Allergy Sufferers also Have More Severe Migraines

Many people suffer from migraines. Many people also suffer from allergies. What may have been suspected but is now clarified is that those individuals who suffer from BOTH allergies and migraines have much more frequent and severe headaches than those who do not have allergies. [link]

Based on a survey response from 5,849 patients who suffer from migraines, over two-thirds also suffered from allergies. From this group, researchers found that the odds of experiencing more frequent headaches for individuals with allergies and migraines were 33 percent greater than those suffering from migraines without allergies.

When patients were further subdivided based on the type of allergy they had (allergic, non-allergic, or both), those who suffered from both allergic and non-allergic had the most frequent and severe headaches.

Although there appears to be an association between allergies and migraine severity, the question now becomes whether the migraines themselves increase sino-nasal symptoms OR does the sino-nasal symptoms of allergies aggravate or trigger the migraine.

Based on a prior study, it is known that migraine patients under 45 years with allergies who received allergy shots had 52% less frequent and severe headaches than those who did not receive allergy shots. As such, it may be worthwhile to aggressively treat any sino-nasal symptoms in patients who suffer from migraine headaches. Such treatment may involve not just medications, but even surgery if anatomic trigger points are seen.

References:
Chronic rhinitis and its association with headache frequency and disability in persons with migraine: Results of the American Migraine Prevalence and Prevention (AMPP) Study. Cephalalgia. Published online before print November 25, 2013, doi: 10.1177/0333102413512031

Allergy and immunotherapy: are they related to migraine headache? Headache. 2011 Jan;51(1):8-20. doi: 10.1111/j.1526-4610.2010.01792.x. Epub 2010 Nov 4.

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Brain Fluid Leakage Out the Nose (CSF Leak)

Image by Patrick Lynch from Wikipedia

Fox News published a story today (12/3/12), describing one patient's runny nose that was not due to allergies, but in fact due to brain fluid leaking through a crack in the roof of her nose. Also known as CSF leak (cerebrospinal fluid leakage), correction of this problem can be performed endoscopically through the nose without any incisions on the face.

An interesting trivia related to CSF leaks is that actor George Clooney suffered one after a blow to the head while filming a torture scene in the 2005 movie "Syriana".

Diagnosis can be obtained simply by taking some of this nasal drainage into a red-top tube and getting it tested for beta2-transferrin which is a protein found in brain fluid, but not in normal nasal secretions.

The take-home message is that not all runny noses are due to allergies, especially if it is continuous and only occurs on one side.

Of note, the Washington Post also published a similar story of a different patient with the same problem in 2010.

Source:
Woman's running nose revealed to be leaking brain fluid. Fox News 12/3/12.

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Nasal Congestion or Obstruction During Pregnancy

When a woman becomes pregnant, it is not unusual for the nose to become quite congested... uncomfortably so, even to the point of being unable to breath through the nose.

This condition known as "rhinitis of pregnancy" affects as many as 30% of pregnant women and can start in the second month of pregnancy; it tends to worsen later in pregnancy. The nasal congestion should ease up soon after giving birth and be gone completely within two weeks after delivery.

The nasal congestion occurs due to elevated amounts of estrogen causing swelling of nasal mucous membranes. Furthermore, there is a marked increased in circulating blood in the body which also leads to swelling of the tiny blood vessels lining the nose. Bloodflow causing nasal obstruction (turbinate hypertrophy) is not unusual and even occurs in men (laying down on one side causes nasal obstruction that than switches when laying down on the other side; improves when sitting/standing).

On exam, a common finding are large inferior turbinates. Inferior turbinates are soft tissue outpouchings within the nose that warm and humidify the air as nasal breathing occurs. Normally, they are quite small, but with rhinitis of pregnancy, they can become enormous... even quadrupling in size.

Inferior Turbinates Seen on Exam

Generally speaking, my approach to treating this uncomfortable condition is as follows (assuming all other causes are ruled out and no medical contraindications):

1) Regular HYPER-tonic saltwater nasal irrigations to the nose 3-4x per day. I recommend HYPER-tonic saltwater rather than regular strength saltwater. Why? Salt sucks moisture out of the nose. With regular strength saltwater (aka, normal saline), the saltwater concentration is equal to that found within the body and minimal if any moisture displacement (osmosis) occurs. With HYPER-tonic saltwater, given the increased salt concentration compared to that found within the body, moisture leaves the nose allowing for decongestion to occur.

Nasal irrigations can be performed with Neti Potor NeilMed Sinus Rinse Bottle. Hypertonic salt packetscan be purchased and mixed with 8 ounces distilled water. Or, if you want to make it yourself, 1/2 to 3/4 teaspoon of salt and 1/4 teaspoon of baking soda in 8 ounces of distilled water.

2) Rhinocort AQ (prescription) steroid nasal spray 2 sprays on each side daily. Steroids help to decrease swelling, especially the large inferior turbinates. This steroid nasal spray is the ONLY steroid nasal spray that is Class B for pregnancy.

3) Keep the head elevated when you lie down. This reduces the blood flow to the nose which exacerbates the nasal congestion.

Of course, steps 1 and 2 assume that there is SOME room for the treatment to occur. If the nose is 100% blocked up, use over-the-counter Afrin nasal spray a few times to get things to open up (never more than 3 days). Once opened up some, immediately start #1 and 2. It is not healthy nor wise to use afrin too much. Ideally, it may need to be used for 1 day only and no more thereafter. There is also some concern that decongestant use during only the first trimester may cause some birth defects (read more). Even in non-pregnant individuals, afrin should never be used more than a few consecutive days otherwise risk addiction!

Response to treatment typically occurs within 2 weeks.

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FDA Approves New "Dry" Steroid Nasal Spray

On March 26, 2012, the FDA approved of a new type of steroid nasal spray in the treatment of nasal allergies that puffs powder into the nose rather than a liquid. Liquid formulations such as nasonex, flonase, veramyst, nasacort, and rhinocort has been until now the only delivery medium of administration.

This new spray made by Teva Pharmaceuticals is called QNASL which puffs a steroid beclomethasone dipropionate. For those who know pharmaceuticals, it is the same active ingredient as (liquid) beconase nasal spray.

Just like the other nasal sprays, administration is 2 puffs (sprays) in each nares daily.

This spray does pretty much the same thing (and has similar side effects) as the other established nasal sprays. However, QNASL may be better tolerated in those patients who HATE the drip down the back of the nose after liquid nasal spray use.

Drug should be available for prescription starting in April 2012.

Source:
Teva Announces FDA Approval of QNASLTM (beclomethasone dipropionate), a New Nonaqueous Nasal Aerosol, for the Treatment of Allergic Rhinitis. Teva Pharma 3/26/12

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Nasal Dripologist

I always thought that pediatricians, primary care physicians, allergists, and ENTs were the true nasal dripologists, but I guess I'm wrong...

Saw this ad by Target promoting their pharmacists...

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