What is the recommended management for headaches caused by bone spurs in the sinuses following trauma?

Management of Headaches Due to Bone Spurs in Sinuses Following Trauma

For post-traumatic headaches potentially related to sinus bone spurs, obtain MRI head without contrast when neurologic signs are positive, headaches are associated with vomiting, or when headaches are increasing in frequency, duration, or severity, and consider surgical intervention only after confirming mucosal contact points are the definitive source of pain. 1

Initial Diagnostic Approach

Clinical Assessment

• Post-traumatic headache is defined as headache beginning within 2 weeks of closed head injury 1
• Look specifically for: unilateral pain (suggests true rhinologic origin), history of recent viral upper respiratory infection, pyrexia, unilateral nasal obstruction, and worsening symptoms rather than improvement 2
• Distinguish from migraine masquerading as "sinus headache": bilateral frontal/temporal headache with nasal congestion is typically vascular (migraine), not sinusitis 2
• Examine for septal spurs, mucosal contact points, or anatomic abnormalities that may have been present pre-trauma or developed post-trauma 3, 4

Imaging Strategy

• MRI head without contrast is the preferred initial imaging modality for headache attributed to remote trauma 1
• Include SWI or GRE sequences to identify hemosiderin deposition from prior trauma 1
• CT paranasal sinuses without contrast is indicated only when severe and persistent headache is the dominant feature AND surgical planning is being considered 1
• Plain radiographs have no role (53-82% accuracy) and should not be obtained 5

Medical Management (First-Line)

Symptomatic Treatment

• Regular paracetamol (acetaminophen) for pain management unless contraindicated 5
• Use opioids cautiously, particularly in elderly patients with renal dysfunction 5
• Avoid NSAIDs in patients with renal dysfunction 5

Treatment of Underlying Inflammation

• Topical intranasal corticosteroids are first-line for mucosal inflammation creating contact points 1, 4
• Nasal saline irrigation to reduce mucosal edema 1
• Treat vasomotor rhinitis (VMR) if present, as it is the most frequent cause of inflammatory contact points 4
• Consider topical vasoconstrictors (oxymetazoline) for acute symptom relief, though primarily studied for epistaxis 5

Duration and Monitoring

• Trial medical therapy for 3 months before considering surgical intervention 1
• 83% of patients with rhinologic headaches improve with medical or surgical therapy 3

Common Pitfall: Misdiagnosis

The vast majority of patients presenting with "sinus headaches" actually have migraine or tension-type headache, not true rhinologic headache 2

• Chronic sinusitis is NOT validated as a cause of headache unless relapsing into acute bacterial stage 2
• Symmetrical frontal/temporal headache = tension-type headache 2
• Unilateral episodic headache with nasal congestion = migraine with autonomic features (vasodilation of nasal mucosa) 2
• True rhinologic headache from bone spurs requires documented mucosal contact points on endoscopy or imaging 3, 6, 4

Surgical Intervention

Indications for Surgery

• Failure of 3-month trial of medical management 1
• Documented septal spur causing mucosal contact point confirmed by nasal endoscopy 3, 6
• Retention cysts or anatomic abnormalities (septal deviation, enlarged turbinates) creating persistent contact 3, 4

Surgical Approach

• Functional endoscopic sinus surgery with minimal operations targeting identified contact points 6
• For septal spurs: septoplasty to remove offending spur 3
• 83% success rate (significant improvement or cure) with targeted surgical therapy 3

Important Caveat

• 3 of 18 patients (17%) in one series had minimal or no improvement despite surgery, including 2 with septal spurs 3
• This underscores the importance of confirming the spur is truly the pain generator before proceeding with surgery

Special Consideration: Frontal Sinus Fractures

If trauma involved frontal sinus with bone spurs/fragments:

• Most posterior table fractures, even with comminution or displacement, can be managed conservatively without cranialization 7
• 78% of posterior table fractures were managed conservatively in one large series with no intracranial infections 7
• Surgical intervention (cranialization/obliteration) is reserved for: CSF leak with nasofrontal duct obstruction, or combined anterior/posterior table fractures with persistent drainage issues 8
• Monitor for delayed complications: mucocele formation, osteomyelitis, chronic sinusitis 8

Neuropeptide Mechanism

Bone spurs causing mucosal pressure trigger Substance P (SP)-mediated pain via afferent C fibers, creating a vicious cycle of neurogenic edema and hypersecretion 6

• This explains why small lesions can cause significant symptoms through axon reflex amplification 6
• "Referred pain" model explains why pain may be felt distant from the actual contact point 6