Rhinogenic Contact Point Headache – a Review

Abstract

Headache is a universal symptom in the course of everyone's life. There are myriads of causes for headache ranging from simple migraine, tension headache, refractory errors in the eye, temporomandibular joint arthralgia, and myofascial spasm to severe form of headache by brain tumors. The anatomical variations in the nasal cavity result in mucosal contact between the opposing surface and cause rhinogenic contact point headache (RCPH). RCPH is a new type of headache in medical literature. The pathogenesis of the RCPH is still the subject of controversy. Nose has diverse anatomical variations. Deviated nasal septum or spur, middle turbinate concha bullosa, and enlarged bulla ethmoidalis are the common anatomical variation in the nasal cavity which can cause RCPH. Diagnostic nasal endoscopy and computed tomography scan are helpful to confirm the mucosal contact points inside the nasal cavity. The precise excision of the contact points with the help of endoscopic approach in patients of RCPH is very effective. Clinicians should not ignore the anatomical variation of the nasal cavity during management of the headache. There is not much literature for RCPH indicating that this clinical entity is neglected. This review article presents an overview of the current aspect of RCPH.

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Matrix Science Medica
Volume 6 • Issue 3 • July-September 2022
The Official Publication of Medic & Public Health Association, Malaysia (MPHAM)
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© 2022 Matrix Science Medica | Published by Wolters Kluwer - Medknow 65
Review Article
intROductiOn
Headache is a very common clinical manifestation among
human beings. The incidence of headache in a lifetime is
approximately 90%.[1] Patients often attend otolaryngology
clinic for sinus headache. The common presentations of the
sinus headache are facial pain or pressure over the maxillary,
frontal, ethmoid sinuses, mandibular or maxillary pain, facial
spasm, temporal pain, or otalgia.[2] Rhinogenic contact point
headache (RCPH) is a secondary headache newly added in the
International Classication of Headache Disorder-2.[3] RCPH
is described as intermittent pain conned to the periorbital and
medial canthal or temporozygomatic areas, associated with
intranasal mucosal contact points conrmed by diagnostic
nasal endoscopy or computed tomography (CT) scan and
supported by limited evidence.[3] However, there has been
controversy regarding mucosal contact point headaches
since its introduction in literature. Many studies on RCPH
emphasized mucosal contact between the nasal septum and
middle turbinate or inferior turbinate of the nasal cavity.
This review article aims to discuss the details of history,
epidemiology, etiopathology, clinical presentations, diagnosis,
and current treatment of RCPH.
MethOds Of liteRAtuRe seARch
Multiple systematic methods were used to find current
research publications on RCPH. We started by searching the
Scopus, PubMed, Medline, and Google Scholar databases
online. A search strategy using Preferred Reporting Items
for Systematic Reviews and Meta-Analyses guidelines was
developed. This search strategy recognized the abstracts of
published articles, while other research articles were discovered
manually from the citations. Randomized controlled studies,
observational studies, comparative studies, case series, and
case reports were evaluated for eligibility. There were total
numbers of articles 96 (42 original articles, 28 case series,
and 26 case reports) [Figure 1]. This paper focuses only
on RCPH. This paper examines the history, epidemiology,
Rhinogenic Contact Point Headache – A Review
Santosh Kumar Swain
Department of Otorhinolar yngology and Head and Neck Surgery, IMS and SUM Hospital, Siksha “O” Anusandhan University, Bhubaneswar, Odisha, India
Headache is a universal symptom in the course of everyone’s life. There are myriads of causes for headache ranging from simple migraine,
tension headache, refractory errors in the eye, temporomandibular joint arthralgia, and myofascial spasm to severe form of headache by brain
tumors. The anatomical variations in the nasal cavity result in mucosal contact between the opposing surface and cause rhinogenic contact point
headache (RCPH). RCPH is a new type of headache in medical literature. The pathogenesis of the RCPH is still the subject of controversy.
Nose has diverse anatomical variations. Deviated nasal septum or spur, middle turbinate concha bullosa, and enlarged bulla ethmoidalis are
the common anatomical variation in the nasal cavity which can cause RCPH. Diagnostic nasal endoscopy and computed tomography scan are
helpful to conrm the mucosal contact points inside the nasal cavity. The precise excision of the contact points with the help of endoscopic
approach in patients of RCPH is very eective. Clinicians should not ignore the anatomical variation of the nasal cavity during management
of the headache. There is not much literature for RCPH indicating that this clinical entity is neglected. This review article presents an overview
of the current aspect of RCPH.
Keywords: Deviated nasal septum, intranasal mucosal contact point, middle turbinate concha bullosa, rhinogenic contact point headache,
spur
Address for correspondence: Dr. Santosh Kumar Swain,
Department of Otorhinolar yngology and Head and Neck Surgery, IMS
and SUM Hospital, Siksha “O” Anusandhan University, K8, Kalinga Nagar,
Bhubaneswar ‑ 751 003, Odisha, India.
E‑mail: santoshvoltaire@yahoo.co.in
Access this article online
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DOI:
10.4103/mtsm.mtsm_1_22
Abstract
How to cite this article: Swain SK. Rhinogenic contact point headache – A
review. Matrix Sci Med 2022;6:65-9.
Received: 14-01-2022, Revised: 18-01-2022,
Accepted: 21-01-2022, Published: 25-08-2022
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Swain: Rhinogenic contact point headache
Matrix Science Medica ¦ Volume 6 ¦ Issue 3 ¦ July-September 2022
66
etiopathogenesis, clinical manifestations, diagnosis, and
treatment of RCPH. This analysis provides a foundation for
future prospective trials of intranasal mucosal contact point
and its manifestations as RCPH. It will also serve as a catalyst
for additional study into RCPH and its manifestations on along
with early diagnosis and treatment.
histORy
McAuliffe et al. in 1943 explicated that the stimulation
of certain anatomical areas of the nasal cavity can lead to
trigeminal nerve stimulation and release of the substance
P (SP) which cause headache in the absence of sinonasal
inammatory diseases.[4] Later on, Zechner used the word
RCPH as the cause of headache due to intranasal mucosal
contact point.[5] Headache classication subcommittee of the
International Headache Society included the RCPH among the
secondary sinonasal causes for headache in 2004.[6] Stamberger
and Wolf described the role of the SP in etiopathogenesis of
RCPH.[7]
epideMiOlOgy
Headache may be classied into primary and secondary
types where primary headache does not have any specic
etiology and include migraine, tension headache, and
cluster headache. Secondary headache is due to trauma,
infections, neoplasm, vascular lesions, and metabolic
diseases.[8] Anatomical variations of the nasal cavity can
result in mucosal contact and headache. Intranasal contact
points are seen in approximately 4% of the noses.[9] Deviated
nasal septum (DNS) is the most common anatomical
variation of the nasal cavity which causes headache (in
approximately 35.18%).[10] Spur is the second most common
cause for RCPH followed by middle turbinate concha
bullosa, inferior turbinate hypertrophy, enlarged ethmoidal
bulla, enlarged pneumatized superior turbinate, medialized
middle turbinate, and nasal septal bullosa.[10] The most
common site for RCPH is frontal area followed by glabellar
region.[1] Occipital region is the rare location for headache
in RCPH.
etiOpAthOlOgy
Headache patients are classied into three groups such as (1)
headache due to sinonasal pathology like inflammatory
diseases or barotraumas; (2) headache not related to sinus
causes like seasonal allergies, migraine, neuralgic pain, and
vascular headache; and (3) headache where sinus origin cannot
be identied.[11] The third category is concerned for clinicians
where nasal mucosal contact point results in referred pain
in the face or head. The pathophysiology for RCPH is still a
subject of debate. A study suggested that anatomical variations
such as concha bullosa or inferior turbinate hypertrophy
cause contact of the mucosa to the nasal septum and result in
pain.[12] One report showed that contact between the superior
turbinate and septum can cause headache.[13] Bulla ethmoidalis
is the largest anterior ethmoidal cell area. When it is larger
than usual, it may push the vertical lamella of the middle
turbinate and cause contact with the septum. In rare cases,
it may be so large that it will contact with septum by itself.
This situation can cause RCPH. Mechanical irritant such as
pressure eect on the mucosal surface of the nasal cavity may
cause release of the neuropeptides through central orthodromic
impulse and peripheral local, antidromic impulse. The
released neuropeptides such as SP and calcitonin gene-related
peptide (CGRP) result in vasodilatation and mucosal edema
in the nasal cavity, which again aggravate the pressure eects
at the contact area. The neuropeptides released from the
central nervous system cause pain sensation which usually
mimic to the migraine without aura. The duration and onset
of the pain are usually similar to the beginning and duration
of the nasal cycle.[14] SP, neurokinin, and CGRP are seen in
nociceptive bers at the central nervous system and also in the
trigeminovascular system. Hence, the contact area between
the opposing mucosal layers in the nasal cavity may result in
secondary headache. SP plays a vital role in etiopathogenesis
of the RCPH. Release of SP results in vasodilatation, plasma
extravasations, and perivascular inammation and manifests
headache similar to migraine without aura.[15] The mucosal
layers of the nasal cavity usually have higher concentration of
SP than chronic hyperplastic mucosa or polypoidal tissues. This
is the explanation for headache due to intranasal contact points
in the absence of rhinosinusitis.[16] There is also controversy
in intranasal contact points and headache. Regarding fact that
intranasal mucosal contact points may be found in the person
who does not have a headache where the causal association
between the mucosal contact points and headache is still not
easily established. The debate over RCPH in the scientic
community has long history.
clinicAl pResentAtiOns
In everyone’s life, headache is a common symptom. Headache
is often associated with various severities. There are dierent
characteristics of headache associated with dierent etiologies
such as migraine, vascular headache, temporomandibular
joint dysfunction, ophthalmological condition, intracranial
lesions, dental abscess, and head-and-neck tumors.[17] One
Figure 1: Flowchart for literature search

Swain: Rhinogenic contact point headache
Matrix Science Medica ¦ Volume 6 ¦ Issue 3 ¦ July-September 2022 67
study showed that the pain in mucosal contact point headache
is localized to the frontal region.[18] Headache and facial pain
by sinus and nasal origin in the absence of the inammatory
sinonasal pathology favors the diagnosis of the RCPH. In the
current clinical practice, headache due to RCPH has received
attention in both otorhinolaryngology and neurology. There
are dierent types of intranasal anatomical variations resulting
in mucosal contact points in the nasal cavity that result in
RCPH. The characteristics of headache in RCPH dier as per
the type of intranasal anatomical variations. Many clinicians
are not well versed with anatomical variations of the nasal
cavity and its impact on headache. One study documented
that DNS and spur cause referred headache in the absence of
the inammation.[19] The DNS may be cartilaginous deviation,
bony deviation, bony spur, and high septal deviation. The
signicant referred headache is seen in sharp septal spur.
Concha bullosa is hypertrophied pneumatized middle turbinate
and rarely found in superior. The mucosal contact between
concha bullosa and nasal septum or other mucosal surfaces of
the nasal cavity can cause referred pain at periorbital or ocular
pain via anterior ethmoidal nerve, a branch of ophthalmic
division of the fth cranial nerve.[19] The contact point between
hypertrophied superior turbinate and upper part of the septum
can cause RCPH. The hypertrophied superior turbinate
often causes pain over the forehead and medial and lateral
canthus.[20] Sometimes, medialized middle turbinate results in
mucosal contact with nasal septum. Bulla ethmoidalis is the
large hypertrophied anterior ethmoidal cell.[21] Hypertrophied
bulla ethmoidalis may push the middle turbinate and cause
a contact with nasal septum. The headache due to sinusitis
can be distinguished by a way such as pain in the sinusitis is
worsened by tilting the head forward and performing Valsalva
maneuvers.[22] The sinusitis is often over diagnosed as a cause
of headache as a belief that pain over the paranasal sinuses
must be associated to the sinuses. However, it is important
to dierentiate the sinus pain from severe headache which
responds poorly to the medication, usually conned to the
frontal and periorbital region of the face. However, the
clinical history, endoscopic examination, and imaging do not
indicate the presence of diseases of the mucous membranes
in the nasal cavity and paranasal sinuses.[23] The headache is
usually dull ache and associated with a sense of pressure, which
oscillates in intensity and localization or pulsates as per the
nasal cycle.[23] Sometimes, the intranasal mucosal contact point
causes referred otalgia through trigeminal nerve.[24]
investigAtiOn
The diagnosis of RCPH needs a multidisciplinary approach.
The diagnosis of the RCPH is often misdiagnosed. This clinical
entity may not be suspected during preliminary evaluation.
Patients with headache in the absence of inammation of
the sinonasal area should be examined by a neurologist,
ophthalmologist, dentist, and internist to rule out other
causes. Diagnostic nasal endoscopy and CT scan of the nose
and paranasal [Figure 2] sinuses are helpful to conrm the
intranasal contact points and also to rule our sinusitis.[25] The
patency is better assessed by endoscopic evaluation along the
exact site of the intranasal mucosal contact points. CT scan
of the paranasal sinuses is helpful to identify the pathological
ndings which cannot be seen by endoscopic examination and
helpful to decide the type of surgery.[26] CT scan is helpful to
decide the exact location of contact pints and necessity before
the surgery.[26] The nasal resistance can be assessed by anterior
rhinomanometry. The intensity of headache is usually evaluated
by using visual analog score. The headache severity is graded
on a scale of 0–10 points, where 0 indicates trouble free and 10
indicates worst thinkable troublesome. To reverse such contact
point, anterior ethmoidectomy and lateralization of the middle
turbinate is required. In RCPH, anterior rhinoscopy is helpful
to rule out sinusitis such as purulent nasal discharge, postnasal
drip, and foul smelling from nasal cavity. Application of local
anesthetics at the contact point relieves the headache which
conrms the diagnosis of the RCPH. In one study of 30 patients
with RCPH, application of local anesthetic agents, 43% showed
complete recovery, 47% showed partial improvement, and 10%
showed no improvement.[27] After diagnostic nasal endoscopy
and CT scan of the paranasal sinuses, it is important to do a
lidocaine test. This lidocaine test help not only the diagnosis
of this type of headache but also useful as an indicator of the
success of the surgical excision of the intranasal mucosal
contact points.[28] There is another nasal shrinkage test where
nasal decongestant with topical anesthetic agents is applied at
the intranasal contact points of the nasal cavity.[14]
tReAtMent
Headache is a common clinical symptom for which patients
need medical attention. Headache is considered a major
factor for disability in the community. RCPH is an important
etiology for secondary headache which can be treated by
surgical or medical therapy. The treatment of RCPH requires
multidisciplinary approaches for early diagnosis and treatment.
Topical nasal decongestant or steroids can relieve the RCPH,
Figure 2: Computed tomography scan of the nose and paranasal sinuses
showing left side spur with mucosal contact to inferior turbinate

Swain: Rhinogenic contact point headache
Matrix Science Medica ¦ Volume 6 ¦ Issue 3 ¦ July-September 2022
68
however, the long-term relieve needs surgical interventions.
[29] The topical nasal steroid improves the patency of the
nasal cavity on short-term basis.[30] Endoscopic surgery is an
ideal technique to relieve mucosal contact point headache.[29]
Endoscopic surgical treatment oers superior visualization
of the intranasal mucosal contact points, which is important
for limited resection of the mucosal contacts and allows for
a more controlled and precise surgery with minimal injury to
the adjacent mucosa. The surgery is usually performed under
general anesthesia. Septoplasty or spurectomy is helpful to
correct the nasal septum deviation and relive contact between
the turbinate and septum. Middle turbinate can be lateralized
to avoid the mucosal contact and also it exposes the superior
turbinate and superior meatus. The superior turbinate can be
lateralized to remove the mucosal contact between the superior
turbinate and nasal septum. Optimum care should be taken
for injuring the olfactory area during the surgical procedure.
If the mucosal contact is present in both sides of nostrils, the
surgery on the other side should be done at the same time after
completion of one side. Endoscopic lateral lamellectomy is
the treatment of choice for middle turbinate concha bullosa.
[31] However, there is chance of recurrence of mucosal contact
points inside the nasal cavity after surgery with formation of
synechia leading to frontal sinus disease as a complication.[32]
Before introduction of the endoscopic sinus surgery, complete
excision of the middle turbinate was done for treating the
middle turbinate concha bullosa. Sometimes, the medialized
middle turbinate contacts with septum and causes RCPH.
Creating a space between the septum and middle turbinate
is required for reversing the contact points between the
medialized middle turbinate and septum. Following surgery,
diagnostic nasal endoscopy, and pain intensity score, average
number of headache attacks per months and average duration
of headache in each attack should be documented at follow-up
visit. Headache is usually resolved in less than a week
following removal of the mucosal contact point of the nasal
cavity.[33] One study with 66 patients of RCPH due to middle
turbinate concha bullosa and DNS and enlarged ethmoidal
bulla showed resolution of the headache after excision of the
contact points.[34] Chow showed a reduction of the frequency
and severity of the headache in approximately 82% of the
patients with RCPH after surgical excision of the intranasal
mucosal contact points.[35] Another study of RCPH showed
reduction of the frequency and severity of the headache after
endoscopic excision of the intranasal mucosal contact points
in approximately 91% of the cases.[36] A systematic review of
the literature with 973 patients of mucosal contact points in
nasal cavity showed no facial pain in majority of patients.
[17] Hence, the authors concluded that the presence of the
mucosal contact point is not a good predictor of facial pain.
They also observed that removal of the contact point rarely
causes complete elimination of the headache. The improvement
of the postoperative symptoms after excision of the mucosal
contact points may be explained by cognitive dissonance or
neuroplasticity.[17]
cOnclusiOn
RCPH is a well-represented clinical entity. RCPH is often
considered an exclusion of diagnosis. The correct identication
of the intranasal mucosal contact points can act as specic
trigger points and responsible for RCPH. Nasal cavity has a
diverse anatomical variation. DNS and septal spur are common
anatomical variations of the nose resulting contact point
headache followed by middle turbinate concha bullosa and
bulla ethmoidalis. Proper investigation is helpful for eective
and appropriate treatment. Diagnostic nasal endoscopy and
CT scan of the nose and paranasal sinuses are important tools
for diagnosis of anatomical variations inside the nasal cavity
causing RCPH. Endoscopic surgical approach is highly useful
for elimination of the mucosal contact points and symptomatic
relief of the headache.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conicts of interest.
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