Study on Headache in ENT Practice

Headache is perhaps one of the commonest symptoms in all level of medical practice. Though most of the time it is very benevolent in nature. Yet, it may be the presenting symptom of a serious or/and life threatening disorder like meningitis, subarachnoid haemorrhage, stroke or brain tumor. It is this dual significance the one benign, the other potentially malignant that keeps the physician on the alert. This is a random prospective study of 120 cases of headache truly reflecting the sufferings of the victims of headache approaching the ENT specialists for the purpose to determine the exact cause of headache and get a satisfactory treatment.


Introduction:
Headache is defined as Pain or any unpleasant sensation in the region of cranial vault above the orbitomeatal line. It is now classified worldwide according to the International Classification of Headache disorders introduced by International Headache Society (IHS) and accepted by WHO into two principal types-Primary headache and Secondary headache. Primary headache is the one where research scientists have failed to reach to any specofic cause. Secondary headache is attributed to innumerable reasons and in fact can be caused by any physical disorder or discomfort. Primary headaches are Migraine, Tension-type headache, Cluster headache and other Trigeminal Autonomic Cephalalgias (TAC) which includes Paroxysmal hemicrania and Short-lasting Unilateral Neuralgiform headache attacks with Conjunctival Injection and Tearing (SUNCT) and other primary headaches of miscellaneous origin. 1 It is hard to find out a human being who had never experienced headache in life time. But consultation with the physician is done very seldom. Therefore true incidence of headache remains unknown. In general primary headache disorders constitute nearly 98% of all headaches; with tension-type headache (TTH) and migraine being the most prevalent. 2 TTH affects 60-80% of the population while migraine has a prevalence of 11-15%. 2,3,4 Cluster headache is not so common ; but often misdiagnosed and mismanaged. 5,6,7 Though many patients come to the ENT specialists with a headache claiming to have "sinus trouble", in reality a minority of these individuals found headaches that are solely nasal or sinus in origin. 2,8,9,10 It is also rarely caused by other secondary reasons though important to be recognized for timely intervention.
Obviously very different possibilities are raised when a person presents for the 1st time in his life with a severe headache & another person who has had recurrent headache over a period of time. The scope of uncovering the cause in the 1st instance is much greater than the later. There is usually no difficulty in diagnosing some serious and life threatening diseases presenting with headache like meningitis, subarachnoid haemorrhage, glaucoma, acute purulent sinusitis by the respective specialists. It is when headache is chronic, recurrent & unattended by other important signs of disease that the physician faces one of his most difficult medical problem.
Diagnosis of the underlying cause of headache depends almost entirely upon an accurate history taking. 2 History must reveal the true characteristics of headache e.g. onset (sudden or gradual), length of suffering (recent or old), periodicity(episodic or chronic), duration of each episode, frequency, site of pain, side of pain, characteristics of pain, progression of pain, whether preceded by aura and premonitory symptoms or not; associated symptoms e.g. presence or absence of nausea, vomiting, photophobia, phonophobia, pallor, flushing of face, watering from the eyes, red eyes, pressure sensation over the head, heavy sensation over the head, nasal blockage, running nose, paraesthesia of limbs, weakness of limbs, dizziness, dyserthria, disability etc; Triggering factors e.g. Stress, nasal blockage, nasal cold, any particular food, insomnia, excessive sleep, weather change etc ; Relieving factors e.g. a good sleep, vomiting, medication etc; complaints in relation to ENT Head-neck region(nasal obstruction, nasal cold, earache, pain on opening the mouth, toothache, dysphagia etc.), complaints in relation to eyes (blurring of vision, pain in the eyes etc.) CNS complaints (high fever with rigor, disorientation, confusion, convulsion etc.), any H/O head injury, any H/O vascular diseases, metabolic disorder or OTC drug taken for headache.
A complete physical and neurological examination should be done though there are seldom any useful physical sign. 11 In the majority of cases investigations are not required to reach a diagnosis. 12,13,14 The approach to reach a diagnosis began with a search for the possibility of a secondary headache. If secondary headaches are excluded either on clinical grounds or through investigation.; the next step was to classify the headaches based on the characteristics of headache and duration of attacks. Attacks lasting less than 4 hours per day diagnosed as Trigeminal Autonomic Cephalalgia (TAC). TACs included cluster headache and chronic paroxysmal hemicrania. Duration of attack e"4 hours per day encompassed the differential diagnosis of migraine, tension-type headache or chronic daily headache (CDH) associated with the overuse or abuse of many common OTC drugs.
Diagnosis of sinus headache was done by the history of headache started with the attack of nasal cold associated with nasal blockage, purulent rhinorrhoea, repeated attempt to clear the throat, foul smell from the nose or oral cavity, heavy feelings of head worsened by bending forward and on examination thick purulent discharge in nasal cavity, DNS or Nasal Polyp, hypertrophied inferior turbinate, tenderness over the affected sinus and thick postnasal drip in the throat. This type of headache is never disabling or associated with nausea or sensitivity to light or sound. And obviously will subside with a course of antibiotic. A simple X-ray paranasal sinus was done to confirm the presence sinus infection. 15,16,17 Tension type of headache or TTH was diagnosed by its gradual development, mild to moderate in intensity; starting from the nuchal & occipital region of head affecting the whole head (sometimes described as a tight band squeezing the head), dull ache, bilateral, more or less persisting in nature and lasting almost unremittingly for weeks or months; associated with nausea, photophobia or phonophobia or vomiting once or twice when the pain is very severe. But it was not incapacitating and not relieved completely by sleep. 11,18,19 Cluster headache also called paroxysmal nocturnal cephalgia was diagnosed from its very characteristic pattern. It comes in clusters; each time lasting for few days to weeks followed by a complete freedom from attack for months to years. During each cluster headache is felt at least once a day at about the same hour lasting in the same intensity for 20 minutes to 1-2 hours. Pain is severe to excruciating in intensity; always unilateral; felt behind the supra orbital ridge or eyeball; stabbing, piercing or burning in nature often unbearable & makes the patient restless. The Eyes may become red & swollen with increased lacrimation on the affected side. The nose may get blocked & runny on the affected side; not preceded by aura or premonitory symptoms ; not associated with nausea, vomiting, photophobia or phonophobia. It often starts after falling asleep and makes the patient awake. Sometimes starts in the early morning in the same time of the day. The pain is triggered by alcohol & cigarette smoking. 20,21,22 Chronic parxysmal hemicranias is a type of headache where pain & vasomotor symptoms are similar to cluster headache. But the attacks are shorter; lasting for 10-30 minutes & occurs more frequently 10-20 times a day for several years. It mainly affects the young women & may be triggered by neck movement or local pressure, responds absolutely to indomethacin. 1,23,24 Aims and Objectives: (i) To find out the common age and gender distribution of headache.
(ii) To find out the triggering and relieving factors of headache.
(iii) To categorize different types of headache cases coming to an ENT specialist.
(v) To find out the frequency of sinus disease causing headache.

Methods:
Total 120 patients were selected randomly attending the ENT outpatient department A ready questionnaire sheet was supplied to every patient which was ticked out after a thorough conversation over a period of 15-20 minutes with the patient. For every case the characteristics of headache, symptoms associated with it, triggering factors (Table-II), relieving factors (Table -III), complaints related to ENT Head-Neck region or Eye or CNS were noted very carefully. Any previous history of Head injury, past or present medical disorder were also documented in the ready sheet. Inquiry was made as to the regular use of drugs particularly OTC analgesics, oral contraceptives and herbal medicines. Every patient went through complete ENT Head-Neck and neurological examinations. Since the main purpose of majority of the patients to see an ENT specialist was the fear of having sinus disease responsible for headache all the patients were advised to do an X-ray PNS occipitomental view either to exclude the sinus disease or to prove sinus disease when history was suggestive.

Results:
For this study a total of 120 cases of headache were selected randomly.

Discussions:
The purpose of this study was to find out the principal age and sexual criteria of headache cases reached to an ENT specialist. The age range scrutinized was 11-60 years; dividing into 5 (five) groups. The prevalence of headache increased with age reaching maximum in age group 21-30 years (39.16%) and declined thereafter. An epidemiological study carried out by M. Sillanpaa, M. Aromaa & H. Aro with the child resident of a fininsh city collecting data in four stages shows rise of prevalence of headache from preschool level of 27.1% to 63.6% at age 14 years to 66.2% at age 22years. 24 The occurrence of headache is seen to be very few after the age of 40 which is supported by different studies in different regions of the world with different types of primary headache. 25,26,27 Females are seen sufferer of headache more than males in every age group as well as in general proved by other literature studied with the epidemiology of headache cases. 28,29 In this study male female ratio was 1: 2.52.
Medication 45(37.5%) was found highest in relieving headache followed by a good sleep 30(25%) and vomiting 9(7.5%). Medication was also noted as the main relieving factor of headache in the review of literature 27,31,32 . Still a large group of patient was not very happy with the way they were using medication to get relief from headache particularly when the attacks were happening repeatedly. This induced them to seek the help of an ENT specialist.
Though sinusitis is a pretty common ailment afflicting millions of individuals worldwide only 2(1.67%) cases of headache were seen truly diagnostic of sinus headache following the criteria of IHS. In this study the headache patients approaching to the ENT specialists diagnosed as having Migraine is seen surprisingly and unexpectedly quite high in comparison to the several surveys on headache carried out at home and abroad. First reason behind this is non-response to different type of abortive and preventive therapy practiced by self and by different medical practitioners and persistence of repeated attack of disabling headache.
Surprisingly a good number of cases 56(46.67%) revealed a co existing significant ENT problem along with a primary headache disorder explaining the reason why headache is thought to be sinus in origin. Since in medical practice it's been seen that the presence of an ENT diseases can trigger or increase the frequency of primary headache disorder treatment of the ENT problem was also considered sincerely to help fast recovery from the primary headache disorder.

Conclusion:
Headache is one of the most common and difficult clinical problem in medicine. It has been estimated that every one in three person suffers from severe headache at some stages of life. More than 1300 tons of aspirin are consumed annually worldwide for the relief of headache. Most patients are in fact suffering from either vascular or muscular headache though diagnosed by a medical person or by self as having "sinus headache. Thus vast majority of cases can be treated effectively by a primary care physician or generalist with a correct clinical diagnosis without any special investigation. However any suspicious secondary etiology should always be excluded first before being diagnosed as a case of primary headache. Till then a group approach consisting of ENT specialist, neurologist, ophthalmologist, psychiatrist & psychologist can bring much benefit to remove or cut short the sufferings of these victims.