Headache and facial pain from a deviated septum

When something touches our skin, it’s generally very easy for our brains to pinpoint the exact location of stimulation due to the dense forest of nerves that cover the outside of our bodies. On the contrary, the insides of our bodies have a much less developed sensory system which often makes it hard to describe and locate a potential source of discomfort. Nowhere is this more of a problem than the head, neck, and face. For example, ear pain can be referred from the back of the tongue, the tonsils, the back of the nose, and even deep muscles of the neck.

In this post, I want to touch on a very specific type of referred pain called Sluder’s neuralgia which are contact headaches caused by a severely deviated nasal septum. I’ll begin by summarizing the clinical course of a recent patient. The patient had been suffering from more than 15 years of predominantly right sided headaches. Her headaches weren’t constant but when they struck, they kept her out of work for days at a time. She didn’t have any blurry vision or visual auras that are typical of migraine headaches. By the time she was referred to me, she had already seen 2 different neurologists and had a MRI of the head and neck area ruling out any intracranial abnormalities. She went to physical therapy to try to improve her posture and even took migraine medications for 6 months without any improvement.

Her headaches were strongly associated with nasal congestion and responded well to decongestants such as Afrin. While not a smoking gun, this certainly raised the possibility that her headaches were somehow related to her nose. On nasal endoscopy in my office, this is what I saw:

 

The tip of my instrument is pointing at a bone spur that likely formed when the patient was struck by a basketball during her high school years. Every time her nasal passage became congested, the spur literally stabbed into the side of her nose, causing her left sided headaches. When I touched the area of the bone spur in clinic, it perfectly recreated the sensations that had plagued her for years.

After a simple 30 minute procedure to remove the bone spur, the patient has been pain free. Here’s an after picture:

I have seen patients with eye pain, cheek pain, tooth pain, and even ear pain depending on where the bone spur erupts. While it’s not a common cause of facial pain, I do think Sluder’s neuralgia should be considered especially when more common pathologies such as migraines, trigeminal neuralgia, sinusitis, and dental issues have been ruled out. If it is diagnosed, I am generally very optimistic for a complete cure after surgery.

21 replies
  1. Jenny ct
    Jenny ct says:

    Thank you! I just came back from the ENT with this dx. It’s horrible! In my case it feels like my eye is being stabbed, my tooth hurts and of course my nasal passage into my temple. Relieved greatly with oxymetazoline.

    Reply
  2. Jack Blanton
    Jack Blanton says:

    My ENT, after a CT scan says I have Trigeminal Neuralgia. I have a deviated septum and a air pocket which looks like it is what has pushed my septum all the whey to my left side. I was in an auto accident in 1971 that caused my left frontal sinus to be removed. My ENT is going to do a Septoplasty on August 6, 2019, I sure hope this will stop the pain. If I talk, eat, brush my teeth, shave, swallow or just about anything causes unbearable pain. He has prescribed Gabapentin which is no help at all.

    Reply
    • lingzhou125
      lingzhou125 says:

      Try spraying some afrin in your nose when you have the pain. If it goes away it’s a very strong sign the septum is your problem!

      Reply
  3. Chris
    Chris says:

    Great post. Do you happen to of a doctor in the boston area you could reccomend for me to possibly do the same for me aswell?

    Reply
    • Bren
      Bren says:

      The Beth Israel Deaconess Hospitals in Boston or Needham, MA have very highly trained ENT specialists and surgeons. Give either hospital ENT departments a call to make an appointment. They have other ( hospital branches) locations also that may be closer to you, but they are the two I am familiar with. Look online for the location most convenient for you. Good luck, I have no doubt they will get to the core of your condition.

      Reply
  4. Chris
    Chris says:

    Same guy from last post

    I have overwhelming nose facial and headaches I also have a deviated septum which I believe is the cause. It is because of my actions I am working on bettering my life and this nuisance I probably have chronic sinusitis/infection or worse it has been on going for a year maybe 2

    Reply
      • Chris
        Chris says:

        Thank you so much I apologize for all the questions.. but do you have any medicine you could reccomend for me? The pain is unbearable at times I cant even look at my phone with the lowest brightness and wakes me from sleep

        Reply
  5. Sarah Jensen
    Sarah Jensen says:

    Thank you for this post! I have an appt with new dr on the Aug 27. I will suggest we start with this. I have been dealing with this for abt 6 years. 3 mon x 2 a yr when the seasons start to change. Nasal sprays, Claritin regiment among other little cocktails I’ve come up with do help alleviate, but nothing to actually fix the problem. I can’t even fly without an episode coming on. Hopefully, this time I can get some answers.

    Reply
  6. Janet
    Janet says:

    I have been dealing with left sided headaches for a few years. Went to ENT yesterday, said I have a 30% deviated septum and a plus 1 spur. I had some bloody mucus from my sinuses before being put on antibiotics. The spur was mentioned when the ARNP was looking at my left sinuses. I’m concerned because of the pain. Plus I have not had a sense of smell in twenty years. I have never wanted surgery but if it would make me better I would welcome it.

    Reply
  7. Alison Young
    Alison Young says:

    Do you happened to know of any doctors that you would recommend in the San Antonio, Austin, or Houston area? I’ve been to 3 different ENT’s now, had the sinus CT, showing the spur, same side pinpoint headaches for years, and no help. Each doctor either wants me to try different pain meds, antibx, or another round of steroids, or wants to refer me to a neurologist. I’ve even said something about this, after doing my own research and the last ENT told me that these contact point headaches were somewhat a controversial thing.?.

    Reply
    • lingzhou125
      lingzhou125 says:

      Try using afrin when you have the pain. If the afrin relieves the pain it confirms the diagnosis. I don’t know anyone in California.

      Reply
    • Kathryn
      Kathryn says:

      Alison, you may want to look into Dr. Kevin Smith in Houston. I live in Houston and am looking into him for these same issues.

      Reply
  8. Ray
    Ray says:

    Hi, I had a concussion on August 6th and still have not recovered over the last week I have been experiencing terrible pains to the left side of my face and mostly when I go to sleep they are unbearable and keep me up.Percocet did not work and other painkillers did not work they first told me it was possibly neorolgia, the only thing they gave me relief was Excedrin of course keeping me up for the rest of the night. It another MRI and the doctor is showing me on the report that it says ossified left septal spur potential trigger for facial pain and or headache. my wife had reminded me that I did complain from day one of the concussion that when the symptoms start to come on during the day I feel like somebody threw a basketball into my nose and that is where it all starts from, I fell on the back of my head hitting the ice playing ice hockey. Started on antibiotics yesterday. Do you think it can be what you are describing here? The pain is in my cheekbone near my ear up the lower levels of my teeth area and then it goes into my head very unbearable. please let me know if you have any advice, I have been petrified to go to sleep at night. Thank you so much and this was incredible post.

    Reply
    • lingzhou125
      lingzhou125 says:

      The best scan is a ct – will show the bony structures better. Give yourself a big spray of afrin on the side with the headache the next time you have one. If it goes away or improves within 5 minutes, that’s a sign the septum is the culprit.

      Reply
      • ray
        ray says:

        I am a big baby lol-I hate to spray anything in my nose, is there any other option you can recommend. The antibiotic started working, but now I feel the pain starting to come back but not as excruciating but still painful…any ideas? thank you so much for the reply

        Reply

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