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Original Article

Contact point headache: Diagnosis and management in a

tertiary care center in Northeast India
ABSTRACT
Background and Objectives: Headache in the absence of infection or inflammation and other causes may be related
with some anatomical abnormalities of nose called contact point headache. Our objective was to study endoscopic
and radiological nasal findings of contact point headache and their outcomes after surgery in patients attending
department of otorhinolaryngology, tertiary care teaching hospital/center in Northeast India.
Study Design: A prospective study.
Materials and Methods: A total of fifty patients attending ear, nose, and throat outpatient department and diagnosed
as contact point headache were selected after a detailed history of symptoms through questionnaires, diagnostic
nasal endoscopy, computed tomography scan, and a positive xylocaine-adrenaline test. All the patients underwent
surgery. Pre- and post-operative pain score (visual analog score [VAS]), mean frequency of pain, and mean duration
of each attack were noted for comparison. Data collected were analyzed using appropriate tools.
Results: A total of thirty males and twenty females were included in the study. At the end of 12-month follow-up, pain
score (VAS) reduced from 7.47 with standard deviation (SD) of ± 1.6–0.2 with SD of ± 0.59 postsurgery and the mean
frequency of pain reduced from 9.10 with SD of ± 2.86–0.22 with SD of ± 0.67. Both were statistically significant.
Conclusion: Contact point headache is a common cause of headache in Northeast India and surgery is effective
in a carefully selected cases.

Keywords: Contact point headache, middle turbinate headache, septoplasty

INTRODUCTION the absence of inflammatory sinonasal disease, purulent

discharge, nasal polyps, nasal mass, or hyperplastic mucosa.
Headache is the most common disorder encountered by Many literatures have described it as rhinologic headache,
physicians in clinic in both adult and child. It can be a symptom rhinopathic, sinogenic, middle turbinate headache, nasal spur
of a number of different conditions of the head and neck and headache, four finger headache, sinus headache, contact point
can result from a wide range of causes both benign and serious headache, Sluder’s neuralgia, and anterior ethmoidal neuralgia.
conditions. Usually, headaches associated with facial pain
are treated as “sinus” headache; hence receive inappropriate Upasana Lungun Rai, Puyam Sobita Devi,
treatment. Headaches secondary to sinonasal anatomic Ningombam Jiten Singh, Nicola C. Lyngdoh,
abnormalities need identification of contact points as a cause Th Sudhiranjan, Nirmala Nongthombam
Department of Otorhinolaryngology, Regional Institute of
for the incapacitating problem and surgical procedures are
Medical Sciences, Imphal, Manipur, India
undertaken to relieve these anatomic abnormalities.
Address for correspondence: Puyam Sobita Devi,
Rhinogenic headache is defined as headache or facial pain Associate Professor, Department of ENT, RIMS,
Imphal - 795 004, Manipur, India.
secondary to mucosal contact points in the nasal cavity in E-mail: [email protected]

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How to cite this article: Rai UL, Devi PS, Singh NJ, Lyngdoh NC,
DOI:
Sudhiranjan T, Nongthombam N. Contact point headache: Diagnosis
10.4103/jms.jms_69_16 and management in a tertiary care center in Northeast India. J Med Soc
2018;32:51-6.

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Rai, et al.: Contact point headache

In the year 1988, Stammberger and Wolf gave the cause of Ribbon gauzes soaked in a mixture xylocaine (4%) and
rhinogenic headache as mechanical contact between two adrenaline (1:200,000) solution were placed at contact points
mucosal surfaces, which creates a sensory stimulus resulting intranasally under endoscopic guidance. Those who were
in release of substance P that is responsible for migraine‑like relieved of pain after 5–10 min were pronounced positive
headache symptoms.[1,2] and were selected for surgery. Informed and written consents
were taken from the patients for surgery. A preoperative pain
Diagnosis of contact point headaches is confirmed by intensity score (VAS), average number of headache attacks
nasal endoscopic examination and noncontrast computed per month, and the mean duration of each attack were
tomography (CT) of nose and paranasal sinuses in patients calculated for future evaluation and outcome comparison.
complaining of headaches not relieved by medications and
whose usual findings are septal deviation contacting nasal The patients underwent endoscopic nasosinus surgery,
wall, middle turbinate, inferior turbinate, concha bullosa, wherein the contact points and ostiomeatal complex
pneumatized superior turbinate, and any other visualized obstructions were relieved under general anesthesia. The
mucosal contact point. Relieving the contact point by surgical surgical procedure was according to each patient’s specific
methods is considered the ideal treatment method.[3] anatomic variations, though septoplasty was the standard
procedure followed to correct any deviation or thickening
This study was conducted to evaluate the surgical outcome of the septum in the area of presumed triggering contact
of patients diagnosed as having contact point headaches. point. Postoperatively, nasal packing was done with merocel,
which was removed after 48 h. Perioperative antibiotics
MATERIALS AND METHODS were given 2 days before surgery and continued until the
7th postoperative day. Endoscopic cleansing of the nasal
The study was done from October 2013 to September 2015 cavity was done on the 3rd and 14th postoperative days.
in the department of otorhinolaryngology of tertiary care Regular saline nasal douching was given for 1 month. For
teaching hospital/center in Northeast India after taking patients with associated allergic rhinitis, fluticasone nasal
approval from the Ethical Committee of the Institute. spray once daily was advised to continue for 12 months.
Nasal endoscopy findings and pain intensity score (VAS),
Patients presenting with headache in the outpatient average number of headache attacks per month, and the
department (OPD) and diagnosed as nasal mucosal contact mean duration of each attack of the patients were noted on
point headache according to The International Classification follow‑up at the end of 3 months, 6 months, 9 months,
of Headache Disorders (ICHD‑2)[4] criterion were enrolled for and 12 months.
the study after taking consent. Inclusion criteria included
headache >2 months, pain or pressure feeling over the nasal Data collected were processed in the IBM‑SPSS‑version
bridge, glabella, or forehead as the main complaint without 20.0 program (Chicago, Illinois, US). Both descriptive and
any apparent sinus disease clinically or radiologically and analytical statistics were calculated. Friedman test[5] was
failure of standard medical therapy for headache, with normal calculated to find the significance of the finding. P < 0.05 was
ophthalmologic, neurologic, dental, and systemic findings. taken as significant for this study.
Nasal contact point was demonstrated either endoscopically
or radiologically or both and relief of headache with local RESULTS
anesthesia packing. All were above 15 years and below
50 years. Patients presenting with primary headaches or A total of thirty males and twenty females within the age
having other known causes of headaches, acute/chronic group of 15–50 years were included in the study. Maximum
rhinosinusitis, patients already undergone sinonasal surgery, cases were seen in the age group of 15–35 years. Majority of
those not willing or fit for surgery, and those lost in follow‑up the headache was located in the frontal region (82%) followed
were excluded from the study. by periorbital (34%), nasal (32%), malar (4%), entire head (4%),
and occipital (2%). Almost all patients had multiple locations
A total of fifty patients were included in the study. A detailed of the headache. Duration of headache ranged from 1 year
history of symptoms through questionnaires, diagnostic to more than 10 years with the mean duration of 6.41 years
nasal endoscopy to identify mucosal contact points, CT scan and standard deviation (SD) of ± 3.25. Ten patients
of the nose and paranasal for evaluation of contact points, had 2–4 attacks/month, 26 patients reported of having
and pain evaluation with visual analog score (VAS) were 5–8 attacks/month, while more than eight attacks/month, and
taken. Xylocaine plus adrenaline test was performed on the daily headaches were seen in seven patients, respectively. In
study cases attending OPD during the attack of headache: 38 patients, duration of each attack lasted for 2–12 h, while
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Rai, et al.: Contact point headache

six patients reported to have headache lasting for 12–24 h patients reported to have headache lasting for 12–24 h
and four patients for more than 24 h. Pulsatile headache and four patients for more than 24 h. Postoperatively at
and photophobia were complained in 11 and 9 patients, 12 months, only five patients suffered headache in the group
respectively. of 2–12 h, while no patients reported headache in the group
of 12–24 h and more than 24 h group in Table 3.
All the enrolled patients had positive xylocaine‑adrenaline
test preoperatively. Preoperative nasal endoscopy revealed Preoperative and postoperative frequency of headache:
anatomic abnormality of septum and the lateral wall in all Preoperatively ten patients had 2–4 attacks/month, 26 patients
patients [Picture 1]. Contact point between septum and reported of having 5–8 attacks/month, while seven patients
middle turbinate were present in 34 patients (68%) followed
by septum and inferior turbinate and spur and inferior
turbinate in six each (12% each) [Picture 2] and between spur
and middle turbinate in five (10%) as shown in Figure 1.

Preoperative CT of nose and paranasal sinuses revealed

contact point between septum and middle turbinate in
34 patients (68%) followed by septum and inferior turbinate
and spur and inferior turbinate in six each (12% each)
[Pictures 3 and 4] and between spur and middle turbinate in
five (10%). Concha bullosa was present in ten (20%) cases as
shown in Figure 2. Figure 1: Preoperative nasal endoscopic findings

After diagnosis, endoseptoplasty was carried out in all fifty

patients. In addition, turbinoplasty was done in 19 patients.

Comparison of pain scores: In comparison, preoperative

average pain score (VAS) was 7.47 with SD of ± 1.6.
Average postoperative pain score at 12 months after surgery
declined to 0.2 with SD of ± 0.59 which is also statistically
significant (P = 0.001) as shown in Table 1.

Comparison of frequency of pain: At the end of 12 months

follow‑up, the mean frequency of pain reduced from
9.24 preoperatively to 0.22 which is also statistically Figure 2: Computed tomography finding
significant (P = 0.001) as shown in Table 2.

Preoperative and postoperative duration of headache:

preoperatively, 38 patients suffered for 2–12 h, while six

Table 1: Comparison of pain scores before surgery and follow‑up

till 12 months
n Pain score, mean±SD P
Preoperative 50 7.24±1.61 0.001*
Postoperative
3 days 50 2.24±1.87
3 weeks 50 0.96±1.47
3 months 50 0.76±1.13
6 months 50 0.36±0.96
9 months 50 0.20±0.60
12 months 50 0.20±0.59
*Friedman test.[5] SD: Standard deviation Figure 3: Preoperative and postoperative frequency of headache

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Rai, et al.: Contact point headache

had more than eight attacks/month and another seven had through xylocaine‑adrenaline test and endoscopically and
daily headaches. Postsurgery frequency drastically reduced radiologically. In our study, all the fifty patients were tested
to 2–4 attacks/month at the end of 12 months in only five positive for xylocaine‑adrenaline test. Other studies used
patients, rest all were symptom free indicating major success cocaine, tetracaine for anesthetic test.[6,7] In the study done
of the treatment through surgery as shown in Figure 3. by Mohebbi et al.,[6] 12 out of 17 patients responded positively
to tetracaine test unlike my study.
Location of pain
Preoperatively, frontal headache was seen in 41 patients (82%) In our study, nasal endoscopy positive contact points were
followed by periorbital (34%), nasal region (32%), malar (4%), noted in all the cases between the deviated nasal septum
entire head (4%), and occipital (2%). A number of patients and middle turbinate; septum and inferior turbinate; spur,
had multiple locations of the headache. Location gradually middle turbinate, and inferior turbinate. More than one
decreased with subsequent visits after surgery as depicted contact points were detected in ten cases. The findings of
in Figure 4. nasal endoscopy were almost similar to the CT findings; in
addition, concha bullosa of middle turbinate was detected in
Comparison of pre‑ and post‑operative nasal endoscopic ten patients. The most consistent findings in the study were
findings: Postoperative contact point was seen in five cases contact between the septum and middle turbinate (68%).
which might justify pain persistence in these patients as Similar finding of anatomical variations of middle turbinate
shown in Table 4. as major causes of mucosal contact points was seen in a study
done by Tosun et al.[8] in Turkey. Another study by Harley et al.[9]
DISCUSSION
Table 2: Comparison of frequency of pain before surgery and
Rhinogenic‑related headache has been recognized since 1888 follow‑up till 12 months
by Roe[5] and it has been a controversial topic. In the year n Frequency of pain (/month), P
1980, Morgenstein and Krieger described middle turbinate mean±SD
headache syndrome caused by the vasoactive‑engorged Preoperative 50 9.10±2.86 0.001*`
Postoperative
middle turbinate that compresses against an often deviating
3 days 50 1.18±1.32
nasal septum.[3] Diagnosis of such contact point headache
3 months 50 0.84±1.4
necessitates a multidisciplinary approach. Diagnostic 6 months 50 0.4±1.12
endoscopy of the nasal passages and CT of the nasal and 12 months 50 0.22±0.67
paranasal region are complementary procedures. Therefore, *Friedman test.[5] SD: Standard deviation
before initiating treatment, correct diagnosis is mandatory
for beneficial results. Table 3: Preoperative and postoperative duration of headache
Duration of each headache (h)
All patients enrolled in the study were diagnosed None, ≤1, 2‑12, 13‑24, >24,
preoperatively according to the criteria set by ICHD n (%) n (%) n (%) n (%) n (%)
Preoperative 0 2 (4.0) 38 (76.0) 6 (12.0) 4 (8.0)
Postoperative
3 days 16 (32.0) 0 34 (68.0) 0 0
2 weeks 32 (64.0) 0 18 (36.0) 0 0
3 months 33 (66.0) 5 (10.0) 12 (24.0) 0 0
6 months 43 (86.0) 1 (2.0) 6 (12.0) 0 0
9 months 45 (90.0) 0 5 (10.0) 0 0
12 months 45 (90.0) 0 5 (10.0) 0 0

Table 4: Comparison of preoperative and postoperative nasal

endoscopic findings
Contact Preoperative Postoperative Postoperative
point contact synechia
Septum/MT 34 2 11
Septum/IT 6 1 2
Spur/MT 5 0 3
Figure  4: Location of pain preoperative and during postoperative Spur/IT 6 2 1
follow‑up (can be multiple sites) MT: Middle turbinate, IT: Inferior turbinate

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Rai, et al.: Contact point headache

Picture 1: Contact between septum and lateral wall Picture 2: Spur touching inferior turbinate

Picture 3: Left spur in contact with the left inferior turbinate Picture 4: Right spur in contact with the right inferior turbinate

pointed anatomic abnormalities commonly at fault include 26% had maxillary pain. Location of pain can be explained
deviation of nasal septum, septal spurring, and hypertrophied by referred pain through the first and second branches of
turbinates. However, Mohebbi et al.[6] reported only 53% of trigeminal nerve.[1,3,13]
positive CT scan findings. Wolff and Stammberger postulated
intranasal mucosal contact as a cause of headaches by In our study, 31 patients underwent endoseptoplasty alone. In
releasing neuropeptides, especially substance P,[1] calcitonin the rest, endoseptoplasty was combined with turbinoplasty.
gene‑related peptide,[10] and neurokinin A.[11] These chemical Several studies have undergone similar surgical procedures
mediators are well‑recognized nocioceptive fibers in the as a treatment modality. Septoplasty (mostly) with
central nervous system and the trigeminovascular system.[1] turbinoplasty (as needed) in the form of middle turbinectomy
This strongly supports our finding of positive contact point were done in almost all studies.[6,12‑17]
in patients with long‑term headache.
Various studies have shown good success rates of surgical
In our study, headache duration of the patients ranged from management of contact point headaches. Ramadan[18] reported
1 year to more than 10 years with an average duration of a 60% improvement rate, while Parsons and Batra[7] reported a
6.41 years which is comparable with other studies done by 91% improvement in the symptoms after the surgery. Clerico
Behin et  al.,[12] Clerico et  al.,[13] and Mohebbi et  al.,[6] with et al.[13] showed that 76% of their patients reported a decrease of
the mean duration of headache for 8 years, 6.1 years, and 50% in pain after the operation. Likewise, Cho et al.[19] reported
5.5 years, respectively. Majority of the headache were located a success rate of 82% in their study. Morganstein and Kreiger
in the frontal (82%) followed by periorbital (34%), nasal (32%), showed a success rate of 89% with surgery.[3] In our study, a
malar (4%), entire head (4%), and occipital (2%). Behin et al.[12] success rate of 90% was achieved with surgical intervention.
also described pain location at frontal region and periorbital
area. In the study done by Clerico et al.,[13] 74% reported pain The postoperative pain intensity and frequency and duration
in the supraorbital region, 37% in periorbital region, and of attacks were fully investigated for 12 months. Several
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Rai, et al.: Contact point headache

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