The Medical Consumer's Advocate
A case of contact point headache?
Q:
For more than a year I've
been suffering from a feeling of dull, achy pressure
under the bridge of my nose. It makes me feel dull,
tired, and stupid, and interferes with my work and family
life. It's not a problem first thing in the morning, but
gets worse during the day, and it's at its worst in the
evening. Alcohol consumption makes it worse. I've tested
negative for allergies. Sudafed helps. Spraying saline
into my nose with a waterpik helps. Lying down helps
after 20 minutes or so. Sometimes after I lie down for a
while, I feel a "pop" in my nose and get a
sudden sense of relief. I can also get these pops by
holding my nose and changing the pressure by blowing or
sucking, though I don't get a feeling of relief when I do
this. I can get these pops only when my nose feels bad.
I've seen a couple of ENT docs who can't find anything
wrong with my nose by exam or CT.
When I came across your mention of "contact
point" headaches, I thought Aha! That's exactly what
it feels like. The ENT doc I'm seeing now agrees that
there is swelling in my nasal passages (by my
description, not by exam) but thinks that this is the
effect, and that the cause is a neurological problem,
chronic headache. (I don't have any discomfort in my
"head," meaning my skull.) He's started me on amitriptyline, 10 mg. It's only been a few days and I
don't notice any particular change, other than
drowsiness. I'll keep it up to see if there is an effect.
If contact point headache is my problem, how should I
approach this with my doc? (Is this a rare condition that
most ENTs wouldn't be familiar with?) How should he make
the diagnosis, and what should the treatment be? I'm an
otherwise healthy man. Thanks so much for reading this
far. I'll be very grateful for any information.
A: Here is how I approach a patient in whom I suspect
contact point pain (also known as Sluder's neuralgia):
I ask the patient to come see me when he is in pain. (In
some cases, I have to squeeze someone into the schedule, but
it is worth it.) I then examine the patient's nose with a
fiberoptic scope. I do this BEFORE spraying a decongestant or
topical anesthetic into the nose. Since I am examining an
unanesthetized nose, needless to say I have to be careful. I
am looking for areas in which two structures are touching
each other. (Typically, I am looking for contact between the
septum and one of the turbinates. The septum is the
cartilaginous/bony partition between the two nasal cavities.
The turbinates are shelves of bone, covered with mucosa,
which jut out from the lateral walls of the nose. The
turbinates warm, humidify and filter the air that we
breathe.)
Next, I place a cotton ball moistened with a decongestant spray (like
Afrin) and an anesthetic (lidocaine) against the contact area. If the patient notes
rapid relief of his pain, AND if reexamination of the nose
with the fiberoptic scope reveals that the "contact
points" are no longer in contact, then this is fairly
convincing evidence that the patient's pain is contact point pain.
The best treatment is surgical, but at times I will
prescribe an anesthetic nose spray. The success of surgery
depends in large part upon (1) the accuracy of the diagnosis,
and (2) the ability of the surgeon to change the nasal
anatomy such that the two areas are no longer in contact.
Share this with your ENT. I hope this helps.