How do doctors know a headache is coming from the nose?

Short answer: An ENT looks for a nasal trigger with nasal endoscopy and a CT scan. If a contact point (Sluder's neuralgia) is seen, a local anaesthetic may be placed on that spot; if the headache eases soon after, it supports the nose as the source. No single test is final, so the history, examination and scan are read together.

Key takeaways

• Most headaches are not caused by the nose, so the first step is ruling out common causes such as migraine and tension-type headache.
• A nasal endoscopy lets the ENT see the septum, the side wall of the nose and any point where two surfaces touch.
• A CT scan of the nose and sinuses shows the bony anatomy and any pressure points in more detail.
• A numbing test, done in clinic, can add supporting evidence if pain eases after local anaesthetic is placed on the contact point.
• The decision is made from the whole picture, not from one test.

Dr. Prashanth's perspective

On nasal examination, when I see the septum or the central bone of the nose touching the side wall, I suspect a contact point headache. Endoscopic assessment with numbing of the area can support the diagnosis if the pain eases. A CT scan of the nose gives more clarity on possible nerve impingement.

— Dr. Prashanth R. Reddy, ENT Surgeon, ENTHealth360

Can a headache really come from the nose?

Yes, in some people. Inside the nose, a bent septum or a bony spur can touch the side wall or a turbinate. This is called a contact point. The pressure can irritate nerve endings and refer pain to the forehead, around the eye or to the temple, even when there is no infection. Doctors also call this Sluder's neuralgia.

These headaches are only one cause among many. Migraine, tension-type headache and sinus infection are more common, which is why a careful assessment matters before any conclusion.

What clues in your story make an ENT think of the nose?

The history is the starting point. Clues that make an ENT look inside the nose include:

• A headache that is long-standing or keeps returning and has not settled with usual headache treatment.
• Pain around the forehead, eye or temple, sometimes with neck or shoulder discomfort.
• A nose that feels blocked, often on one side, or headaches that worsen when you catch a cold.
• No clear aura, nausea or vomiting, which are more typical of migraine.

None of these proves a nasal cause. They only tell the doctor where to look next.

How does nasal endoscopy help?

A nasal endoscopy uses a thin camera passed gently into the nose after a numbing spray. It takes a few minutes and lets the ENT see the septum, the side wall, the turbinates and the drainage pathways.

On examination, when the septum or the central bone of the nose is seen touching the side wall, a contact point headache becomes a possibility. Endoscopy also shows other findings such as polyps, swelling or discharge that may explain the symptoms.

Why is a CT scan of the nose useful?

A CT scan of the nose and sinuses gives more clarity than endoscopy alone. It shows the bony anatomy, the exact points of contact, and the state of the sinuses, which an endoscope cannot fully see. It helps the ENT judge whether a contact point could be pressing on a nerve pathway.

Because CT uses radiation, it is advised when the result will change decisions, for example in a long-standing headache with suspected contact points or when surgery is being considered.

What is the numbing test?

If a contact point is seen, the ENT may place a small amount of local anaesthetic on that spot during the endoscopy. If the headache eases soon afterwards, it supports the idea that the pain is being triggered from that area.

This test is a clue, not a final answer. Pain relief can have other explanations, and a lack of relief does not always rule the nose out. That is why it is read together with the history, the endoscopy and the CT scan.

What else is done?

• A review of your headache diary, if you have kept one, noting timing, side, triggers and nasal symptoms.
• A check for other causes, such as migraine, allergy or sinus infection, sometimes with a physician or neurologist.
• Review of what treatments you have already tried.

What happens if the nose is the cause?

The right option depends on the cause. Some people are treated with medicines such as saline rinses and nasal sprays. Surgery is considered only in selected people in whom examination and scans show a clear nasal cause and other treatment has not helped. Your ENT will explain the choices that suit you.

When should you see a doctor?

See an ENT if headaches keep returning, have not settled with usual treatment, or come with a blocked nose on one side.

Seek urgent medical care for a sudden, severe "worst-ever" headache; headache with fever, a stiff neck or confusion; swelling or redness around the eye, double or reduced vision; weakness, numbness or difficulty speaking; or a headache after a head injury.

Frequently asked questions

Can a CT scan alone prove my headache is from the nose? No. It shows anatomy, but doctors read it together with your symptoms and the endoscopy.

Is the numbing test painful? The nose is first numbed with a spray, and the test is usually brief. Discomfort differs from person to person.

Does a deviated septum always cause headache? No. Many people have a deviated septum without headaches. It matters when it causes a contact point or blocks drainage.

Could my headache be migraine instead? Yes, migraine is more common. A proper assessment helps separate the two, and some people have both.

References

• Headache Classification Committee of the International Headache Society. The International Classification of Headache Disorders, 3rd edition. Cephalalgia. 2018;38(1):1-211.
• Fokkens WJ, Lund VJ, Hopkins C, et al. European Position Paper on Rhinosinusitis and Nasal Polyps 2020. Rhinology. 2020;58(Suppl S29):1-464.
• Schreiber CP, Hutchinson S, Webster CJ, Ames M, Richardson MS, Powers C. Prevalence of migraine in patients with a history of self-reported or physician-diagnosed "sinus" headache. Archives of Internal Medicine. 2004;164(16):1769-1772.

About the author

Dr. Prashanth R Reddy is an ENT surgeon at ENTHealth360, Bangalore (MS ENT; MBA, IIM Bangalore; Seoul Rhinoplasty Fellowship), seeing patients at Sakra World Hospital, Marathahalli and in Koramangala. His practice focuses on how breathing affects sleep, headaches, energy and everyday performance.

Related reading: Why do I get nose blocks and headaches in AC? · Why does my sinus keep coming back every few months?

For educational purposes only. Not a substitute for medical advice. Please consult a qualified ENT specialist.