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.