The nasal region is a somewhat unique area of the head/face which can be a source of chronic headache symptoms often secondary to peripheral nerve pathology. The primary symptoms in this area consist of significant pressure over the medial eyes at the sides of the nose which can occasionally lead to headaches emanating from between the eyes and extending to the forehead region. These patients will often complain of worsening symptoms with changes in the weather or with allergy flares. As with all headache symptoms secondary to peripheral nerve compression and irritation, these symptoms are not absolutely consistent and can vary significantly from patient to patient. Unlike the other areas of the head and neck, there is no one specific nerve or nerves that are felt to contribute to headache symptoms emanating from this region. Rather, it is the multitude of highly sensitive nerve endings that line the mucosa of the inner nose which are the culprits. Specifically, there can be a contact point, often emanating from the septum (the divider between the 2 sides of the nose) that can physically impinge upon the turbinates (normal outgrowths from the sides of the nose). When the richly innervated mucosal lining of these turbinates rubs against the mucosal lining of the septum as a result of inflammation, an upper respiratory infection or perhaps a deviated septum, pain can result. This type of headache is sometimes referred to as Sluder’s neuralgia although that designation is somewhat inconsistent. In other cases, a significant enlargement of the inferior or middle turbinates can impact the septum itself, whether deviated or not, a condition known as concha bullosa (see picture below). In either case, when the richly innervated mucosal surfaces impact one another, pain can be the result.
Treatment for these types of headaches is therefore targeted toward improvement of the structural issue(s) noted above. As always, a good history and physical examination are required to rule out other types of nasal structural pathology or sinus issues. Often, patients will have seen an ENT surgeon and have failed over-the- counter medications or nasal sprays (e.g. decongestants), which can improve symptoms, albeit only temporarily. Imaging studies are often positive for a deviated septum, a contact point, or concha bullosa. Sometimes, different types of local anesthetics can be used in procedures such as sphenopalatine ganglion blocks that will provide longer-term relief, however such modalities do not typically produce permanent results. An appropriate evaluation by an ENT or plastic surgeon with experience in septo-rhinoplasty can lead to a more accurate diagnosis and surgical intervention can relieve the nerve irritation thus significantly improving symptoms.