Unclear diagnosis of morning headache, ET fullness etc.

[JacGallo]

Hello Doctor:

About 2 or 3 days per week, I wake up with a dull pressure-headache in my forehead, fullness in my eustachian tube, a slight nasal congestion, a feeling of malaise, very dry mouth, and scratchy throat..  The symptoms usually reduce a lot by the afternoon. I have also noticed that this happens when I get a full night's sleep.  In other words, if I sleep only 5-6 hours at night, then I don't get these symptoms. However, if I sleep a full 8 hours, I invariably get the symptoms.

I have had this problem for several months now following a bout of Otitis Media in Oct 2008.  Back in October I was told that I 'might' have an underlying sinus infection and was put on Flonase for 6 weeks. This did not help the problem. I was then sent for a Sinus CT scan that showed all sinuses to be clear, except a mild mucosal thickening in maxillary sinus. I was subsequently but of 3 rounds of antibiotics by my ENT, first Cefuroxime, and then back-to-back rounds of Azythromycin (6-Pak).  None of this helped.  The ENT then did an endoscopy of sinuses and found everything to be normal. At this point the ENT gave up on me.

In early Jan 2009, I went to an Otoneurologist, who sent me for a Brain MRI.  This showed no problems in the brain and mastoiditis. It did show mild mucosal thickening of Ethmoid and Maxillary Sinus, which was dismissed as insignificant and unlikely to cause my symptoms.  The OtoNeuro says that I had some ET dysfunction leftover from the Otitis Media, and my headaches are tension headaches. I have now been put on Astelin nasal spray and told 'wait out' the headaches. If the headaches don't clear, he wants to put me on Effexor. I'm scared about this, because I've read that Effexor causes a whole host of side-effects, and besides I don't feel depressed! I'm a happy person.

Question: Can even 'mild' sinusitis cause morning pressure headache, malaise? Is it possible that i just need more aggressive antibiotic treatment for this?

thanks,

Akshay

[Rosi3e]

I had those I read somewhere it could be because ur head is too elevated, if u sleep with a lot of pillows try sleeping with 1 or 2 thin ones.  Well i did it and i stopped waking up with head aches and kneck and shoulder pain.

[Neuro Forum]

Thanks for using the forum. I am happy to address your questions, and my answer will be based on the information you provided here. Please make sure you recognize that this forum is for educational purposes only, and it does not substitute for a formal office visit with your doctor.

Without the ability to examine you and obtain a history, I can not tell you what the exact cause of your symptoms is. However I will try to provide you with some useful information.

It sounds like you have been evaluated by an ENT, so I will not really comment on the ENT causes of headache except to say that sinusitis is not as common a cause of headaches as it is usually thought. It sounds like you have had extensive imaging, and if your imaging is not showing definite sinusitis, then treatments with antibiotics will not be indicated. Chronic sinusitis does not necessarily respond to antibiotics. Other issues regarding Eustachian tube dysfunction etc are not within my field of expertise, so I will defer these questions to your ENT.

Reading your symptoms, one potential cause that comes to mind give the throat symptoms you experience in the morning is acid reflux from your stomach.

Regarding the neurologic causes of morning headache, the most concerning would be something that is causing elevated pressures in the brain, and a tumor would be of most concern. Luckily it sounds like you have had a normal MRI of your brain which implies the radiologist who read the MRI did not see a tumor or another mass lesion.

One potential cause of morning headaches is sleep apnea! If a person is having a breathing disorder during sleep, he/she may wake up with morning headaches. Sleep apnea most commonly occurs in over-weight people who snore, but it can occur in thin people with narrow throats, large tongues, etc. The symptoms of sleep apnea besides snoring interrupted by loud gasps of air include day time sleepiness, poor concentration, and morning headaches. Left untreated, sleep apnea can contribute to high blood pressure, depression, and heart disease. It is best diagnosed with a study called a polysomnogram, or sleep study.

Another cause of morning headaches is bruxism: biting down on the teeth at night. This can cause pain referred to the ear: pain can be within the ear rather than the temple area.  Bruxism may lead to arthritis of the temporo-mandiublar joint, commonly called the TMJ. This can sometimes occur due to bruxism, biting down at night or during the day, and other stresses to the joint. This is best diagnosed/managed by an orthodontist or an ENT, and treatment includes braces and other dental fixtures and sometimes muscle relaxants, depending on the exact cause.

Other possible causes could include tension type headaches, migraine headaches, or cervicogenic headaches (headaches due to neck arthritis or muscle tension).

Effexor is an antidepressant medication and maybe useful if you suffer from depression or anxiety. In patients with chronic headaches, treatment of underlying depression or anxiety is often helpful in improving the headache.

I can not diagnose you with any of the above conditions given that i have not examined you or obtained a history, however, they may be things you would like to discuss with your primary doctor. If your headaches persist, I recommend you be evaluated by a neurologist. After he/she examines you, he/she may be able to classify your headache and offer appropriate therapy.

Thank you for this opportunity to answer your questions, I hope you find the information I have provided useful, good luck.