Harvey Blumenthal

Sinus headache: a neurology, otolaryngology, allergy, and primary care consensus on diagnosis and treatment.

Sinus headache is a widely accepted clinical diagnosis, although many medical specialists consider it an uncommon cause of recurrent headaches. The inappropriate diagnosis of sinus headache can lead to unnecessary diagnostic studies, surgical interventions, and medical treatments. Both the International Headache Society and the American Academy of Otolaryngology-Head and Neck Surgery have attempted to define conditions that lead to headaches of rhinogenic origin but have done so from different perspectives and in isolation of each other. An interdisciplinary ad hoc committee convened to discuss the role of sinus disease as a cause of headache and to review recent epidemiological studies that suggest sinus headache (headache of rhinogenic origin) and migraine are frequently confused with one another. This committee reviewed available scientific evidence from multiple disciplines and concluded that considerable research and clinical study are required to further understand and delineate the role of nasal pathology and autonomic activation in migraine and headaches of rhinogenic origin. However, this group agreed that greater diagnostic and therapeutic attention needs to be given to patients with sinus headaches.

An Otolaryngology, Neurology, Allergy, and Primary Care Consensus on Diagnosis and Treatment of Sinus Headache:

While “sinus” headache is a widely accepted clinical diagnosis, many medical specialists consider it to be an uncommon cause of recurrent headaches. Unnecessary diagnostic studies, surgical interventions, and medical treatments are often the result of the inappropriate diagnosis of sinus headache. Both the International Headache Society and the American Academy of Otolaryngology–Head and Neck Surgery have attempted to characterize conditions leading to headaches of rhinogenic origin. However, they have done so from different perspectives and in isolation from the other specialty groups. An interdisciplinary ad hoc committee recently convened to discuss the role of sinus disease and the nose in the etiology of headache and to review recent epidemiologic studies suggesting that sinus headache (headache of rhinogenic origin) and migraine are frequently confused with one another. Clinical trial data are presented which clearly indicate that the majority of sinus headaches can actually be classified as migraines. This committee reviewed scientific evidence available from multiple disciplines and concludes that considerable research and clinical study are needed to further understand and explain the role of nasal pathology and autonomic activation in migraine and headaches of rhinogenic origin. However, there was a consensus from this group that greater diagnostic and therapeutic attention needs to be given to patients complaining of sinus headache that may indeed be due to the nose.

Headaches and sinus disease

Modern diagnostic tools like fiberoptic nasal endoscopy and CT imaging of the sinuses are very sensitive in helping clinicians diagnose sinus disease; we may now reevaluate the symptoms and signs most useful in making a clinical diagnosis of rhinosinusitis. Two major systems of classification and diagnostic criteria relating headaches and sinus disease have achieved currency—that of the International Headache Society (IHS) (1988) and the more recent task force recommendations of the American Academy of Otolaryngology‐Head and Neck Surgery (AAO‐HNS) (1997). This report compares and contrasts the different starting points, certain assumptions, and conflicting conclusions of these two classification systems and recommends a cooperative alliance of the IHS and AAO‐HNS when these diagnostic criteria are revised.

Sumatriptan/Naproxen sodium for migraine: efficacy, health related quality of life, and satisfaction outcomes.

Objective.—To describe the pain relief, satisfaction, and health‐related quality of life results of moderate or severe migraines treated with a sumatriptan/naproxen sodium combination tablet.

THE CLINICAL SPECTRUM OF MIGRAINE

The wide clinical spectrum of migraine frequently challenges the physicians diagnostic acumen. A structured approach to the patient and a better comprehension of this variability of presentation, should translate into better quality of care for migraineurs.

Standard of Care

“Standard of care” sounds like a medical term, but actually it is a universal legal concept. It is codified differently by individual state statutes and is written into each states uniform jury instructions. The phrase increasingly appears in scientific articles discussing the management of patients with headache. But, the term usually is not defined nor is evidence presented to justify the notion that the so‐called standard has any scientific basis. In a courtroom, jury instructions using this phrase can be a legal sword aimed at a defendant doctor, rather than a shield. At risk is a physicians basic right to care for a patient according to that individuals particular needs.

Hormone‐Related Migraine Headaches and Mood Disorders: Treatment with Estrogen Stabilization

Because estrogens and the trigeminal system are inherently linked, prescribers who are treating a woman with a hormonally related mood disorder and migraine headaches should consider hormonal options to optimize the patients treatment. This article discusses the interrelationships of estrogen, serotonin, and the trigeminal system as they relate to menstrual migraine occurrence and hormone‐related mood symptoms. In addition, clinical examples are provided to facilitate the prescribers treating women during reproductive transitions in which declining estrogens are related to their suffering.

Barcelona Poster Boy.

In June 1999 my wife, Sandy, and I traveled to Barcelona for the meeting of the International Headache Society; a poster presentation of my research on hospital emergency department treatment of patients with severe acute migraine attacks had been accepted for exhibition at the meeting. The unforeseen events described hereafter ignited 45-year-old memories, long dormant— memories of Henry Schemmer, my high school track coach, and his discipline, motivation and preparation to deal with unexpected obstacles. These fundamentals were to sustain me in Barcelona, almost half a century later. The conference was held in the Palacio de Congreso. My assigned poster space, A-47, was in the worst possible location, a back corner. There, I was unable to press my tacks into the hard wooden wall, but a page in a red uniform found a hammer and helped hold my poster as I tacked it up. While hammering, one of the plastic tack heads shattered and flew into my eye. Fortunately, I suffered no injury. Just then an American acquaintance arrived to put up his poster near mine; he was more experienced than I, and pointed out that my poster should have fewer panels, less text, and larger print so it could be read from six feet away. He explained that viewers will spend about 10 seconds looking at each display. I was in a drenching sweat after these misadventures. I stood by my exhibit for the 10:30 viewing session. With my poor position, small print and lots of text, only a few of the many doctors gave it more than a passing glance, so I was shocked when Dr. Anne MacGregor, chair of the awards committee, came up and affixed a large red arrow with white letters, SELECTED, on my poster. Mine was one of only eight of the 48 posters in Group A, “Clinical Studies,” chosen to be discussed at the 3 pm viewing session of “selected” research. Fig. 1.—. . .

Dr. Nat Blau, The City of London Migraine Clinic and the Esterhazy Orchestra: The American Connection

In October 1985 my wife, Sandy, and I stayed at the mid-priced Vanderbilt Hotel on Cromwell Road when we visited London. We decided to splurge a little, so I made a reservation at the Ritz for brunch on Sunday. Mirrored on one end, the large dining room in the Ritz was dominated on the opposite wall by floor-toceiling windows that overlooked a patio brightened fully with green plants. Ornate gilded chandeliers hung from the ceiling, and mauve carpeting matched the marble walls with mauve overtones. Waiters in formal wear were extraordinarily attentive. It was all . . . well, very ritzy. Our reservation was for 12:30, but we arrived early and had time for a libation in the Ritz’s Palm Court. By 1:30, the dining room was almost full when Oklahoma Governor George Nigh and his small party entered and were seated at a nearby table. When Sandy and I walked over and introduced ourselves as Tulsans, the governor acquainted us with his guests and we exchanged a few pleasantries. After lunch, we strolled into the hotel lobby where we were happily surprised to run into Dr. Manny and Mim Brown, long-time Tulsans. I joked, “So the Ritz is the place in London to meet all your Tulsa friends!” We had a chat and agreed to have dinner together Thursday evening. Two weeks before we had left Tulsa, my friend, John Coates, MD., wrote a letter introducing me to his long-time friend and fellow neurological colleague in London, Dr. Nat Blau. In 1961, John, a skillful Tulsa neurosurgeon, spent 1 year at the renowned National Hospital, Queen Square, in London, where he worked with Nat. Through John’s introduction, Nat invited Sandy and me to join him and his family for high tea at the Blau home on Sunday afternoon. I called Nat from the Ritz lobby, and he gave us instructions how to reach his home via “the tube,” the London subway system. Sandy and I had a wonderful visit with Nat and his family at their home. He was well known as one of the world’s most respected experts on migraine. A published eulogy upon his death in 2010 described Nat as a “deep thinker (who) loved to discuss all aspects of migraine.” “He received invitations from all parts of the globe” to speak about migraine, and he “talked to people, rather than at them.” None of this surprised me, for in 1985 I saw how he took pleasure in expressing his ideas about migraine, but he also wanted to hear about my experience. I was pleased that our thoughts were so similar – about the practice of neurology, philosophy of medicine, and relationships with patients. Some of his comments were wordfor-word my own expressions. One of his “profound truths” was, “Treat the patient not the scan.” When I turned some of our conversation to British culture, Nat preferred to return to the topic of medicine. I felt we could have visited for another ISSN 0017-8748 doi: 10.1111/head.12567 Published by Wiley Periodicals, Inc. Headache