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.
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.
Best of luck with your treatment and thank you for sharing your experience.
That’s how I feel. My eye pain feels like someone is stabbing me in my eye! My ENT discovered I had a deviated septum and significant bone spur in my nose. I’m hoping my upcoming operation will cure my migraines.
For me I had a giant bone spur on the bottom of my passage. My ENT surgeon literally described as “profound, severe, massive” three adjectives that are almost always bad coming from a doctor, or a 55 year old doctor telling you it’s the largest he’s ever seen.
Normally on the bottom isn’t too bad but whenever I got congested or a infected it would push right into my tooth where I had a root canal and crown. I apologized to my former dentist later becuase I thought he screwed up.
Could you recommend a doctor near Santa Cruz, CA? I have all these symptoms and was diagnosed with a deviated septum and bone spur before I was relocated to CA for job change. I’m having severe pain.
Did you find a doctor to relieve your symptoms?
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.
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!
Hi, did the surgery fix the Trigenimal neuralgia? I have had it for 26 years and recently discovered I have a deviated spectrum.
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?
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.
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
I don’t but if you can make it to nyc try Seth Lieberman or Richard Lebowitz. Best of luck!
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
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.
How can you tell if it’s the septum causing the contact or the turbinate?
I have had horrible right sided facial pain since a septoplasty/fess surgery. I feel like something is constantly pushing or pulling and get horrible headaches in eye, teeth, neck.
Feels like something is stuck in my nose constantly causing pressure.
I have had Chiro work, Cranial work to try to relieve the pain.
Nothing seems to help.
I’m having sort of the same symptoms? Did you make progress on this? I saw my ent today but my symptoms are mild and I didn’t make a point to me too mention the pain. It’s getting pretty distracting though and does seem kinda abnormally painful.
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.
Try a spray of Afrin when you have the headache. If it helps then that supports the diagnosis.
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.?.
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.
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.
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.
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.
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
Hi Ray — I think you’d have to visit an ENT to confirm the diagnosis then.
Do you ever practice in New York or have an affiliate in NYC?
try Seth Lieberman or Richard Lebowitz at NYU
Hi,
The end of December 2019 I had a Septoplasty for a spur and deviated septum towards a left sided facial pain and headache I had 2 years. I have septal swelling that doesn’t go down plus my headache is still as bad as Before the headache. My ENT says the swelling is normal . Afrin doesn’t even help. I keep irrigating and don’t know what to do. Should I get a second opinion?
I live in Buffalo and already take Gabapentin. Do you recommend anyone in NY?
Hi Susan,
Sorry to hear about your ordeal. The key to predicting whether septoplasty will help with pain is to determine if Afrin reduces or relieves the pain prior to surgery. If not, it’s very likely the pain isn’t due to your deviated septum in the first place. Assuming the surgery was technically well performed, the poor result essentially rules out the possibility of Sluder’s neuralgia. I would seek consultation with a neurologist in the area to rule out migraine before considering another consultation with an ENT at this point.
Hi,
Since September 2019…I have been dealing with left sided headache, neck to shoulder pain,rare teeth pain,also nose pain , left nostril blockage and sometimes when i touch my eye watery sound i hear..
ENT said its Trigeminal neuralgia..
Then i consulted with neurologist who said its just migraine or just muscular pain.. prescribed painkillers didn’t work!
Two months ago i am again consulted with the ENT due to same problems.. and he did nasal endoscopy and said i have nasal septal spur.
Which causes these pains and recommend me steroidal nasal spray, decongestant( Telfast D) and diclofenic potassium..
This prescription works but not all time..
What type of diagnosis/scans help me to find exact problem??
And also suggest me medicines.
CT sinus can confirm the ENTs finding. If there is a large bone spur and it is relieved with nasal decongestion, you will need septoplasty to permanently resolve the problem.
Thanks Dr ☺
Hello, I have had left side migraines for a very long time. They start in the inner corner of my left eye and the side of the nose. The pain is like a hot poker stabbed in the side of my nose. The pain then goes into the bones around my left eye, cheek and temple. I end up taking maxalt, a pain med and a sedative before it is relieved. May take a day or two before I get relief.
Three weeks ago the headache started again but this time it would not go away!! I took everything I could think of. I could get it tamped down but it just came back. I stood the pain for 5 days and then went to ER where I was admitted. Last year I was diagnosed and treated with high dose steroids for Giant Cell Arteritis. At the ER they at first thought it was a relapse of that. But after two IV bags of 100 mgs steroids the pain was still there. So the neurologist diagnosed me with Trigeminal Autonomic Cephalgias. The medicine recommended for it has terrible gastro side effects. Could hardly make it to the bathroom. Long story short my neurologist wanted me to see an ENT. I saw him today and after a nasal endoscopy and many questions he looked at my scan from the hospital and said “well I’m not a brain doc but look at this” he turned the screen around and said “you have a nasal bone spur”!! I was so shocked! All those doctors I saw in the hospital and not one of them saw it. I’m not a doctor and I could clearly see it on the scan! The ENT has me on Flonase for a couple weeks and then surgery. But I am going to try the Afrin before I go back to him.
I am very unhappy no one spotted the spur, as I thought I was loosing my mind. The pain was so excruciating it was making me feel like giving up.
Thank you for all the information and making me feel not so alone!
Did you have the surgery and get any relief. Our headaches sound familiar!!
How did you do after the surgery ?
Hello, I am a 53 y-o male. One year ago, I suffered a serious sinusitis that required two rounds of antibiotics and daily ciclesonide spray that I am still taking. After the second visit to my GP (in December 2019), in addition to the antibiotics, he prescribed a CT Scan. I had the CT Scan done in April 2020. The scan revealed that the sinusitis had cleared but that I had a left septum deviation of 2.5mm and a bony bar of 5mm. Since the sinusitis (roughly one year), I suffer from moderate headache and pain on my face in the nose area. I also suffer from a kind of bursting headeache when I sneeze except if I sneeze in bed in the morning or laying on the couch for 10-15 mins, then no bursting headache. Last spring, for about one month, I experience electric shock like pain in my forehead, something I never had before. I have tried to stop ciclesonide but find the pain is worse if I stop. I have seen an ENT doctor but he says that since the sinusitis has cleared and the drainage is good, the source of the pain is something else. I did not experience that pain before the sinusitis last year. Thanks for your assistance.
Unclear what’s happening here, but pretty sure the septum is not the culprit. Sinusitis doesn’t move bones — you probably had that deviated septum all your life.
Thanks for the speedy reply. What can I do ? Should I stop ciclesonide ? I was hit by a badminton racket in the face 40 years ago (loosing 2 teeth in the process). Can sinusitis make tissue swollen or more sensitive ? What caused the electric shock in the forehead that I experienced in the spring ? Could the bony spur be the cause of it ?
That’s tough to answer without seeing you. I’m not that familiar with the medication. I’d suggest seeking out an ENT in your area.
Thanks for your speedy replies. I will seek a 2nd and 3rd opinion. This issue is really bothering me although the symptoms have decreased since their peak 10 months ago.
This is so insighful. I have been suffering from severe pain in my corneas, (both), off and on for the past 5 years, (38yofemale). This past January it became a chronic daily issue. I was originally diagnosed with dry eyes, but after none of the incredibly expensive out-of-pocket treatment worked, I was finally referred to a corneal specialist, who determined I do not have dry eyes, not even close, but corneal neuralgia. He tried Lyrica, it helped slightly/briefly. Then, amitriptyline, it helped 100% but only for a couple months. I’m now with the Pain Management Specialists at Wash U and they added gabapentin, better, but who knows for how long… they also ordered a brain MRI, came back clear, the follow up appt. to that is next week. However, I had a sudden loss of hearing in my left ear 6 years ago and when the audiology report came back as nerve damage, they, (ENT’s office), also ordered an MRI, that too was clear, except for showing a deviated septum. They referred me to a surgeon for it, but I didn’t follow through. And, even though the hearing issue was never resolved, I think I just got used to it. Any chance the 2 issues could both be the result of the deviated septum?
My best guess is that the septum isn’t related as it’s rare for septal spurs to cause bilateral symptoms.
My mom discussed this with her ENT the other day. He told her pressure on the bone releases a chemical which effects the nerves in the brain. Any insight into what chemical a he referring? And, if not a n issue from deviated septum? Any guesses as to a pathological cause? I have 2 small children and I’m running out of ideas as to how to get to the root of the problem for this. My family desperately needs me well, so I’m leaving no stone unturned. Your input would be greatly appreciated!
Hi doctor,
I have had terrible eye pain mainly below my eyes from 3months on a day to day basis. I had CT of PNS which shows slight mucous in maxillary sinusitis and a deviated nasal spectum. I just have around eye severe pain and no headaches. Is it because of deviated nasal spectum as pain due to sinusitis has been ruled out. Please help me
Provide a link to a picture of your CT showing the deviated septum.
Kindly see the link for attached CT report. Pls guide me…..
https://drive.google.com/file/d/1gyj9-Qeu3dLCsC4Xio2BsHa2ignxWEN_/view?usp=drivesdk
Which eye hurts?
Eye socket hurts.. smtyms left eye and sometyms right eye.. majorly right eye socket and eye corner near nose.
Less likely to be your nose if it’s both sides. You can try spraying some afrin in the right side when it hurts. If the pain stops immediately then perhaps it’s related to the septum. Hard to say otherwise. Best of luck.
Ok thanku so much
Hello doc, after u asked me to use nasal drops, i found it when there was pain near my eye socket i used to use nasal drops on that nostril and the pain would reduce after few minutes. What is your observation on this ?
Ok thanku so much
Dear Doctor Zhou,
Thank you for sharing you experience and expertise here, it is very valuable and I am sure you attention and caring for patients is highly appreciated.
I’d like to know if you have ever encountered similar symptoms (unilateral headache, unilateral orbital and/or eye pain, and so on) in cases where the septum isn’t deviated and there is no touching between the bone and the nasal mucosa,
BUT rather there is contact between a bone spur pointing outwards, and the external part of the bridge of the nose (in fact, there is even a red spot on the skin where the spur poiting outwards is touching)?
I hope I was clear enough,
Thank you very much and keep up your great work and service,
regards
Giacomo
Hi – I can’t say that I have. But if you only have symptoms on that side, you can try asking a physician to inject that area with lidocaine to anesthetize it to see if it gets rid of your pain.
Dear Doctor,
Thank you very much for your kind reply!
I’ll try to ask my physician about the lidocaine test when I get to see him.
i guess that if the spur is pointing outwards rather than inwards, the Afrin test is useless, am I right?
Thanks again for your invaluable service,
Giacomo
Hello doctor. Actually I’m also going through the same problem. I have a septal spur in my right nostril. But i don’t feel any severe pain. I just feel constant facial pressure particularly in the areas around my nose and sides of my forehead. I have lost my all focus due to this. Currently I’m on medication and if it is not corrected by it then I will look for surgery
Having this surgery tomorrow for touch spot in septum and large bone spur , no relief with Afrin . Major head pain , facial pain , upper teeth . For 1.5 years now , hope this helps
Hi there! I have had pressure in my face and upper teeth along with mild headaches in same areas for last 8-12 weeks. I got a CT scan and showed my sinus is clear but It showed that i have a deviated septum and bone spur. And going by other peoples experience it seems that maybe getting this fixed will hopefully fix that! I’m booked to see the ENT next month! Fingers crossed!
A quick trial of afrin should tell you whether or not the spur is the cause of the pain.
Would you expect if the afrin didn’t improve my symptoms that the spur could be the potential issue?
Exact opposite.
I have the same issue. Initially congestion and moderate/severe pain in upper teeth on my left side. Ruled out dental causes. Flonase, zyrtec, aleve provide temporary relief. Saw the ENT today (FINALLY) along with CT. Deviated septum and bone spurs noted. ENT said that I should see a neurologist. No migraines. I feel like I should get a second opinion. No possible treatment offered. Simply “not sure there is anything I can do”. Am I right to seek a 2nd opinion?
The spray to try is afrin. If your dental pain goes away immediately after the afrin you should consider finding someone willing to fix the septum for you.
I had moderately severe pain on the nose ridge on 11th July twice, once afternoon for 3 hours and then night for 2 hours. Went to ENT next day, had CT and endoscopy— DNS with spur on the right side.
I was diagnosed with Sluder’s neuralgia and told to use Oxymetazoline when in pain.
I had been having mild congestion for 3 weeks preceding but didn’t really use nasal spray.
On 18th, I had pain on the nose bridge again, right where it meets the joint between nose and the body.
I applied Oxymetazoline spray but it didn’t work. The nose pain lasted 7 hours,
Now I am using saline nasal drops thrice a day and congestion is much better.
But does it mean I don’t have Sluder’s? since the decongestant didn’t help?
I am worried about the pain coming again and welcome any suggestion.
On the first occasion, the pain was the the nose bridge and slightly to the right side but on the latest occasion, it was entirely central.
To confirm, I would perform a nasal endoscopy while you’re under effects of the afrin. If the nose is decongested well and the pain doesn’t go away, then you probably don’t have sluder’s neuralgia.
Several months ago I broke my nasal septum accidentally by pressing against my nose too hard. Might sound silly, but at the time I was unaware that my septum broke. Few weeks after that I started feeling some nasal congestion recurring in my right nostril depending on the nasal cycle. Together with that I started feeling some slight pain, or rather weird sensation around my right cheek and right forehead. At first I thought I’m experiencing sinusitis, but I realized that I have no rhinorrhea, and the feeling is on the skin of the face rather than deep in the sinuses. I also noticed that this sensation is more severe whenever my right nostril gets congested, but it doesn’t disappear entirely when it gets decongested. It came out that when I broke the septum it regrew with a deviation and a septal spur that goes back to the middle turbinate. I’ve read some articles about it, some are declining the existance of this phenomenon, but it really does exist. My question to anyone here who has some experience regarding this: can I safely travel on an airplane with this condition? My sinuses are fine and so are my ears. I have no problem equalizing the air pressure. My only concern is if this weird feeling on my face might get worse on an airplane. Also, I’m planning to get my nose sorted soon but I have some travelling coming up first.
If this is truly your problem a quick spray of afrin will resolve it within minutes. Bring it with you on your flight. As long as you don’t exceeds 3-4 uses per week you’ll be fine. Permanent fix would be septoplasty.
In my case decongestants work well in reducing this sensation, but it doesn’t disappear entirely as there still remains some degree of contact. I hope it’s still fine to travel by plane though. Thank You very much for such a quick response, I appreciate it!
Dealing with this now. Terrible constant pain into eye, cheek, and most of all teeth. Sometimes I feel faint and dizzy. The pain is consuming. Dr wants to try steroid sprays and I hate surgery. I’m ready to go in there myself and nip it out!
I have been suffering from ocular discomfort pain on left side only. Started at eye doctor. Then went to the Ent did a who CT scan which shows a nasal septum spur on the left side. Would you be willing to look at my scan and advise if you think the pain could be result of spur?
It’s been on-going for 2 years. I have 4 small children and desperately need to resolve this. Really appreciate your input.
Best way to figure out if the two are related is by using afrin. If they are related the pain will subside right after the afrin use.
Oh my god, thank you! I have been having right-sided headaches for over a decade with every neurologist telling me it’s migraines and inundating me with migraine meds that made me violently nauseous and did nothing for the pain, rheumatologists telling me it’s TMJ in spite of my regularly seeing my dentist and said dentist repeatedly telling these people it is NOT TMJ, and eventually I gave up. I guess I am an odd duck in that I don’t normally suffer allergies, or at least not so severely that I notice, and my nasal passages are so clear that I didn’t notice until my first sinus infection after 21 years that, no matter how much I recovered, my right nostril was never NOT congested, even if everything else was otherwise clear. I just can’t breathe through it, and somehow I never noticed. I played sports all through my childhood and high school, up until I required major spinal surgery at the age of 23. While I can’t say I *recall* taking any basket-, soccer-, or volleyballs to the face, it’s reasonable to assume that I occasionally did because that’s just the nature of those sports, just not hard enough to leave an obvious impression (ie, a completely broken nose, because I’m sure I would remember that!). When I came to this realization I started researching deviated septum, noticing that when a headache started, if I pull the skin of my cheeks outward, essentially forcibly pulling my nasal passage open, the pain stops! This article explains what is probably the most likely source of my issue, and now I can go back to my PCP and tell her we may have another route to explore! Thank you so much for writing this out since it is apparently not something anyone ever thinks of, be they professional or people who suffer like me. Thank you, thank you! I am literally crying because I thought I had exhausted all avenues of exploration, and now I have a new one that seems way more promising than the others!
The fact that your pain and breathing are so well correlated gives me optimism we’ve got the right diagnosis.
I seen an ENT yesterday, I have been suffering from Extreme Headaches for 5 years now. He said I had a deviated septum but prescribed me nose spray and told me to take Allegra allergy medicine. So I did this after the appointment yesterday and still woke up twice last night with a headache on my left side. It always happens in my temple and behind my left eye. He did not even scope my nose to see if there was anything further up causing an issue. Is this common for ENT’s do they not do a full work up when there is deviated septum. You would think after 5 years of constant headaches he would have been a bit more thorough. This is very frustrating and more money out of my pocket without a result. So tired of doctors just saying do this and give me money without a result.
Hey Chris,
Sorry to hear that. If you haven’t tried the simple sprays it’s reasonable to give it a shot. You were probably prescribed something like Flonase, which takes a few weeks to work. A scope in your nose can cost hundreds of dollars so we usually reserve it for after you’ve tried the cheaper solutions. To help determine if your headaches are related to your septum – spray your nose with afrin when you have a headache. If it goes away, then there’s a chance the two are related. Best of luck.
I was told to stay away from any kind of decongestants for sprays. I did buy some Flonase and the nose spray does help when I use it to alleviate the headache but that was a decongestant spray I was using. I am just tired of throwing money at the problem and getting told the same thing over and over use nose spray and allergy medicine. My PCP told me the same thing the ENT told me and it has not worked yet. So there is another issue.
If the decongestant helped, you are right – someone should scope your nose and see if sluders neuralgia could be your problem.