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Rhinogenic contact point headache – Frequently missed clinical entity

Article · August 2016

DOI: 10.1016/j.apme.2016.08.001

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 apollo medicine 13 (2016) 169–173

Available online at www.sciencedirect.com

ScienceDirect

journal homepage: www.elsevier.com/locate/apme

Review Article

Rhinogenic contact point headache – Frequently

missed clinical entity

Santosh Kumar Swain a,*, Ishwar Chandra Behera b, Sidharth Mohanty c,

Mahesh Chandra Sahu d
a
Department of Otorhinolaryngology, IMS and SUM Hospital, Siksha ‘‘O’’ Anusandhan University, K8, Kalinganagar,
Bhubaneswar 751003, Odisha, India
b
Department of Community Medicine, IMS and SUM Hospital, Siksha ‘‘O’’ Anusandhan University, K8,
Kalinganagar, Bhubaneswar 751003, Odisha, India
c
Department of Anesthesia, Apollo Hospital, Bhubaneswar, Odisha, India
d
Directorate of Medical Research, IMS and SUM Hospital, Siksha ‘‘O’’ Anusandhan University, K8, Kalinganagar,
Bhubaneswar 751003, Odisha, India

article info abstract

Article history: Background: There are different anatomical situations inside the nasal cavity leading to
Received 11 June 2016 rhinogenic contact point headache (RCPH), where each contact point has its own character-
Accepted 4 August 2016 istics. The precise excision of contact points by endoscopic approach in patients with RCPH
Available online 21 August 2016 is very effective and could be done carefully in selected patients. This review presents an
overview of the current aspects in pathophysiology, clinical profile, and management of
Keywords: RCPH.
Anatomical variations Method: Relevant literature was searched from PubMed, Science direct, and Scopus data-
Headache bases.
Contact point headache Results: Headache is a common clinical entity and is nearly universal in the course of
Computed tomography everyone's life. Pressure of two opposing mucosa in the nasal cavity without evidence of
inflammation can be a cause of headache or facial pain. Minor intranasal anatomical
variation leading to mucosal contact point may be an etiological factor for causing headache
and often misdiagnosed and forgotten by clinician during evaluation of headache patients
and sometimes considered as headache of unknown etiology.
# 2016 Indraprastha Medical Corporation Ltd. All rights reserved.

headache varying from simple tension headache, migraine,

1. Introduction
Headache is a common complaint by the patients in day-to-
day clinical practice and creates a distressing situation for both
patient and the physician. There are myriads of causes for
refractory errors in eye, temperomandibular joint arthralgia,
myofacial spasm to severe brain tumors. Headaches may be
classified into primary and secondary types, where primary
headache does not have specific etiology and include
migraine, tension headache and cluster headache. Secondary

* Corresponding author. Tel.: +91 9556524887.

E-mail address: santoshvoltaire@yahoo.co.in (S.K. Swain).
http://dx.doi.org/10.1016/j.apme.2016.08.001
0976-0016/# 2016 Indraprastha Medical Corporation Ltd. All rights reserved.
170 apollo medicine 13 (2016) 169–173
Table 1 – Anatomic variations noted on diagnostic nasal
endoscopy and CT scan anatomic variations.
Serial no. Anatomical variations of nose
1 Deviated nasal septum
2 Septal spur
3 Concha bullosa
4 Hypertrophied superior turbinate
5 Overpneumatised ethmoidal bulla
6 Hypertrophied agger nasi cells
7 Malformed uncinate process
8 Paradoxical middle turbinate
9 Hypertrophied inferior turbinate
headache may arise owing to infections, trauma, tumor,
vascular lesions, and metabolic diseases.1 It needs a multidis-
ciplinary approach to diagnose the causative factors for
headache. Often the rhinogenic cause of headache is undiag-
nosed; even worse, this cause is not suspected on preliminary
evaluation. Headache together with facial pain owing to nasal
origin in the absence of inflammatory sinonasal pathology is a
new clinical entity that has received attention in medicine.
This is called as rhinogenic contact point headache (RCPH),
which is a new terminology in medicine. Even without the
presence of sinusitis, the referred headache often due to
pressure on the nasal mucosa because of the anatomical
variations in the nose.2 Contact point headache is a new type
of headache in the International Classification of Headache
Disorders (ICHD), supported by limited evidence. RCPH is
defined as intermittent pain localized in the periorbital and
medial canthal or temporozygomatic regions; evidence of
mucosal contact points with postural movements; cessation of
headache within 5 min following topical use of local anesthe-
sia at contact area and significantly resolution of headache in
less than 7 days following removal of contact points.3
Intranasal contact points denote to a contact between two
opposing intranasal mucosal surfaces. Intranasal contact
points are present in about 4% of noses.4 Different intranasal
anatomical variations causing RCPH are given in Table 1.
Stammberger and Wolf documented the role of substance P
(SP) in RCPH. They also described that this kind of headache is
not only because of abnormal middle turbinate but also by
abnormal mucosal contact causing referred pain.5 This review
article describes the role of anatomical variations in nose
leading to headache, which is a prudent evaluation with
diagnostic nasal endoscopy and computed tomography (CT)
scan before accurate diagnosis of rhinogenic cause of
headache. It also describes details of pathophysiology, clinical
profile, and management.
2. Pathophysiology
The pathogenesis of RCPH is still the subject of controversy by
some authors. The mechanical irritants such as pressure on
the nasal mucosa may cause release of neuropeptides through
the central orthodromic impulse and peripheral local, anti-
dromic impulse. Neuropeptides like SP and calcitonin gene
related peptide (CGRP) cause vasodilatation and edema of
mucosal membrane, which again intensifies the pressure of
contact area. The release of neuropeptides from central
nervous system causes the pain sensation, which is almost
similar to migraine without aura. The duration and onset of
pain coincide with duration and beginning of the nasal cycle.6
The middle turbinate is covered with mucosa on the lateral
nasal wall. Its anterior wall and nasal septum are supplied by
anterior ethmoidal nerve. RCPH is usually a referred pain
where two different afferent sensory neurons, one with its
receptor in the nasal cavity mucosa and other in the skin of
forehead, zygomatic, temple and medial canthal area synapse
on the same sensory neuron of sensory nucleus of trigeminal
nerve. If the receptors in the nasal mucosa are stimulated,
leading to the misinterpretation by the sensory cortex as
originated from the skin, causing referred pain to the
supraorbital or glabellar region. The cause of RCPH is
multifactorial. RCPH may result from nociceptors in the nasal
mucosa, which ends up in the sensory nucleus of the
trigeminal nerve. Pressure effect on the nasal mucosa is
associated with changes in micro vascular supply, followed by
release of biologic substances, induces pain or decreasing the
pain threshold. The contact between mucosal lining of concha
bullosa and nasal septum or the lateral wall of nose results in
release of SP, CGRP,7 and neurokinin A.8 These chemicals are
found in nociceptive fibers in the central nervous system and
trigeminovascular system. So the contact point between
intranasal mucosa may be a cause of secondary headache
or triggering factor to primary headache.9 This phenomenon is
also called as middle turbinate syndrome.10 SP has a known
role in pathophysiology of contact point headache.5 SP is a
neuropeptide that can be identified in the mucosa of the nasal
cavity. When SP is released around vascular area, vasodilata-
tion, plasma extravasation and perivascular inflammation,
causing headache similar to clinical manifestations of
migraine without aura.9 Normal nasal mucosa has a higher
concentration of SP than chronic hyper-plastic mucosa or
polypoidal tissue. This explains why contact point headaches
are almost always seen in patients without rhinosinusitis.
3. Clinical profile
Headache is a very commonly encountered clinical symptom
seen in everyone's life. Facial pain and headache due to sinus
and nasal origin in the absence of inflammatory sinonasal
pathology is a clinical presentation which has received
attention in both otorhinolaryngology and neurology. Differ-
ent types of intranasal anatomical variations with mucosal
contact points can lead to RCPH. The characteristic headache
may be different in each type of intranasal anatomical
variation. Many clinicians are not well versed with these
types of clinical condition with headache. Intranasal mucosal
contact headache was added as a secondary headache
disorder in the ICHD.11 Most relevant etiology concerned for
otolaryngologists includes anatomical variations of nose
causing secondary headache, which includes septal deviation,
septal spur, and concha bullosa.12 Wolf and Tosum et al.
documented that nasal septal deviation and spur are causing
referred headache in the absence of inflammation.2 There are
different types of septal deviations including cartilaginous
deviation, bony deviation, bony spur, and high septal devia-
tion. The significant RCPH is seen in septal spur (Fig. 1). Concha
 apollo medicine 13 (2016) 169–173 171
[(Fig._1)TD$IG] [(Fig._2)TD$IG]

Fig. 2 – Endoscopic picture showing concha bullosa of

middle turbinate.

needed. Hypertrophied bulla ethmoidalis pushing the middle

turbinate leading to contact between nasal septum and middle
Fig. 1 – Endoscopic picture showing septal spur. turbinate causing contact point headache. In RCPH, no
features of sinusitis like purulent nasal discharge, postnasal
drip, and foul smelling are seen.
bullosa is hypertrophied pneumatized middle turbinate and
rarely seen in superior and inferior turbinates. The compres-
sion of middle turbinate because of congestion of nasal 4. Management
mucosa or concha bullosa may cause periorbital or ocular pain
through anterior ethmoidal nerve, a branch of ophthalmic Headaches are the most frequent causes for patients to seek
division of fifth cranial nerve.2 The superior turbinate is often medical attention and one of the largest factors for disability in
forgotten turbinate during assessing the nasal pathology. the community. Early management of headache helps a
Superior turbinate is innervated by maxillary and ophthalmic patient to protect from disability. Multidisciplinary approach is
branches of trigeminal nerve. The facial area supplied by V1 always a need for diagnosis and treatment of headache.
and V2 affected with referred pain due to concha bullosa of Headache without evidence of inflammation in nose and
superior turbinate. RCPH is a referred pain which arises owing [(Fig._3)TD$IG]
to intranasal mucosal contact points, where a patient presents
with facial pain and headache. The intranasal mucosal points
which are seen in case of septal deviation, septal spur, concha
bullosa of middle turbinate (Fig. 2), large ethmoidal bullosa and
nasal septal bullosa (Fig. 3). If no other findings of inflamma-
tion for headache are seen, intranasal mucosal contact points
should be given due importance. RCPH is frequently seen in
septal deviations/spur followed by concha bullosa of middle
turbinates in many cases. Hypertrophied superior turbinate is
rarely seen and is often mistaken with a posterior ethmoidal
cell. The contact point between upper septum and medial
lamella of hypertrophied superior turbinate leads to headache.
The contact point headache due to hypertrophied pneuma-
tised superior turbinate usually causes pain over forehead,
medial, and lateral canthus. Sometimes medialized middle
turbinate causes mucosal contact with nasal septum. Creating
a space between middle turbinate and septum is needed for
reversing this situation. This is done by trimming the parts of
middle turbinate. Bulla ethmoidalis is the large anterior
ethmoidal air cells and when it is larger than normal; its
medial surface may push the middle turbinate and may cause
a contact with nasal septum. To reverse this situation, anterior Fig. 3 – CT scan of paranasal sinus showing nasal septal
ethmoidectomy and lateralization of middle turbinate are bullosa.
172 apollo medicine 13 (2016) 169–173
paranasal sinuses is usually examined by neurophyscians,
ophthalmologist, otolaryngologists, dentist, and internist to
exclude other causes of headache such as neuralgia, temporal
arteritis, and vascular headache.13 Evaluation of intranasal
contact points should be thoroughly done by otolaryngolo-
gists. The combination of diagnostic nasal endoscopy and CT
scan provides maximum information for the diagnosis of
RCPH.14 Diagnostic nasal endoscopy in conjunction with CT
scan has proven to be ideal combination for diagnosis of
sinonasal pathology. Anatomical variations such as septal
deviation, septal spurs, concha bullosa (Fig. 4), hypertrophied
inferior turbinate, medialized middle turbinate, uncinate
bulla, medially or laterally bent uncinate process, paradoxi-
cally middle turbinate, and large ethmoidal bulla are best
assessed by CT scan and diagnostic nasal endoscopy which are
often cause for contact headache. However, there exist
limitations in diagnosis, as characteristic headache should
be relieved after application of local anesthetics, which is
usually not done in all cases of headaches. In one study of
30 patients with applications of local anesthetic agents, 43%
showed complete recovery, 47% showed slight improvement,
and 10% showed no improvement.2 This is why RCPH are
properly diagnosed by endoscopic examination and CT scan to
rule out differential diagnosis. Different anatomical variations
of nose causing contact point headaches are given in Table 1.
After identification of contact points, RCPH can be treated with
surgical management.13 After evolution of endoscopic sinus
surgery, many authors described different techniques such as
partial turbinectomy and turbinoplasty aiming to decrease
contact point headache and minimize postoperative syne-
chia.15 The limited endoscopic sinus surgery is a useful
surgical technique which helps to remove the contact points
(Table 2). Patients with deviated nasal septum (DNS) or septal
spur need septoplasty or spurectomy, which causes removal of
mucosal contact points. In case of concha bullosa, concho-
plasty is done by resecting the lateral wall of superior or
middle turbinate. In case of large bulla ethmoidalis, anterior
ethmoidectomy is usually a best option to remove the contact
[(Fig._4)TD$IG]
Fig. 4 – CT scan of paranasal sinus showing bilateral concha
bullosa showing contact points.
Table 2 – Mini functional endoscopic sinus surgery
procedures applied to patients with RCPH.
Serial no. Surgical procedure
1 Septoplasty
2 Septal spur resection (spurectomy)
3 Lateral resection of concha bullosa
4 Subtotal resection of concha
bullosa
5 Segmental resection of concha
bullosa
6 Submucosal resection of
hypertrophied inferior turbinate
7 Excision of overpneumatised bulla
(anterior ethmoidectomy)
points. For inferior turbinate hypertrophy, turbinoplasty or
conservative partial turbinectomy are done to release the
nasal obstruction and helping to remove the intranasal
mucosal contact points. Few authors described treatment of
contact point headaches using transaction of fifth cranial
nerve or injection of Gasserian ganglion by alcohol or
novocaine.3 Before the era of endoscopic sinus surgery,
complete removal of middle turbinate was done to manage
concha bullosa. After evolution of endoscopic sinus surgery,
techniques such as partial turbinectomy and turbinoplasty are
practiced aiming to relieve the contact point headaches.16
Septal spur has a significant relation with headache in case
RCPH. Other than septal spur and hypertrophied middle
turbinate, contact point headache may also cause by the
contact between the septum and superior turbinate or medial
wall of the ethmoidal sinus.13 Nose has a diverse anatomical
variation. Relation between these anatomical variations and
contact point headache was confirmed in septal spur, septal
deviations, concha bullosa, and large ethmoidal bulla. So
above lesions should not be ignored from mind during
evaluation of headache and their respective treatment helps
to relief the symptoms. Some anatomical variations of nose,
which cause RCPH, are given below with its treatment.
4.1. DNS
DNS is the most common anatomical variation of nose.17 It has
been reported that DNS and septal spur may cause referred
headache and facial pain in absence of inflammation.2 DNS
along with variation of middle turbinate is a major contributor
for contact point headache.2 DNS along with hypertrophic
rhinitis is also a major concern for nasal obstruction, leading to
headache. Patient will get maximum benefit from septoplasty
surgery.
4.2. Concha bullosa
Concha bullosa is the hypertrophied pneumatized middle
turbinate. Concha bullosa occupies the space between the
lateral wall of nose and nasal septum, cause large areas of
extensive mucosal contact. Intranasal mucosal contact
between enlarged middle turbinate or superior turbinate
and nasal septum may lead to stimulation of sensory
component of trigeminal nerve, causing RCPH. Concha
bullosa causes impairment of ventilation of sinuses if it
 apollo medicine 13 (2016) 169–173
blocks the osteomeatal complex area leading to vaccum
headache and often predisposes sinusitis. Concha bullosa of
middle turbinate results in periorbital or ocular pain through
anterior ethmoidal nerve, which is a branch of ophthalmic
division of trigeminal nerve.2
4.3. Prominent ethmoid bulla
This is the largest, anterior most, and consistent ethmoid air
cells. The ethmoid bulla can be extensively pneumatized and
hypertrophied causing contact to the middle turbinate. This is
treated surgically with the help of endoscope. The endoscopic
conchoplasty can be done for removing contact point between
two apposing nasal mucosa.
4.4. Agger nasi cells
These are the most anterior extramural ethmoid air cells, seen
anterior superior to the attachment of middle turbinate at the
lateral wall of nose. Hyperpneumatised agger nasi cells may
cause contact to nasal septal mucosa, followed by contact
headache. This is treated surgically by an endoscopic approach.
5. Conclusion
Headache due to contact of nasal mucosa is often considered
as an exclusion of diagnosis. RCPH should be included in
the list of differential diagnosis of headache, and it should be
properly investigated so that the management will be effective
and appropriate. The outcome of this study highlights that
diagnostic nasal study and CT scan are important tools in the
diagnosis of anatomical variations of nose causing contact
point headache. Anatomical variations such as DNS, nasal
spur, concha bullosa, hypertrophied inferior turbinate, med-
ialized middle turbinate, and septal bullosa are important
causes for a headache. Nose has a diverse anatomical
variation. DNS and/or septal spur are common anatomical
variations of the nose causing contact point headache
followed by concha bullosa and enlarged bulla ethmoidalis.
Relation of anatomical variations with headache should not be
ignored during decision making for headache management.
Conflicts of interest
The authors have none to declare.
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