By Tedler D. Depaynos, MD
Headache is a general term and has various etiologies. The signs and symptoms maybe non-specific and confusing sometimes, so that the tendency is to consider and eliminate the more serious causes first.
In general our old medical textbooks classify headaches into intracranial like headache due to a “stroke” and extra-cranial.
The extra-cranial maybe due to “vascular spasm” like the classical migraine or muscular contraction or spasm which are termed sometimes as “tension”, “psychogenic” or “nervous” headache. They may also be dental, aural or ocular in origin. It may also come from the paranasal sinuses called paranasal headache.
Paranasal headaches are in general mild or ordinary but as usual there could be exception to the rule just like a patient of a colleague.
The lady patient was 62 years old and was brought to the Emergency Room (ER) 1 or 2 hours before midnight. As a silent rule, patients especially the elderlies when brought to the ER at an unholy hour, something must really be wrong!
The patient was complaining of severe frontal headache with dizziness and numbing of her left upper extremity. The ER personnel feared for a serious condition like an impending stroke which suddenly changed their yawning appearances with sleepy eyes. They immediately requested for an emergency CT Scan of the head especially when they got a highly elevated blood pressure which the patient was never aware of.
Although the CT Scan result was normal giving them slight relief, the attending doctors could not rule out their initial impression because of the patient’s manifestations. She was admitted into the hospital to relieve her of her complaints and of course for further work up and monitoring.
With slight relief of her headache, her severely elevated blood pressure went down which was followed by a relief of her dizziness and arm numbness. Obviously, it was the severe headache that caused her sudden hypertension. A more detailed history and examination was then done.
She used to stay in a warm place but because of her “apostolic” work she transferred where her grandchildren are staying which is a cold place because it is near the top of a well tourist – visited mountain. It is much colder at night especially during the rainy season so that she noticed that she was having “colds” with chronic obstruction of her nasal openings and attacks of tolerable frontal headaches from time to time. It was only when she was brought to the hospital when her headache was continuously severe and unbearable.
Paranasal sinusitis was later considered and a simple x-ray of the paranasal sinuses confirmed the diagnosis. The sinuses are practically “cavities” around the nasal area. They drain into the nasal cavity and they have practically the same mucosal lining. Nasal congestion, edema due to “colds” may extend into the sinuses and blockage of the drainage may occur. Accumulation of edematous fluid or mucous or even pus if there is infection may occur and this may cause the headache. The sinuses may then appear whitish on x-rays instead of the blackish appearance due to the expected presence of air. If neglected, it may become chronic and the infection may extend into the bony area resulting into “osteomyelitis” and even into the intracranial cavity.
The sinuses below the eyebrow are called “frontal” while those at the maxillary are called “maxillary” sinuses. Again from our old textbooks, headaches from the former supposedly occur in the morning while that originating from the latter, occur in the afternoon. This is however difficult to determine clinically. They are also expected to subside in the evening. They are described as dull aching and are worsened by head movements especially by bending down. There is usually tenderness over the involved sinuses even by slight pressure.
Sinusitis may also be caused by the deviation of the nasal septum or to the presence of nasal “polyps” blocking the nasal drainage. These could easily be appreciated on plain x-rays however. In this patient it could be due to “nasal allergy” manifested as “chronic colds” which she developed when she transferred into the cold place.
Decongestant and antibiotics are the usual treatment but allergy especially to cold weather is now routinely taken into consideration. Hence anti-allergic drugs are also prescribed. Presently, some more aggressive young Ear, Nose and Throat Specialist with their sophisticated instruments do some suctioning of the sinuses and prescribe nasal spray decongestants or even antibiotics.
The patient was referred to an ENT by our attending colleague but she preferred to visit the specialist after being discharged because she was in a hurry and more worried of her “apostolic” work. The parents of her “apo’s” are abroad.**
