ORLANDO, FL-Researchers recommended that otolaryngologists might empirically treat selected patients with sinus headaches as if these patients actually had migraines, following study results illustrating that the use of triptans brought relief to more than 80% of these individuals.
Our data support the idea that otolaryngologists should consider migraine when we are evaluating sinus headaches, said Elina Kari, MD, a medical house officer in the Department of Otolaryngology at Emory University in Atlanta. She presented her paper at the 111th annual meeting of the Triological Society, held at the Combined Otolaryngology Spring Meeting.
This study demonstrated that the demographics of patients with self-described ‘sinus headaches’ who did not have findings of sinusitis on endoscopy and CT scan closely reflected the demographics of patients afflicted with migraines, Dr. Kari said.
Of the 38 patients who were able to complete the study, 31 achieved a 50% or greater relief in headache symptoms while on triptan drugs. The patients were assigned to take eletriptan 40 mg upon onset of perceived sinus headache pain, and were instructed to repeat the dose within two hours if the headache was not adequately relieved. If eletriptan was ineffective, patients were switched to sumatriptan or rizatriptan. Seven of the 38 patients, in fact, were successfully treated with a trial of these other drugs because of an inadequate response to eletriptan.
Dr. Kari said that one additional patient reported between a 25% and 50% reduction in pain symptoms. Another three patients achieved significant reduction in pain relief by following non-triptan migraine-directed therapy with lifestyle or diet changes. Three patients reported no change in symptoms with eletriptan use.
The vast majority of these patients who completed the trial-82 percent-had a significant improvement in pain relief, she said.
Patients eligible for the trial were those who presented to the practice of the senior author, John M. DelGaudio, MD, at a tertiary care otolaryngology department with primary complaints of facial pain, pressure, or headache localized over the area of the sinuses, and a self- or physician diagnosis of sinus headache.
The participants underwent a directed history, physical examination including rigid nasal endoscopy, a sinus computer-assisted tomography (CT) scan, and completed a headache questionnaire. Those patients completed a headache diary for each headache using a visual analog scale to rate the headache before and after triptan use.
Our data support other studies that have looked at this topic, Dr. Kari said, although she noted differences in methodology in the other studies, including the use of a single agent at a single interval.
Implications for Diagnosis and Treatment
There is a tendency among primary care physicians to classify facial pain as a sinus headache. All these patients had negative sinus computed tomography findings, so we know they didn’t have sinusitis, said Harold C. Pillsbury, MD, Professor and Chair of Otolaryngology-Head and Neck Surgery at the University of North Carolina, Chapel Hill. Dr. Pillsbury, President of the Triological Society, was co-moderator of the session at which Dr. Kari presented her report.
Dr. Kari is absolutely correct in her findings, he said.
In presentation of her prospective trial results, Dr. Kari noted that sinus headache is a common diagnosis given to the patient with facial pressure or pain. However, she added that sinus headache appears to be overdiagnosed and overtreated, and that it is a common chief complaint in otolaryngology and often involves surgical intervention.
Dr. Kari said that the Rhinosinusitis Task Force of the American Academy of Otolaryngology-Head and Neck Surgery includes facial pain or pressure as a major diagnostic symptom of sinusitis when present in conjunction with one of the other major symptoms, such nasal obstruction, nasal discharge, hyposmia or anosmia, or fever in acute rhinosinusitis. Minor factors include headache, halitosis, dental pain, cough, and facial fullness or pressure.
The International Headache Society defines migraine as two attacks fulfilling the following criteria if aura is present:
- A headache that lasts four to 72 hours;
- Headaches that have two or more of the following factors: unilateral, pulsating, moderate-severe intensity, aggravated by or causing avoidance of routine physical activity;
- One of the following occurs during headache: nausea, vomiting, photophobia, or phonophobia; and
- Headache cannot be attributed to another disorder.
Dr. Kari said that their results suggest that an empiric use of triptans in CT-negative patients might lead to relief of pain-indicating that the original diagnosis of sinus headache is incorrect, in fact, and migraine headache is the correct diagnosis.
Structure of the Study
Drs. Kari and DelGaudio enrolled 55 patients in their study, but only two-thirds completed the treatment. There were 37 women and 18 men in the study, reflecting the natural preponderance of migraine among women. The patients’ median age was 39. Patients were instructed to treat every headache.
Patients were followed up within one to three months, at which time they returned the headache diaries logging response to triptan therapy to each headache.
I need to emphasize that we had a highly selected study population, Dr. Kari said. In fact, 73% of the patients enrolled met International Headache Society criteria for migraine. Of those 41 patients, 31 met criteria for migraine but had not been previously diagnosed with migraine.
About 82 percent of the patients in our study had a significant reduction in headache with triptan use, she said. However, she did note significant attrition, as nearly a third of enrolled patients did not follow up. Many of the patients did not follow up because there was a significant resistance to believing a diagnosis of migraine headache. Many people consider migraine headaches only in the setting of a debilitating headache, which many of these patients did not have. Also, these patients have been treated for years by other physicians for presumed sinus headaches, and they were unwilling to believe that all of these previous diagnoses were incorrect, she said.
Dr. Kari noted that their results concerning the effectiveness of triptans for sinus headache were similar to results seen in the use of patients who have been diagnosed with migraine.
Although the results appeared to indicate the use of triptans as a potential diagnostic tool for migraine, she said that minimal data exist in the literature for this purpose.
©2008 The Triological Society