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headache when I bend, cough, sneeze or strain. MRI showed cyst in sinus. Any ideas?

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ENT Specialist
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I have been having headaches for over 5 months now. They occur mainly when I bend over, cough, sneeze, strain, lift my head while in bed at night, or shake my head from left to right. They are mainly across my forehead. If I shake my head it always hurts. I was treated for a sinus infection 3 times (different antibiotics each time). I do not have any sneezing , itchy eyes or runny nose. I have also had a CT of sinus and brain and a MRI w/wo contrast. The only thing that showed up was a small retention cyst in my lower left maxillary sinus. The neurologist referred me back to the ENT stating that he thought the headaches were more related to something in his field. He also was wondering if it could be a fungal infection. I went back to the ENT and he gave me amitriptyline 25mg to take. I have been taking it for 3 days and have not noticed a change. I have also tried nasal steroids with no results. The ENT said he did not think surgery was appropriate at this time since the headaches are my only symptom (along with some hearing distortion that comes and goes). I have also had my eyes checked and was tested for allergies. My eyes were ok and the allergy test showed I had a level 5 sensitivity to dust mites and to dairy. I have cut down on milk and took precautions for dust mites with no significant improvement. The things that occurred about 5 months ago were I started on synthroid (50) to try to suppress a 2 cm thyroid nodule (thyroid function is ok). I stopped synthroid for several weeks but head still hurt so I started back. They also began tearing an old mill down across the street from my house and I was next planning to stay in a hotel for a few days to see if my symptoms improve. I tried using a netti pot last night and my head hurts worse today, more pressure in the frontal sinus region. I am wanting to know if there is anything else I can try or do to narrow down the root cause of my headaches or any other ideas? It seems my doctors are at a loss at this point. I would think that the symptom of my head always hurting when I shake it from side to side ought to narrow it down.
Thanks for your help. XXXXXXX Walls
Posted Tue, 8 May 2012 in Ear, Nose and Throat Problems
 
 
Answered by Dr. Sumit Bhatti 5 hours later
Hi,

Thank you for your query.

1. I recommend that raised intra-cranial pressure should be ruled out. Bending over, coughing, sneezing, straining, liftng your head while in bed at night, or shaking your head from side to side increases intra-cranial pressure momentarily.

2. Is your cough aggravated or triggered by the above maneuvers? Do your headaches last only a few minutes or do they last several hours?

3. By an eye check up, did they only check vision or was papilledema ruled out?

4. Starting Levothyroxine Sodium (Synthyroid) when you are euthyroid may cause headaches due to increase in blood pressure or brain metabolism since the thyroid is the master gland of the body. Thyroid hormine, natural or synthetic, acts on each and every cell of the body. Stopping Synthyroid for a few weeks may not help as Thyroid hormone is also stored in the thyroid gland.

5. There may be an interaction between Prilosec (omerazole) and Synthyroid at an enzymatic level. Prilosec or Acidity may by themselves cause headaches.

6. A rare diagnosis to explain the distorted hearing will be a mild XXXXXXX Chiari Malformation. Distorted hearing may also be due to Eustachian Tube dysfunction. However you do not have a confirmed sinusitis. Fungal sinusitis may be missed on a CT Scan, but it will show up on an MRI. A small maxillary retention cyst requires no treatment. You also do not have any allergic symptoms. A mucosal contact or ethmoidal headache should be ruled out. Cervical spine or skull spine joint problems and a small cervical spinal cord syrinx should be ruled out.

I must emphasize that many times this is an idiopathic or unknown etiology. You may start further investigation in the light of the above. You may get your scans reviewed or share the images here or via a free file sharing site.

It is impractical to measure intra-cranial pressure by Lumbar Puncture. A short two week trial with Acetazolamide may be taken under medical supervison. Anti migraine medication may help control the headaches till investigations are complete.

I hope I have answered your query. If you have any follow up queries, I will be available to answer them.

Regards.
Above answer was peer-reviewed by
 
Follow-up: headache when I bend, cough, sneeze or strain. MRI showed cyst in sinus. Any ideas? 5 hours later
Dr. Bhatti,
Thanks for your reply. Here are the answers to your questions and my follow ups per your numbering:

1. How can I rule out raised intra cranial pressure? Can this be seen in an MRI? I have a compressed zip file containing my MRI w/wo contrast.

2. My cough is not triggered by any maneuvers. I have a slight/mild headache most of the time. The severe headache only occurrs when I perform a maneuver and it only last about a minute or less.

3. I have had no changes in my vision and my optic nerve was examined.

4. I was given the synthroid just to see if it would possibly shrink a thyroid nodule. My thyroid was functioning properly. I did start taking it about the time I started having headaches. As I mentioned I stopped for a few weeks but you said that might not be long enough. How long should I stop to rule out this being the cause of my headaches?

5. Step 4 could rule this out.

6.My hearing has gotten better, hardly no distotion anymore just some tinnitus.

I will await your response and plan to share your recommendations with my doctor. Please let me know if any of the additional information I have provided leads you to any particular conclusion. I would have attached my MRI but do not see an option for sending the zipped file. Please let me know about the synthroid.

Thanks for your help!
Best Regards, XXXXXXX Walls

 
 
Answered by Dr. Sumit Bhatti 4 hours later
Hi,

Thank you for writing back.

1. Mild benign or idiopathic intra-cranial hypertension is a diagnosis of exclusion.

2. Your magnetic resonance imaging scan (MRI scan) could not be attached as the files in the zip format cannot be uploaded. I would suggest that you email the report to me at YYYY@YYYY with the subject line being “ Attention to Dr. Sumit Bhatti”. It is very difficult to detect increased intra-cranial pressure without papilledema on MRI/CT images. However you may request a review by a radiologist who is familiar with the subtle changes which may have gone unnoticed.

3. Discontinue all current medication including Synthyroid and discuss the trial with Acetazolamide (Diamox) and anti-migraine medication with your doctor. A lumbar puncture may be avoided at present.

4. In view of the tinnitus, get a Neck ultrasound (USG) Doppler study done.

I hope I have answered your query. If you have any follow up queries, I will be available to answer them.

Regards.
Above answer was peer-reviewed by
 
Follow-up: headache when I bend, cough, sneeze or strain. MRI showed cyst in sinus. Any ideas? 6 hours later
Dr. Bhatti,
I emailed the copy of my MRI report to you to your attention. Please let me know your comments. One last question:

1. If I stop taking the synthroid today, how long do you think it would be before I would see an improvement with the headaches if the synthroid is the cause?

Thanks and Best Regards, XXXXXXX Walls
 
 
Answered by Dr. Sumit Bhatti 7 hours later
Hi,

Thank you for following up.

1. It will take three to six weeks for you to see a reduction in your headaches if Synthroid is the cause.

2. Serial estimation of your Thyroid Function Tests (TFTs) is an important guideline for the effect of thyroid hormone supplementation. You may also request for a TFT and re-evaluation of your thyroid nodule.

3. The type of nodule, functioning or non-functioning, may be elicited with a radionuclide Thyroid Scan.

4. I will be forwarded your scan images only if you have specifically marked them to my attention. Please add 'Attn: Dr. Sumit Bhatti' to the subject line and e-mail to ' YYYY@YYYY '.

Regards.
Above answer was peer-reviewed by
 
Follow-up: headache when I bend, cough, sneeze or strain. MRI showed cyst in sinus. Any ideas? 4 hours later
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Follow-up: headache when I bend, cough, sneeze or strain. MRI showed cyst in sinus. Any ideas? 1 hour later
Thanks Dr. Bhatti,
I sent an email that contains my MRI report to your attention. I would appreciate any comments you may have.
Thank You XXXXXXX Walls
 
 
Answered by Dr. Sumit Bhatti 6 hours later
Hi,

Thank you for following up.

1. Your MRI (Magnetic Resonant Imaging) report is within normal limits.

2. The maxillary retention cyst requires no treatment.

3. The 'UBO's (Unidentified Bright Objects) seen in the peri-ventricular and XXXXXXX white matter may represent changes associated with episodes of hypertension. They are sometimes associated with migraine. You should review your blood pressure issue with your physician. If you have any subsequent MRIs, keep track of any increase in the UBO size and number (which may signify an active process).

4. You should get your MRI images (not the report) reviewed by a radiologist to rule out the conditions mentioned above.

I hope I have answered your query. If you have any follow up queries, I will be available to answer them.

Regards.
Above answer was peer-reviewed by
 
Follow-up: headache when I bend, cough, sneeze or strain. MRI showed cyst in sinus. Any ideas? 2 days later
Hello,
I would like to know if I take Diamox and it releives my symptoms, is this something I can take on an ongoing basis or is it just used as a diagnosis for raised intracranial pressure?
Best Regards, XXXXXXX Walls
 
 
Answered by Dr. Sumit Bhatti 3 hours later
Hi,

Thank you for following up.

1. You should take Diamox only under strict medical supervision.

2. This is because Diamox is a potent diuretic and prolonged use also causes electrolyte disturbances in the blood, making it more acidic.

3. Hence it will work only as an adjunct to diagnosis and not for long term use.

4. Your doctor will review any contraindications and keep track of the any side effects.

I hope I have answered your query. If you have any follow up queries, I will be available to answer them.

Regards.
Above answer was peer-reviewed by
 
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