We also performed a subgroup analysis based on whether patients had a positive response to a preoperative local anesthetic test, because this is a common diagnostic criterion for contact point headache.17 Of the 39 original articles, 25 studies reported using a local anesthetic test as part of their selection criteria. These 25 articles included 979 patients, with 855 patients (87.3 percent) having a positive response to the anesthetic test preoperatively. Of this subgroup, 582 (59.4 percent) had an excellent response to surgery, 285 (29.1 percent) had partial improvement, and 112 (11.4 percent) were unchanged (Fig. 6, above) (p < 0.001).
Although these studies included the anesthetic test as part of their diagnostic criteria, not all patients were positive on this test before undergoing surgery. Therefore, we elected to separately analyze studies in which 100 percent of the patients who underwent surgery had a positive anesthetic test (Fig. 6, below). This included 17 studies totaling 694 patients. Of this subgroup, 454 patients (65.4 percent) reported total cure, 178 (25.6 percent) reported partial improvement, and 62 (8.93 percent) were unchanged (p < 0.001). Similarly, when these studies were compared with studies in which the anesthetic test was not performed or the results were unknown (12 studies, 538 patients), these results were also significant (p < 0.001). For those 12 studies in which the lidocaine test was not included as part of the selection criteria, 144 patients (26.8 percent) reported total cure, 278 (51.7 percent) reported partial improvement, and 116 (21.5 percent) reported no change.
This systematic review of 39 studies demonstrates a significant association between functional nasal surgery for treatment of nasal mucosal contact points and improvement in headache symptoms. Overall, 85 percent of patients undergoing nasal surgery with or without endoscopic sinus surgery had at least partial improvement in their headache symptoms, with 47.9 percent of patients reporting complete cure. These results were consistent across multiple metrics, with patients reporting significant improvement in average visual analogue scale scores and number of headache days postoperatively. These results suggest that the use of nasal surgery to improve headache symptoms is a viable treatment option in appropriately selected chronic headache patients. Functional nasal surgery has previously been shown to improve nasal airway breathing,1–3 allergic symptoms,4,5 and obstructive sleep apnea,6–8 and this study adds another important “function” to this commonly performed procedure.
Our review demonstrates that inferior turbinate reduction and septoplasty are the most commonly performed procedures in headache patients, likely because they address the most common nasal mucosal contact points. A number of different intranasal contact points have been implicated as potential sources of referred facial pain and headache. In their 2013 study, Bilal et al. quantified the anatomical variations in 65 patients who presented for nasal surgery for treatment of headaches.24 The most common anatomical variations included turbinate hypertrophy, nasal septal deviation, agger nasi cells, and concha bullosa. Therefore, it is unsurprising that procedures that are used to correct septal deviation and turbinate hypertrophy would be used in headache patients to address these common anatomical variants.
The overall headache cure rate of 47.9 percent and improvement rate of 37.1 percent following functional nasal surgery suggests an important relationship between intranasal anatomy and headache feedback loops. Although the proposed pathophysiology is not fully understood, a feedback loop through the trigeminal nerve distribution is thought to play a major role.56 The nasal cavity and the frontal parts of the head and sinuses are predominantly innervated by branches of the trigeminal nerve. Aberrant contact points within the nasal mucosa could lead to stimulation of the trigeminal system, leading to release of neuropeptides that cause neurogenic inflammation associated with migraine headaches, and sterile edema within the nasal mucosa.57–59 This proposed mechanism is supported by previous studies demonstrating that patients with migraine headaches report increased nasal congestion during migraine attacks, and have objective differences in measured nasal resistance during attacks.60
In addition to nasal contact points, sinus disease and possibly sinus pressure may also play an important role in headache pathophysiology. Eighteen of the studies in our systematic review included endoscopic sinus surgery as a means of addressing additional contact points in selected patients. When a subgroup analysis was performed to compare improvement in headache symptoms for patients undergoing functional nasal surgery only versus nasal surgery plus endoscopic sinus surgery, we found that approximately 85 percent of patients reported improvement in each group. However, when results for the nasal surgery–only versus nasal surgery plus endoscopic sinus surgery groups were compared, the results were significant (p = 0.007), with a higher proportion of patients reporting cure of headache symptoms with inclusion of endoscopic sinus surgery in their procedure (51.2 percent versus 44.7 percent). This finding is consistent with previous studies demonstrating improvement in sinus headaches with surgical management of sinus disease.42,44,58,61,62 Considered together, these results underscore the importance of a thorough diagnostic workup to help tailor individualized surgical treatment to each patient’s unique anatomy.
The variability in the types of procedures that can be used to treat chronic headache symptoms also highlights the need for consistent diagnostic criteria to identify patients that might benefit from surgery. According to the International Classification of Headache Disorders, the diagnosis of mucosal contact point headache must satisfy several criteria, including intermittent pain localized to the periorbital, medial canthal, or temporozygomatic regions; direct clinical or imaging evidence of mucosal contact points without acute rhinosinusitis; elimination of symptoms within 5 minutes of topical application of local anesthesia; and resolution of pain within 7 days after surgical removal of the contact point.17 The majority of the studies in our analysis confirmed the presence of mucosal contact points with computed tomographic scans and/or nasal endoscopy, indicating that these studies should be routinely conducted when identifying patients for surgical intervention. Furthermore, there is evidence that a positive anesthetic test can be predictive of surgical success. In the 2010 report by Mokbel et al., 80 percent of lidocaine test–positive patients were cured of their headaches, although 60 percent of those who were lidocaine test–negative had no change in headache symptoms.40 Similarly, Mohebbi et al.39 analyzed four different groups of patients based on computed tomography/endoscopy findings and results of a lidocaine test, with their results demonstrating significant improvement in all patients who tested positive on their anesthetic test. We attempted to control for this variable in this review by analyzing only those studies that included 100 percent positive anesthetic tests, with the results being highly significant. Subgroup analysis of patients with positive preoperative lidocaine tests demonstrated a significantly higher cure rate of 65.4 percent compared to the 26.8 percent cure rate among patients in studies that did not include a preoperative anesthetic test.
Comparison of these two groups was significant by chi-square analysis, indicating that the response of patients to surgery was more robust when they had a positive preoperative lidocaine test. Based on these results, it appears that local anesthetic testing should be a routine diagnostic criterion when considering whether a patient will benefit from functional nasal surgery for headache treatment.
Although our study demonstrated a strong correlation between nasal surgery and improvement in headache symptoms, there are several study limitations. First, the majority of the studies that were included in the analysis were retrospective chart reviews, prospective preoperative/postoperative studies, or case series, and there were only two randomized controlled trials identified in the literature.35,52 There was also no standard surgical procedure that was performed across all groups of patients. The extent and type of septoplasty or turbinate reduction that was performed was frequently not described, which could be problematic, given that we have previously demonstrated that there is wide variation among American Society of Plastic Surgeons members with regard to turbinate procedures.63,64 In addition, endoscopic sinus surgery was frequently performed in multiple studies, with variable approaches. It is therefore impossible to determine the exact effect of each individual surgical intervention on the relief of headache symptoms. In addition, patients likely had different presentations and different trials of medical treatment, which were often not described in the analysis. The type of headache symptoms that were included in each of the studies varied widely, with some studies including primary headaches such as migraines or cluster headaches, and others describing nonspecific facial pain. Finally, the outcomes that were measured in the studies were often variable or vague, with multiple studies describing “cure” or “improvement” in headache symptoms with no quantification of the severity or frequency of headache symptoms. When specific variables were reported, subjective measurements such as visual analogue scale scores were frequently used, limiting the conclusions that could be drawn from these data given the inherent bias in this type of measurement.
Finally, multiple studies have demonstrated the link between obstructed nasal breathing, obstructive sleep apnea, and migraine,60,65,66 and have also demonstrated an association between poor sleep and the development of migraine symptoms.67 Given that the primary indication for surgery is correction of nasal obstruction, it is possible that the results of our study are reflective of improvement in nasal breathing and sleep rather than a direct effect of removal of contact points on headache symptoms. Only two of the studies in our analysis included data on nasal obstruction symptoms in their postoperative study populations.33,47 In the study by Schønsted-Madsen,47 the author directly compared postoperative headache symptoms in the group of patients who had completely resolved nasal obstruction with those who had persistently obstructed breathing. This study demonstrated that 83 percent of patients with normal breathing were headache-free, whereas only 30 percent of patients with persistently obstructed breathing were free of headache symptoms. Similarly, patients in the study by Harley et al.33 demonstrated statistically significant improvements in nasal obstruction, irritability, and restlessness after undergoing surgical intervention, potentially indicating an indirect effect on sleep quality in this population. These results suggest that the improvement in headache symptoms that is demonstrated with nasal surgery is likely multifactorial in nature, and that there may be other indirect effects of these operations on sleep and breathing that have not yet been elucidated.
We have performed the first systematic review to determine whether there is an association between functional nasal surgery for treatment of mucosal contact points and improvement in headache symptoms. Although there are limitations in terms of sample size, selection criteria, and availability of randomized controlled trials, available evidence does appear to suggest that the use of functional nasal surgery is a viable treatment option in appropriately selected headache patients. Further investigation with a randomized, double-blinded, controlled study with careful selection criteria is required to identify those patients that might benefit the most from this intervention.
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