An Inflammatory condition involving the paranasal sinuses and linings of the nasal passages that lasts 12 week or longer This diagnosis requires objective evidence of mucosal inflammation DEFINITION

Types of Rhinosinusitis per Temporal Course based on Duration of Symptoms ACUTE : lasts up to 4 weeks, with total resolution of symptoms SUBACUTE : lasts > 4 weeks but < 12 weeks RECURRENT ACUTE : 4 or more episodes per year, with resolution of symptoms between attacks CHRONIC : 12 weeks or more of signs / symptoms ACUTE EXACERBATION OF CHRONIC RHINOSINUSITIS

Primary or secondary headache ? Primary : - No other causative disorder Secondary : - Headache occuring with another disorder

Headache attributed to rhinosinusitis commonly known as sinus headache is probably one of the most prevalent secondary headache Chronic rhinosinusitis is not always associated with headache Headache is experienced in three out of four patients with chronic rhinosinusitis ( Moretz, 2006) Chronic rhinosinusitis gives a ninefold increased of chronic headache (Aaseth, et al. 2010) EPIDEMIOLOGY

Sinusitis is overdiagnosed as a cause of headache and facial pain 60 % of patients with unrecognized migraine attrributed to their symptoms to sinusitis Rhinosinusitis is an uncommon cause of facial pain > 80% of patient with purulent secretions visible on nasal endoscopy have no facial pain

The headache associated with rhinosinusitis are usually continuous Pain in maxillary sinusitis usually in the : – Cheek – Gums – Maxillary teeth on affected side Pain in frontal sinusitis: – frontal headache over the sinus – the medial side of the orbital floor – under the supra orbital ridge CLINICAL FEATURES

Frontal sinusitis can result in : – Brain abscess – Meningitis – Subdural or epidural abscess – Osteomyelitis – Orbital edema – Orbital cellulitis Ethmoid sinusitis typically produces pain in between the eyes – Coughing, straining and lying supine can worse the pain – Keeping the head upright lessen it Complication of ethmoid sinusitis: meningitis, orbital cellulitis, cavernous sinus thrombosis

Headache is always present in sphenoid sinusitis : – Frontal – Temporal Complication of sphenoid sinusitis: – Meningitis – Cavernous sinus thrombosis – Subdural abscess – Ophthalmoplegia – Pituitary insufficiency

A. Frontal headache accompanied by pain in one or more regions of the face, ears or teeth and fulfilling criteria C and D B. Clinical, nasal endoscopic, CT and MRI imaging and/or laboratory evidence of acute or acute on chronic rhinosinusitis C. Headache and facial pain develop simultaneously with onset or acute exacerbation of rhinosinusitis D. Headache and/or facial resolution within 7 days after remission DIAGNOSIS Diagnostic criteria: (ICHD-II / IHS 2004) Headache attributed to rhinosinusitis

Notes: 1. Clinical evidence may include purulence in the nasal cavity, nasal obstruction, hyposmia/anosmia 2. Chronic sinusitis is not validated as a cause of headache or facial pain unless relapsing into an acute stage.

A major challenge to studying headache attributed to sinus disease  Lack of uniform diagnostic criteria 1. The AAO-HNS Classification : Headache as one of several criteria for diagnosis 2. The ICHD-II/IHS Classification: Requires the existence of specific pathophysiological condition that explain the headache

The ICHD-II does not accept chronic rhinosinusitis as a cause of headache or facial pain unless relapsing to an acute stage Several primary headache : migraine, tension-type headache and cluster headache  misclassified as rhinosinusitis or sinus headache On the other hand, nasal and sinus related pain may mimic migraine attacks or Tension-type headache attacks

Major Factors Minor Factors ― Facial Pain / Pressure ― Nasal Obstruction / Nasal Congestion ― Nasal or Post-Nasal Discharge/ Purulence/ discoloured post nasal drainage ― Hyposmia / Anosmia ― Purulence in nasal cavity on examination – Headache – Fever – Halitosis – Fatigue – Dental Pain – Cough – Otologic symptoms – Ear p ain/pressure/fullness Diagnostic criteria for Rhinosinusitis and headache attributed to rhinosinusitis (requires 2 Major Factors, or 1 Major & 2 Minor) The AAO-HNS Classification

One of these signs of inflammation must be present and identified in association with ongoing symptoms consistent with chronic rhinosinusitis: A. Discoloured nasal drainage from the nasal passages, nasal polyps or polypoid swelling as identified on physical examination with anterior rhinoscopy after decongestion or nasal endoscopy B. Oedema or erythema of middle meatus or ethmoid bulla on nasal endoscopy

Migraine and tension-type headache are often confused with Headache attributed to rhinosinusitis because of similarity in location of the headache

Patients with chronic rhinosinusitis experience headache relief after sinus surgery Topic nasal corticosteroids were reported as the second most frequent reason for headache improvement ( Aaseth, et al. Cephalalgia 2010, 30 (2) : ) TREATMENT

SUMMARY Chronic sinusitis is significantly associated with chronic headache Both the classification of The AAO-HNS classification and The ICHD-II/IHS classification provide diagnostic criteria for the diagnosis rhinosinusitis related to headache Patients with chronic rhinosinusitis experience headache relief after sinus surgery