[Allergy & Asthma Corner]

Sinus Headaches Can Be Quite Distressing

“Doc, I have a sinus headache. What can I take?”

This is a common question in and away from my office (from patients, family and friends). The question is difficult to answer without more information about the nature of the headache, other symptoms, the duration of the headache, severity, and possible triggers or precipitating factors.

It is important to consult your doctor about very severe, persistent or progressively worsening headaches.

The most common type of headache experienced in this country is tension (stress headaches). Sinus related headaches are probably not far behind. There are 28 million migraine sufferers in America (about 10% of Americans), and 75% of them are women. There are a number of other types and causes of headaches which are less common. Tumors account for less than 5% of headaches.

Many patients in my allergy practice have sinus related headaches. These headaches may be related to nasal blockage which disrupts the normal ventilation pathways of the paranasal sinuses. The paranasal sinuses are located to the side, above and behind the nasal passages. They are cavities (spaces) in the face which are lined with special sheets of cells that are capable of making mucus. Nasal congestion easily blocks off the tiny channels which connect the sinuses with the nasal passage. Pressure may then build up in the sinus cavity and cause headache. Two of the most common reasons for the nasal congestion are viral upper respiratory infections (common cold) and allergic rhinitis (hayfever). Acute sinusitis may be a complication of the common cold as well as hayfever.

People with throbbing headache over the forehead sometimes think they are having a migraine headache. I have provided a link to a site which gives much more detail on migraine headache syndrome. Underlying the forehead are the frontal sinuses. Sinus pressure from infection, cold virus, or allergy may result in pain in this area. Migraine headache may also cause frontal head (forehead) pain.

So How Can Your Doctor Tell The Difference?

It may be difficult to know with certainty what the cause of a headache is. Many questions have to be asked and answered. Other aspects of one’s medical history are also important. Last but not least, a focused physical exam helps to make the determination of cause. For this reason you are often told to come in to see the doctor when you call with complaints of headache, sinus headache or sinus pressure.

Did You Know that Migraine is Not Diagnosed by X-ray, Blood Test or Physical Exam?

Such tests are sometimes done to rule out other possible causes of headache. Migraine is considered a possible cause when characteristics of the headache include:

-Unilateral (to one side) head pain or pressure

-Severe headaches generally lasting from a few hours to 3 days

-Throbbing or pulsating headache pain

-Periods of inactivity are common because of the headache

Other criteria include:

-Photophobia (avoidance of light because headaches are worsened by it)

-Headaches worsened by loud noise

-Nausea

-Relief from migraine medications

All the above criteria are not necessary to make the diagnosis of migraine. Your doctor knows how to interpret answers to your questions and will determine if tests or labs are indicated in order to rule out other causes of headache.

Since allergic nasal problems impact about 30 million people nationwide, and migraine disorder, 20 million, the likelihood of someone having both problems is not uncommon. Some patients are referred to allergists for food testing in order to look for possible migraine triggers. This is not usually necessary because migraine problems are not directly related to food or environmental allergy. Some foods should be avoided in the setting of migraine headaches because of their chemical nature. These potential migraine food triggers include: caffeine, chocolate, hard cheeses, wine, beer, cured meats (ham, salami, and beef jerky), MSG (Monosodium Glutamate)and pickled foods. None of these foods trigger migraine on the basis of allergy. Skin testing to these foods is not indicated.

If a person with a history of migraines also has allergy problems, flare-ups may occur as a result of worsening allergy symptoms. In this case, testing to environmental triggers (pollen, mold, dust mite etc.) may be helpful. Often, if the allergic component is well managed, migraine headache may be prevented or better controlled. Unfortunately this does not always work, especially when the pattern of headache episodes are not similar, in timing, to the pattern of nasal allergy symptoms.

Treatment of allergic nasal problems has been covered in previous postings. Sinusitis often requires an antibiotic (to be determined by your doctor). Decongestants, and steroidal nasal sprays may be considered for further management of intranasal swelling and inflammation associated with infection. Migraine headaches have their own list of drug considerations. Your doctor must carefully weigh the risks/benefit of any medication chosen. A trial of different medications may be warranted.

In conclusion, headache or sinus pain may be related to a small number of disorders. A visit to your doctor may be required if it is severe, prolonged or of uncertain cause.

Again, the above comments are not to be used for self diagnosis or treatment. Consult your family doctor for advice on how to treat a bothersome headache.

Some links related to this posting are: www.mayoclinic.com/health/sinus-headaches/DS00647  and: www.medicinenet.com/migraine_headache/article.htm

Future Topic: Eye allergies: Are your allergy medications enough?

Outdoor Sports Can Be Hazardous If You Are Not Prepared.

What’s out there now?

If you are in the vicinity of Chicago or in the Midwest the air is filled with mold spores, grass pollen, tree pollen and pollution. Allergy sufferers have missed the respite usually associated with a drenching rain, this time of year. Although rain has been sparse, humidity levels remain high enough to support soaring mold growth.

This time of year you get the “One-Two punch” of outdoor triggers and indoor triggers. People with seasonal allergy problems may have a lower threshold to respond to indoor allergens and irritants because of priming from the outdoor factors. Grass pollen is prevalent in the air through May and June (in the Midwest). People allergic to grass may notice problems persisting or even peaking overnight and in the early morning hours. Some of this may be explained by the late phase of the allergic reaction, which causes allergic symptoms 4-8 hours after exposure (mostly nasal congestion and post nasal drip).

Priming occurs when it takes smaller amounts of pollen exposure to cause allergy symptoms (which may be increasing in severity). This priming process may in fact lower the threshold for other allergens (for example dust mite or pets) to cause allergy symptoms. Irritants (tobacco smoke, fragrances, fumes, odors) may be more bothersome when priming has occurred.

So, grass pollen may be the start of the problem, but then repeated outdoor exposure may escalate runny nose, itching and sneezing even when indoors for several hours or overnight (in part because of priming).

What Can You Do?

I am not able to recommend a specific medication in this venue but I can give you some guidelines, if you are already on allergy medications. First, if you have seasonal allergic problems don’t be fooled by having a few good days, and forget to take your medicine or prematurely stop them. Continue to take your allergy medicine until your season is over. If you are on an intranasal steroid, read my posting about proper nasal spray technique (read it again, if you have already read it). Also review my posting on spring seasonal allergy tips. Remember, antihistamines block histamine, which is released when you have exposure to an allergen. If you take your antihistamine after you start having symptoms you have missed the boat. Do you think a coach would tell a student boxer in training to put his arms up to block a punch after he feels a hit to the face? The first punch might knock him out. Well you have to get the antihistamine (and prescribed nasal spray) on board when things seem to be well, in anticipation of what’s surely to come. If you let up too soon the price may be that you fail to respond to the medication. Now, this doesn't mean you have become immune to the medicine (as I am often asked). This means the severity level has probably gone beyond your medication’s capability.

Try to reduce or eliminate indoor allergy triggers and irritants. Do you have those special encasements on your pillow, mattress and box spring? Are you keeping your pet out the bedroom? Do you have a smoke free home and body? Are you staying away from aromatic cologne, body washes, soaps and sprays? Are you keeping your air conditioning running, instead of opening windows? Are you doing nasal rinses (see posting on Nasal Rinsing, last month)?

The best recourse if you are closely following directions given to you previously may be to follow-up with your allergist or primary doctor.

Next week: Migraine or Sinus Headache? What’s the difference?

Approximately 20 million people have asthma in the United States. The challenge of health care providers is to make the diagnosis, identify trigger factors for avoidance measures, and establish effective treatment with reliever and controller medications.

Inhaled steroids have proven to be the most effective controllers for people with more moderate to severe asthma. When combined with non-steroidal controllers, the dose of inhaled steroid may be kept lower. Many patients are managed with dual and triple controllers (for example Advair, which has two medications in one inhaler device, and combinations of Advair and Singulair). When severe attacks occur, oral steroids are usually given for a few to several days.

In 2003, a new class of asthma medication became available for treatment of moderate to severe asthma. A drug which has the brand name, Xolair (generic name Omalizumab) was the first of this class to get approval by the FDA (Food and Drug Administration). Xolair improves asthma control by neutralizing (blocking) the effect of IgE antibody. IgE antibody is over produced in the majority of asthma patients that have allergic trigger factors. IgE is made by white blood cells and circulate through the body in the blood. They attach to specific cells, called mast cells located in the skin, nose, eyes, lungs and stomach. There they pose as receptors which when in contact with a specific allergy trigger (for example dust mite) sends a signal to the inside of the mast cell to release histamine and other substances which lead to asthma symptoms (by causing inflammation).

We have several of our patients on Xolair which is given by injection. Xolair is reserved for patients that are not adequately controlled on low to medium dose inhaled steroids and require frequent oral or injected steroids. Patients must have a perennial allergy trigger (by skin test or blood test for allergy) and be 12 years or older. Some insurance companies ask for more clinical information before approving coverage for this expensive medication. A blood test for IgE level must be done in order determine eligibility (for insurance coverage). The IgE blood level is also used to calculate the dose needed for treatment. The injections (only given by injections, no oral or pill form) are given every two to four weeks (based on IgE level).

Xolair is not a cure for asthma. Most people benefit from treatment by having fewer asthma attacks and better symptom control. It often takes between a few weeks to four months to improve. Not all patients respond favorably to Xolair. There are potential side effects which are reviewed in detail before starting treatment.

Recently the FDA recommended that the makers of Xolair have patients under treatment wait 2 hours after all injections, and that patients on Xolair keep Epinephrine available for emergency use. Anaphylaxis, a severe form of allergic reaction, has been reported in a small number of patients, following injection of Xolair. We have passed this information on to our patients. We await further information from Novartis and Genentech.

In summary, Xolair is currently available for treatment of moderate to severe bronchial asthma which has proven to be difficult to control, and not adequately responsive to low to medium doses of inhaled steroids. Patients must meet the criteria reviewed above. How long treatment should be continued has not been well established.

Sites of interest: www.webmd.com/asthma/news/20070221/fda-warns-about-asthma-drug-xolair

and: www.medicinenet.com/omalizumab-injection/article.htm

Next Week: Update on Seasonal Allergy Triggers (What's Out There Now?)

Future Topics: Non-Allergic Rhinitis (If It's Not Allergy What's Making My Nose Stuffy and Runny?) // Ocular Allergy (eye allergy): What If Antihistamine Pills Don't Work?

Smokers will require more reliever meds.

You don’t smoke do you? There are several good reasons to avoid smoking. I will not be listing or discussing all of them. People that have allergic sinus problems, asthma or any breathing problems should never smoke. In fact, second-hand smoke exposure is associated with many of the same problems as active smoking. Second-hand smoking (also called passive smoking) is involuntary smoking which occurs when someone is in close vicinity to another who is actively smoking.

Here are some facts:

-Tobacco is the leading avoidable cause of cancer

-Smoking increases risk of heart disease, stroke, emphysema, bronchitis and complications during pregnancy

-Non-smokers that inhale second-hand smoke have increased risks of lung cancer, asthma attacks and heart disease

-Children exposed to second-hand smoke have increased risks of sudden infant death syndrome, ear infections, respiratory infections and asthma

People that have asthma and smoke are elevating their risk for severe health problems. They generally have more severe asthma, more rapid loss of lung function, more asthma attacks (which are difficult to treat), more fatal asthma attacks and less responsiveness to steroids (a chief class of drugs used for controlling asthma).

Allergic respiratory problems invariably involve inflammation (increased mucus, swelling, increased activity of white blood cells…). Tobacco inhalation also causes inflammation, although some of the cell types involved differ. This is why smoking is considered akin to: “fanning a flame with a fuel”. One can greatly increase the lung inflammation by smoking which further worsens asthma control and may lead to earlier scarring in the lung. Exposure to second-hand smoke may do the same thing.

Tobacco use is probably the single most preventable cause of death in America. The top three causes of death in this country may be influenced by smoking (heart disease, stroke, and cancer). Asthma becomes better managed after smoking is stopped. Respiratory health starts to benefit immediately from smoking cessation.

Physicians are learning more about how to assist patients and the parents of their patients in smoking cessation. It begins with talking to your doctor and taking some first steps. Understanding why it is important to stop is essential to making the decision to stop.

To the parents of my patients that are struggling with this problem (currently smoking):

Realize that smoking anywhere in the house, including the bathroom, near a window or fireplace, in an attached garage or basement, still exposes your child and others in the home to damaging tobacco smoke. The ash that forms from the burning of the tobacco infiltrates ducts, carpets, mattresses and pillows. The ash is not easily removed by typical house cleaning. It usually gets displaced by vacuuming and sweeping, but not removed. There should be no smoking anywhere in the house.

According to the Centers for Disease Control (CDC): “There is no risk-free level of exposure to second-hand smoke.”

The car should also be smoke free at all times, for similar reasons discussed above. Your car becomes a gas chamber for you and others when there is smoking inside of it. Having the windows down or cracked does not eliminate the smoke.

If you don’t want your kids to ruin their lives by smoking, you better find a way to quit (or never start). Children tend to do what parents do.

According to a survey conducted by Morbidity and Mortality Report: “Teens who reported second-hand smoke were twice as likely to be susceptible to start smoking”

I’m a smoker what can I do?

First learn more. Go to the site of the American Lung Association and find your local chapter. There are several smoking cessation programs that may be available to you. Call your local hospital and inquire (try the Respiratory Department). Talk to your doctor about it. Take action and follow through.

I have included a few sites for more information. I hope to develop a smoking cessation program in the oncoming weeks (in my office).

Some of my resources: www.webmd.com/asthma/guide/smoking-trigger

and www.lungusa.org

Next Topic: Is Xolair (IgE blocking medicine available for treatment of severe asthma since 2003) for you?