMS study, Sinus Allergy and Migraine Study. And what this study did was look at the reasons behind the diagnosis of sinus headache. Ask patients, also ask some healthcare providers – like allergists, immunologists, otolaryngologists and neurologists – about patient symptoms and why the patient felt that they had a diagnosis of sinus headache, or why their doctors felt that they had sinus headache.

This study looked at these presentations, and it turns out that almost 9 out of 10 of the patients with self-diagnosed sinus headache met criteria for migraine or probable migraine, whereas only 3% of the headaches were attributable to inflammatory rhinosinusitis by current criteria. 

So, many patients are likely misattributing sinus infection or sinus headache when the underlying condition is actually a migraine.

So what were the reasons that sinus headache was reported by these patients? Well it turns out that the location of the discomfort in the sinus area and the face, triggers like weather change, seasonal allergies, altitude change, associated nasal symptoms, runny nose, congestion, and stuffiness, plugging in their ears or ear pain, drip from the nose, sore throat, and puffy eyes. These were all reasons that people felt that their discomfort was due to a sinus headache.

Additionally, some of these patients had prior diagnoses by a physician or that sinus medication was effective, so that further reinforced the view that these were sinus headaches.

The location of the pain was frequently in the midface, the cheeks, the forehead – sometimes single sided but often bilateral. You can see here the middle-right and middle-left images. The bilateral forehead and the bilateral forehead and midface region are the most commonly affected in those presenting with sinus headache.

Sometimes unilateral upper left and upper right here, upper forehead or midface, you can see that the region around the nose, eyes, forehead, and cheeks is the most commonly affected area in these patients. Sometimes the lower jaw or temporal region in my experience as well. But really that midfacial region, nose, eyes, sometimes, patients describe a sensation of pain behind the eye or pressure.

Often this headache is pressure based more so than pain or throbbing, which can be confusing for patients with a prior history of more classic migraine headaches, when they now have a pressure sensation in the midface, forehead, behind the eyes, whereas perhaps their prior migraines were side of the head, temporal or occipital region, and of a different quality and character.

So pain in midfacial migraine presentations or sinus migraine may be different from your prior migraine and maybe a different location, maybe different quality, pressure, rather than pain, and it may last for a different length of time. I frequently see this in patients with more chronic or chronified headache presentations.

Patients will tell me this couldn’t be my migraines, it’s a sinus headache, it’s different. I’m congested all of the time, but nothing comes out when I blow my nose, there must be something blocked in my nose. Or this certainly couldn’t be a headache because I’m just so congested and pressured within my nose and sinus area.

This all makes sense, however, when we think about the biology of migraine. We know that the trigeminal nerve is highly activated in migraine states. This is a nerve that creates sensation from our face, the skin of our face, for example. It runs in three divisions. The first division is the ophthalmic, the upper division, second division maxillary division, third division mandibular division. And the trigeminal nerve is activated in migraine and also carries sensory information from the region of our paranasal sinuses and nose. 

So, it makes sense that we might have these sensations when this nerve is activated in migraine states.

We also see prominent nasolacrimal symptoms in migraine, also other headache conditions, especially autonomic cephalalgias like cluster headache, for example, that involve the sphenopalatine ganglion and the autonomic or automatic nervous system of our nose.

So we know that the lining of the nose, the mucous membrane of the nose and sinuses, are an end organ, especially the turbinates, inferior turbinate, in particular, is an end organ of the autonomic or automatic nervous system.

And when this is activated, it can cause runny nose, swelling of the mucous membrane in the nose, tearing of the eyes. And patients who come to see me with midfacial migraine presentations, they frequently have a pressured sensation in their nose. 

Some of them have runny nose, some don’t. Some have a posterior nasal drip, or postnasal drip sensation, some don’t. But this autonomic dysfunction in headache states and migraine, in particular, can be fairly prominent.

In my practice, I also spend a lot of time sorting through other what I call rhinologic comorbidities in migraine. Some patients turn out to primarily have migraine presentations, but many have overlapping common conditions. These include rhinitis, both allergic, and nonallergic, chronic sinusitis, or recurrent acute sinusitis, which is a short-term sinus infection. 

Allergic rhinitis is a condition of IgE-mediated inflammation caused by an allergen. It can cause runny nose, clear mucous, nasal blockage, congestion, sneezing, itchiness of the nose, watery, itchy eyes due to allergic conjunctivitis. So many of these symptoms overlap with what we see in midfacial migraine. 

Migraine and allergic rhinitis, the connection or the relationship is still somewhat unclear. We know that both conditions are very common. Migraine is common, allergic rhinitis is common. 

When I have patients who present with a lot of nasal congestion, symptoms of allergy, but also who have a history of migraine or a suspect midfacial presentation or sinus presentation of migraine, I offer allergy testing to these patients, especially if they’re prominent allergy-related symptoms.

Some of these patients test positive for aeroallergy, and some test negative for aeroallergy. So, if both conditions are common, is this co-occurrence by chance alone? Or maybe allergic rhinitis is a trigger for migraine. Maybe these two conditions have a shared underlying biology or pathophysiology. This relationship is still unclear. 

Chronic rhinitis is a condition similar to allergic rhinitis but not caused by an allergic trigger, and it doesn’t involve IgE-mediated inflammation. Extrinsic causes could be an irritant or say an occupational exposure.

Medications like Afrin overuse can cause a rebound congestion, a condition we call rhinitis medicamentosa. 

Intrinsic causes include what many people call vasomotor rhinitis, but this term lacks diagnostic specificity. It does allude to that autonomic nervous system and dysregulation of the mucous membrane of the nose in terms of how it manages mucous production or swelling, vasomotor dysfunction.

I frequently see patients who are maybe in the sixth, seventh, eighth, ninth decades of life who have a nonallergic form of rhinitis characterized by frequent runny nose. They tend not to have as much blockage or sensation of congestion. They don’t have pain or discomfort. They just have a runny nose that really bothers them. I call this nonallergic rhinitis of aging, but it is sort of a vasomotor phenomenon. 

In midfacial migraine, I frequently see patients with congestion, even swelling of especially the turbinates in the mucous membranes of the nose. And the autonomic dysfunction of migraine in the nose, in my mind, can be fairly unmistakable. I call this dysautonomia rhinitis of migraine. But there’s no real specific term for this presentation or midfacial migraine patients with nasal congestion. We also have to keep in mind allergic rhinitis as a potential cause.

Rhinosinusitis, both chronic and acute, is a condition of inflammation in the mucosa, the mucous membrane of the paranasal sinuses. Chronic rhinosinusitis causes nasal blockage or obstruction, congestion. More specific to chronic rhinosinusitis would be reduced sense of smell or hyposmia. These patients may experience pressure or fullness.

Although many of them with fairly florid nasal polyposis, a nasal polyp, a high burden of objective findings of mucosal inflammation in their sinuses, tend not to have as much pain, in my experience.

I’ve diagnosed patients with chronic rhinosinusitis with nasal polyp who have loss of sense of smell as really their only symptom. They tell me maybe they have maybe very little or no pain ever. And so the difference between this, in my mind, is often quite striking in terms of the presentation.

But often it’s very similar to midfacial migraine or migraine presentations with midfacial pressure. Sometimes the nasal discharge is intermittently discolored or mucopurulent. And so distinguishing the two conditions can be challenging. 

To make a diagnosis of rhinosinusitis, either acute or chronic, we really need to see objective signs of mucosal inflammation in the sinuses. So this can be done with nasal endoscopy, for example, in my practice, or anterior rhinoscopy, which is looking in the front of the nose with a headlight through a nasal speculum. This should show mucopurulent discharge.

Many times, though, this is not readily apparent, or the endoscopy is equivocal and doesn’t really yield a diagnosis. This is where imaging can be very useful. So to make a diagnosis of chronic sinusitis, we need to see either mucopurulent discharge or inflammatory findings on imaging, some sort of objective finding.

So I find that early use of CT scan in the sinus headache patient is extremely helpful. It’s ideally performed when symptoms are active or close to an active interval of symptoms. And I like to keep in mind that CT evidence of sinusitis does not rule out a migraine diagnosis. Migraine diagnosis is based on symptoms. So you can have both sinusitis and migraine or allergy and migraine. Early CT scan may speed time to a correct diagnosis in patients with recurrent sinus headaches. 

I also find, in my practice, when I look at patients with migraine presentations, that they tend to show turbinate hypertrophy that is similar to that seen in other inflammatory conditions in the nose such as allergic rhinitis.

And that patients who have both migraine and allergic rhinitis have the worse turbinate hypertrophy. This is unpublished data, but certainly a pattern that I notice in my practice.

So a case example. This was a 38-year-old woman who had pressure and pain in both cheeks. She reports problems with her sinuses for years. She notices that it actually gets worse when she touches her face, but she has minimal nasal discharge. She tried a nasal steroids spray Flonase with little improvement.

Tried an antihistamine, it helps, but temporarily. She tried an oral decongestant, Sudafed, and that helped, but only temporarily. She notes a history of seasonal allergies in the past, and she also has some bothersome ear pressure and an ear itchiness at times.

On exam, she has inferior turbinate hypertrophy. Nasal endoscopy didn’t demonstrate any remarkable signs of inflammation like mucopurulent discharge, polyp, or swelling in the middle meatus, that’s the central region of the nose farther back.

Allergy testing did show positives for 19 out of the 20 tested aeroallergens. And a CT scan showed normal paranasal sinuses. 

So the diagnosis, at this point, was allergic rhinitis. This was actually a patient seen by another physician in my practice who then subsequently moved to another country, actually, so I assumed care.

And she had initiated immunotherapy, allergy shot therapy for allergy desensitization. So when I assumed her care, we had a visit, and we did a check-in, and I took a migraine history. 

And it turns out she was having headaches with photophobia, nausea, and activity intolerance about 15 days a month. She sometimes had a visual aura. And she never had a prior diagnosis of migraine. No prior therapies for migraine. And I added the diagnosis of chronic migraine.

Her discomfort was in her midface, forehead, sinus migraine presentation or midfacial migraine.

She was given a prescription for an abortive headache medication, sumatriptan, found that very effective. Due to the frequency of her headaches, she elected to start topiramate prophylaxis therapy, and that was effective.

She continues with allergy immunotherapy, but her headaches were much improved at the next six-week follow-up.

So what is the role of an otolaryngologist in migraine care? I think ways that we can participate in multidisciplinary care are to clarify a diagnosis, initiate medical treatment if needed. We can offer, some of us offer allergy testing, or immunotherapy to those with concurrent allergic rhinitis. 

We can offer rhinologic procedures to those with prominent nasal symptoms, turbinoplasty. There’s a procedure called posterior nasal nerve ablation that, interestingly, treats nerves that emerge from the sphenopalatine region. And we’ve seen some early responses, especially in terms of nasal symptoms, which is what this procedure is primarily studied for thus far. But may help with some of the midfacial migraine-related symptoms.

Other procedures that we can offer in some of our practices would be Botox, peripheral nerve block therapy, sphenopalatine ganglion blocks which can be performed through a transnasal endoscopic route. This is a well-established technique for headache block. Fairly straightforward to do through the nose, whereas oftentimes this is done transcutaneously with a needle and fluoroscopy. We can do this with an endoscope in the office, either with topicals or injectables or both.

Peripheral nerve blocks or even peripheral nerve decompressions are an option that some otolaryngologists may offer for peripheral neuralgias or migraine trigger points. 

So I think it’s important to keep in mind that we don’t see things the way that they are, we seem them the way we are. So I like to put on the three different hats in my practice. I wear primarily the ENT or otolaryngology hat. But I think it’s important, when faced with patients, to think about things from different perspectives. I like to put on that neurologist hat and the allergist/immunologist hat. 

So I ask you, when you look at these images again, what do you see now? The image on the left here, you can see this younger profile. The jawline, the nose, so there’s a younger woman with curly, dark hair. But we may also see this more elderly woman with the longer chin, nose, and the lighter-colored hair. So there’s a double image there. And it may depend on what you’re looking for and what you see.

This picture of Eeyore here, if you notice his nose, actually, there is a head with a little bit of hair in the center, two eyes, and ears. So there’s sort of like a floating head on Eeyore’s nose that until I was putting together this presentation, I never knew was there. So it’s something that’s there that you may not see, but it’s right there in front of your nose.

I like to think of that the same way with midfacial migraine and headache presentations.

So thank you for the opportunity to talk to you about facial discomfort and migraine from our otolaryngology perspective.

Voice-over: …for tuning into Spotlight on Migraine. For more information on migraine disease, please visit MigraineDisorders.org.

*The contents of this podcast are intended for general informational purposes only and do not constitute professional medical advice, diagnosis, or treatment. Always seek the advice of a physician or other qualified health provider with any questions you may have regarding a medical condition. The speaker does not recommend or endorse any specific course of treatment, products, procedures, opinions, or other information that may be mentioned. Reliance on any information provided by this content is solely at your own risk.