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Local Doctor Successfully Treats Recurrent and Chronic Migraine-Type Headaches


Bone Spurs in the Nose can Cause Migraine-Type Headaches


Local Doctor Successfully Treats Recurrent and Chronic Migraine-Type Headaches
HOUSTON, Texas June 27, 2001


Local facial plastic surgeon and otolaryngologist, Kevin R. Smith, M.D., F.A.C.S., of Smith Cosmetic Surgery Center has successfully treated numerous patients suffering with recurrent and chronic migraine headaches with a simple 30-minute procedure. On average, Dr. Smith cures 15 to 20 chronic headache sufferers annually by repairing the patient’s deviated septum with a procedure called septoplasty.


“Over the years, I have found that one simple reason for recurrent or chronic headaches and migraines is a deviated nasal septum,” said Dr. Smith. “Throughout life, the nose can be traumatized resulting in a septal bone spur. When the nasal tissues swell and touch the bone spur, it often refers pain to the forehead and temples. This cause of chronic pain is often overlooked.”


A large number of headache sufferers would benefit from a nasal/septal exam and the septoplasty procedure. Repairing the deviated septum is a relatively simple procedure, which takes about 30 minutes. During this surgical procedure, the bone spur is removed and the septum is straightened so the contact point that creates the headache is eliminated. “Many of my patients experience dramatic results after the procedure,” said Dr. Smith.


Jana Johnson, a medical student at the University of Texas- Houston Medical School, suffered from migraines since she was in second grade. “Over the years, I had been to a series of specialists and tried countless treatments to no avail. I had determined that I would just have to deal with the pain for the rest of my life,” said Johnson. “Dr. Smith lectured in one of my classes and explained that a nasal bone spur could cause severe headaches and migraines. I immediately made an appointment with him and discovered that I was a candidate for the procedure. It has been ten months since having the procedure, and I have not had a single migraine. I am a whole new person.”


Other patients have also experienced dramatic relief after having the septoplasty procedure. Donna Riefkohl suffered from migraines for thirty years. “I had to quit my teaching job because I was so debilitated. There were days at a time when I could not even get out of bed and often vomited because the pain was so bad,” said Riefkohl. “After having the procedure, I have not had one headache. I feel like I have a whole new life.”


Another patient, John Porter, experienced such intense pain that his right eye would close and the veins on the side of his head would swell. He was virtually homebound because almost every scent would trigger a migraine. “I was completely debilitated,” said Porter. “It was so intense that I was a slave to pain killers. Demerol, morphine, valium- none of it helped.” Dr. Smith examined him and found a large septal spur. After the septoplasty, Porter is able to function more normally without the excruciating pain. Now, the pain is manageable without taking medication.


Dr. Smith’s education includes specialty training in both facial plastic surgery and otolaryngology/head and neck surgery. “This has afforded me the knowledge to deal not only with the changing of the external look of the nose, but also ensuring that the internal nose functions optimally,” said Dr. Smith. He completed his pre-med requirements at the University of Michigan. His medical degree and residency were achieved at The University of Texas Medical School - Houston where he currently holds an assistant clinical faculty appointment in the Department of Otolaryngology. He performed a fellowship in facial plastic surgery at McCollough Plastic Surgery Clinic in Birmingham, Alabama.

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Migraine headaches are a very debilitating problem that affects millions of Americans annually. There are an estimated 23.6 million migraine sufferers in the United States. There are another 11.3 million who suffer moderate to severe headaches, and another 4.5 million who have at least one or more migraine headaches per month. These are staggering figures. Approximately 18% of all adult women are afflicted with the problem. Women also suffer from migraines at a rate of 3:1 ratio over men. This equals approximately 18 million women or 1 in 6 American women suffering from headaches. In addition, 90% of all migraine sufferers have a positive family history of migraine.


There are numerous types of headaches that can be classified into primary and secondary. Primary, or benign headache disorders, include:
(a) Migraine with or without an aura.
(b) Tension type headaches, which are episodic or chronic.
(c) Cluster headaches.
(d) Other benign headaches.
(e) Rebound headaches.
Post traumatic headaches are within the category of primary headaches. These include rhinogenic causes of headaches such as deviated septum and bone spurs within the nose that can cause severe headaches.
Secondary headaches are headaches with symptoms of organic disease, such as hypoglycemia, diabetes, and other chronic health conditions.


The implications of migraine headaches include a myriad of problems. Migraine sufferers are usually thought to have a "short fuse". They can be very unpleasant because of their debilitating headaches. They tend to isolate themselves from others while suffering these headaches. Other problems include missed work or school, and limited involvement in social activities. They are often labeled as "sickly" because of multiple visits to the emergency room or the doctor's office. They can be labeled as having "poor attitudes" or drug dependent. All of these are compounded by marital and family discord. The relationships within families are strained when there is one member who is isolated from the family because of debilitating migraine headaches.


Migraine headaches can affect productivity in the workplace across the board. It is stated that 89% of migraine sufferers worked at about half their usual level of productivity for an average of 6 days per month. Fifty-six percent of migraine sufferers miss an average of 2.2 work days per month. These figures equate to monthly lost labor costs of $570 per working male and up to $300 per working female.


The impact of migraine headaches on health care costs is staggering as well. Migraine sufferers frequently visit the emergency rooms and doctors' offices and account for a significant number of pain medication prescriptions each year. For migraines that are refractory to treatment, other nontraditional expenditures can include visit to the chiropractor, trials with acupuncture, meditation, and other relaxation techniques. These sufferers also consume a significant number of herbal supplements and over-the-counter medications searching for headache relief. Overall, the average cost incurred by a patient over a period of 18 months has been estimated as approximately $2,500 or more. Migraine sufferers use medical resources in disproportionate numbers compared to non-migraine patients. They account for 70% more medical claims and 73% more physician visits. They account for nearly 300% more emergency department visits and 70% more hospital visits. In essence, migraine sufferers' activities revolve intimately around hospitals, doctor visits, and other medical resources. Healthcare becomes an integral part of their daily lives.


The first encounter with healthcare for a migraine headache sufferer usually starts with the over-the-counter preparations. Mild headaches can sometimes be relieved with these medications. However, when a persistent severe migraine headache arises, it usually alerts the patient to seek treatment from their primary care physician. The primary care physician is obligated to rule out organic causes or medical causes of the headache after obtaining a thorough history and physical examination. Common non-prescription medications include non-steroidal anti-inflammatory medications such as Motrin, aspirin and acetaminophen. Chronic use of these medications can lead to the development of gastritis and possibly ulcers of the gastrointestinal tract. Once a trial of these medications has failed, stronger medications such as Tylenol with Codeine, Vicodin, Fioricet, or even morphine and methadone are prescribed. Of course, these medications are potentially addictive and can lead to abuse. Some signs of abuse might be persistent calls for prescription refills, shorter intervals between prescription requests, creative excuses for needing prescription refills and doctor-shopping behavior whereby a patient will go to multiple doctors in order to obtain these medications.


From the primary care's office, a resistant headache can be referred to specialists. This typically involves a neurologist who will examine the patient for possible brain abnormalities, such as tumors and aneurysms. The neurological work-up often includes obtaining an MRI or a CAT scan of the brain and, if negative, these patients are placed on migraine headache medications such as Imitrex and ergotamines. Should these medications prove ineffective, the patient can then be referred to headache and/or pain management clinics that specialize in chronic pain. Here headache sufferers can be subjected to injections of long-acting local anesthetic agents into the vertebrae and muscles. Botulinum toxin injections into the muscles of the neck and forehead have been proven to relieve some migraine headaches. Other common non-surgical therapies include acupuncture, biofeedback technique, hypnosis, and stress management strategies.

For those who suffer from nasal airway obstruction, allergies or sinus problems, referral to an otolaryngologist is indicated. It is this referral that I will be expounding upon, because I feel that the nose potentially plays more of a role in headaches than we are led to believe. Bone spurs within the nose can contribute to migraine headaches and the development of nasal airway obstruction and sinus problems. However, although it is taught in residency training programs and medical seminars, not much emphasis is placed on the potential importance of the nasal structure and the potential to cause headaches.
When headaches are refractory to non-surgical therapies and medications, patients are desperate to find a cure. During this desperate time it is common to be told that the headache is stress related or "in your mind." This response contributes to added stress and desperation and can lead to another debilitating medical entity, depression. The depression then leads to visits to the psychiatrist or psychologist and the use of antidepressant medications. At this point the sufferer is left with compounded problems, no relief and additional medication with potential side effects.


The septum is a midline partition inside the nose comprised of cartilage anteriorly and bone posteriorly. It divides the right nostril from the left nostril and aids in supporting the nose. Within the nose there are three pairs of turbinates along the lateral nasal wall. These turbinates are vascular erectile structures that can become engorged and swell in response to allergies, flu, sinus problems, etc. There are several nerves which innervate the internal nose, namely the anterior ethmoid nerve the branches of the nerve of the pterygoid canal and nasal palatine nerve which innervate the septum. Along the lateral nasal wall the sphenopalatine ganglion and the anterior ethmoid nerve innervate the turbinates and the lateral nasal wall. Trauma to the nose at any time can contribute to the development of a septal spur. A septal spur is a sharp bony projection that can impinge on the lateral nasal wall and the turbinates, irritating nerves and referring pain to the head.


Simple living can be hazardous. From the time we are born, trauma can ensue while traveling through the birth canal. During labor the nose is pressed against the mother's sacrum for a period of minutes to hours. Because the nasal bones are soft, the nose is not broken. However, the growth centers can be altered such that as we age, the external nose and the internal nasal septum can grow out of line, thus developing a spur that can impinge onto the lateral nasal wall. As we grow older, childhood accidents are common causes. With the advent of roller blades, scooters, and bicycles, it is not uncommon that children will fall, hit their noses on their bicycles, or be hit with a ball or a baseball bat while playing sports. As adults, more common etiologies will include motorcycle or motor vehicle accidents where the nose can hit against the dashboard or steering wheel quite easily. The nose is the most traumatized part of the face because it projects away from the face, thus it is the first structure to be traumatized in an accident. Again, the nose does not have to be broken, but the simple jarring effect can place stress on the septum. The thin bone within the nose can fracture and develop bone spurs. Just as bone spurs in the feet and vertebrae can cause pain, bone spurs in the nose can also cause pain to the head which result in chronic migraine-type headaches in some individuals.


Triggers of headaches involving septal spurs include anything that cause the intranasal cavity to swell. Hormones, environmental changes, health conditions, and allergies to food and beverages can all lead to intranasal swelling of the turbinates against a bone spur, triggering a headache. Women who suffer headaches during their menstrual cycle do so because of hormonal imbalances which lead to retention of water that causes the turbinates to become engorged and swell against a septal spur or deviation. This same mechanism can explain why women during pregnancy can get migraine headaches. Most common etiologies are those of allergies, colds, and flu that commonly lead to nasal congestion due to turbinate engorgement. This pressure against the septum can cause headaches. The location of these headaches is typically around the forehead, temples, top of the head, or can be located around the eyes, nose, and cheek regions.


An otolaryngologist should be a key contributor in evaluating headache sufferers for possible septal spurs. A nasal exam is rarely performed by a primary care or neurologist An otolaryngologist is trained to examine the nose with the application of a topical decongestant spray in order to obtain a clear view of the entire nasal airway. It is with this examination that septal spurs can most commonly be diagnosed. When a septal spur is not obvious on exam, a CAT scan of the sinuses can demonstrate a septal spur and other nasal and sinus conditions that cause headaches. These include polyps, mucoceles, and sinusitis. A CAT scan of the sinuses can be of key importance in demonstrating other subtle contact points within the nose that can cause headaches.


Intranasal surgery can potentially eliminate headaches. When a septal spur has been diagnosed, the surgical procedure to remove it is called a septoplasty. With this procedure, a small incision is made inside the nostril, and the mucous membrane is elevated off of the septum. The septal spur is removed to relieve the pressure point. The turbinates can be pushed aside to eliminate any other contact points with the septum. If congestion is a major problem, the turbinates can be trimmed to allow for improved breathing. Once the septum is straightened, the mucosal flaps are reapproximated with a dissolvable suture. There is no need for intranasal packing unless there is excessive bleeding during the operative procedure. In the past, patients who under went septoplasty had their noses packed tightly with gauze and during the first post operative visit. When the gauze was removed these patients described excruciating pain. Surgical techniques have progressed over the years, and now if packing is required, it usually consists of a soft sponge that applies gentle pressure to the nose in order to minimize bleeding. In my practice the goal is to not pack the nose if possible. This makes the post-operative recovery period much more pleasant.

One benefit of my training in facial plastic surgery is that I can offer patients to have a rhinoplasty performed in conjunction with the septoplasty. This can easily be performed while addressing the septal spur. The rhinoplasty includes an incision made inside the nose to gain access to the cartilage and bone. The tip of the nose can be made smaller, a dorsal hump can be reduced, the nasal bones can be narrowed, and the nostrils can be narrowed. Of course, a rhinoplasty is considered cosmetic, and is not covered by insurance plans.


The surgery can be performed under intravenous sedation with local anesthesia or general anesthesia. Post-operatively there is minimal pain. Patients take their pain medication one to two days after surgery. There is also very little swelling. Cold compresses applied to the nose minimize both the pain and swelling and reduce the need for narcotic medication. A patient can be back on their feet and working within 3 days if only the septum is addressed, but if the turbinates are trimmed, recovery can take 5 to 7 days.


Migraine-type headaches are a very debilitating disorder and have multiple etiologies. However, the presence of a septal bone spur can account for a large number of these migraine-type headaches. A review of my practice in the year 2000 consisted of 25 patients, ages 17 to 74 years. The cure rate was 40%. Fifty two percent had improvement of their headaches (fewer or less severe) and 8% had no change in their headaches. I recommend all headache and migraine sufferers to visit an otolaryngologist who can thoroughly examine the intranasal cavity and rule out the presence of a bone spur. Please keep in mind, however, that there are some otolaryngologists that do not recognize the potential importance of this deformity. So before you make your appointment, talk to the doctor to see if they believe a septal spur can cause headaches. A septoplasty is a very simple procedure that can dramatically change someone's life.


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