“One of the most disabling diseases on the planet…”
That’s how the American Migraine Foundation describes migraine headaches. Migraine can be a debilitating disease, as those who suffer from it know all too well. It affects forty-two million Americans and over one billion people worldwide.
The cause of migraine has largely eluded physicians and researchers, and there is currently no proven cure for migraine. Or is there?
Dr. Dean Clerico is an Otorhinolaryngologist (Ear, Nose, and Throat surgeon) in Northeastern Pennsylvania. He has been studying the relationship between migraine and nasal/sinus disorders for over 30 years. Ben Keiser interviewed Dr. Clerico on behalf of John Eric Home to discuss his experience and his approach to migraine that offers hope of a cure for what has until now been found to be an incurable disease.
BK: Migraine has always been considered a neurologic disease, the domain of neurologists. How did you as an ENT specialist become interested in this disorder?
DC: Way back in my residency training, a friend of mine came to me asking for advice. She had severe migraines, so severe that she had to be admitted to the hospital and underwent many tests, including a CT scan, an MRI, and even a spinal tap. Her physicians thought she might have had bleeding inside her brain or even an aneurysm, but all the scans and tests were negative.
The medications they gave her did not control the pain. She was in a really tough spot and asked me what she should do next, not necessarily expecting me to help her symptoms, but just asking my advice about what to do next. With my interest in nasal and sinus disorders, I had read that certain abnormalities in the nose can cause headaches. I examined her and found an obvious abnormality in the nose; a massive enlargement of a normal structure called a concha bullosa. Looking at her CT scan, it was confirmed. I thought surgery could help her, or at least it couldn’t hurt, and was worth a try since she had exhausted every other option available to her. A senior physician and I performed endoscopic nasal surgery to correct the problem. She had a remarkable result, the complete elimination of her headaches.
That got me wondering: how many other migraine sufferers are out there with this overlooked nasal problem?
BK: It seemed so easy for you to diagnose and treat her headache, why didn’t the other physicians notice this abnormality?
DC: Neurologists overlook the nasal cavity and ENTs largely ignore migraine. Plus, there is contradictory information in the medical literature. There is too little cross-communication between neurologists and otolaryngologists.
BK: You have researched the relationship between migraine and the sinuses more than anyone I’m familiar with. What were you looking for with these research projects?
DC: We found early on that migraine is not associated with sinus infection per se, but with structural issues occurring outside the sinuses, within the nasal cavity. This is a phenomenon known as “mucosal contact,” or more accurately, “mucosal compression.” The mucosa is the mucus membrane that lines the inside of the nose. The septum is the wall that goes down the middle of the nasal cavity. From the side walls of the nasal cavity on each side protrude turbinates, which are structures composed of thin bone covered with mucus membrane. There are three sets of turbinates on each side, but we’ve discovered that one in particular, the superior turbinate, is the most important one dealing with migraine. We’ve found that when this turbinate grows in such a way that it is compressed against the septum, it commonly causes migraine.
BK: Why is that?
DC: Mucosal contact is like a pressure point. The two mucus membrane surfaces are very sensitive to pressure and these sensitive membranes are in effect being squeezed tightly together between two hard bones, the bone of the septum and the bone of the turbinate. This causes nerve compression in the area, which results in pain. We have shown that the superior turbinates from migraine patients demonstrate evidence of chronic pressure and that this pressure causes tissue injury. So, migraine, at least in some patients, represents a painful syndrome resulting from damaged superior turbinate mucus membrane caused by compression.
BK: But Migraine pain is found in the forehead or temples, not in the nose, isn’t it?
DC: Most patients with migraine experience pain in the forehead, temples in and around the eyes, and do not experience nasal pain. It’s referred pain, based on how the nerves in the nose send branches to the head and brain.
BK: Migraine is usually treated with medications. If the medications do not work, what is the next step?
DC: If we see mucosal contact on examination, I will try to apply numbing medication to that area right in the office. If the headache lessens significantly, we have good evidence to proceed with surgery. The decision to offer surgery is based on the frequency and severity of migraines, the failure of other treatments, the nasal exam and CT scan findings, and other factors. If surgery is offered and elected, we aim to eliminate the areas of mucosal contact.
BK: From the papers that you’ve published, it seems that you’ve achieved some amazing results. Does your treatment offer a cure?
DC: We have to use the term “cure” very carefully medicine. We’ve been successful at eliminating or reducing migraine in most but not all patients.
BK: Do you believe that there will one day be a cure for Migraine using this method?
DC: Not everyone with migraine will benefit from this approach. People whose migraines affect the back of the head or neck are not likely to have this mucosal compression. Patients whose migraines result from head trauma are unlikely to benefit from our approach.
