Brief Answer:
NDPH extremely unlikely at your age

Detailed Answer:
Good evening. My name is Dr. Saghafi. I am an adult neurologist and headache specialist. I'd like to give you a few comments on your headaches which I hope will be helpful to you.

You didn't specify this detail in what you wrote but I will assume that NDPH refers to one of the newer classifications of headaches referred to as New Daily Persistent Headaches. These typically do not occur until a person's 40's or 50's. They present in a completely different way from how you've described the pain and for those reasons I think it unlikely that either you or your girlfriend could have the headache type NDPH.

The fact that a spinal tap, CT scan and other tests have come back negative rules out any secondary cause to your headaches such as aneurysms, obvious infectious source although I realize you were told by at least 1 doctor that you had Lyme. I would tend to go with the opinion of the infectious disease specialist and not only that you've been treated so the likelihood of an ongoing Lyme infection is almost zero at this point.

The sinus condition you're describing also is not something we would consider of any significance in terms of causing headaches. Chronic mucosal thickening is not considered a risk factor for headaches and more so when you refer the presence of fluid drainage. It is simply coincidental that you have the headaches on top of the sinus drainage. I would caution on how aggressive you try to be with nasal or other forms of steroids (fluticasone) which can and do have a propensity of making headache states worse by way of their chemical properties and side effects.

Be sure you are not using more than 10-15 doses of analgesics per month such as Tylenol, aspirin, ibuprofen, naprosyn, and other over the counter preparations (or even prescription such as Imitrex, Maxalt, Zomig, and others) though you are not referring migraine symptoms I have seen these medications used in other types of headaches (i.e. inappropriately) simply because providers may feel that they need to try other medications since standard drugs don't always work.

You've not said what if any medications you've been tried on over 8 months so feel free to elaborate on that detail. In my headache practice both in the office as well as the VA Headache Clinic I have patients keep careful track of their headaches using daily diaries and logs. In order to get the most information about the headaches and determine the best interventions (pharmacological or not) at least several weeks of data should be collected and analyzed by a physician skilled in this type of problem.

Therefore, I may make the suggestion that you seek out a Headache Specialist in your area (unless of course, you'd like to see the Rock 'N Roll Hall of Fame then, I'll make some room for you in the office! LOL). There are many ways to approach chronic daily headaches of the less intense nature as yours aside from using medications and it simply depends on other symptoms that you may have that drives us to offer one over another.

The fact that your girlfriend developed similar headaches is certainly a curiosity but such headaches obviously are not contagious. But what I would look at as a possibility is the environment you're living in. Do your headaches ever subside when you removed from your residence for any length of time...especially if you go out of town for a few days either on business or vacation?

I recently had a patient who lived in XXXXXXX and who had a similar story of headaches with their significant other living in the same apartment. However, their headaches were much more dramatic and became severe within moments of entering their dwelling, despite opening windows and so forth. They had gone so far as to call both the police as well as fire depts who did not find anything. When I consulted on the case and they described similar symptoms of headaches that were severe and developed at the same time I had them begin searching for chemicals in the apt or asked if they'd had any construction work done recently.

As it turned out they had had their kitchen repainted and hardwood floors refinished by the landlord about 1 month before. The painters had left residual paints and varnishes on top of the furnace in the basement. The heat from the furnace vaporized the paint products which traveled through the ductwork and into the apartment which was directly above. Headaches resolved immediately when those open cans were removed.

I wish that your headaches could be the same.....although if this turns out to be the case for you guys....I'll have to write a book...and then, we'll all go on the Dr. Oz show together so he can get rich! LOL.

Think about your environment and how it's changed in the last 8-10 months and how whether or not your girlfriend shares that same environment with you etc. etc.

If this answer satisfactorily addresses your question then, I'd appreciate the favor of a HIGH STAR RATING with some written feedback on your part.

Also, CLOSING THE QUERY on your end (if there are no further comments) will be most helpful and appreciated so that this question can be transacted and archived expeditiously for further reference by colleagues as necessary.

Please keep me informed as to the outcome of your situation by writing me at: bit.ly/drdariushsaghafi

All the best

The query has required a total of 60 minutes of physician specific time to read, research, and compile a return envoy to the patient.

---

Brief Answer:
Thank for your compliments.....BUT...May I disagree with a thing or 2? LOL

Detailed Answer:
Many thanks for your compliments...I hope that doesn't mean that I can't DISAGREE with a couple of important points you mention having to do with headaches and the current party line on what can and what cannot cause them.

I will concede your point regarding an environmental factor being responsible for yours and your girlfriend's headaches since you explained in MORE DETAIL why that is not likely to be the case. Prior to your explanation, however, I believe it was a plausible thought.

I'm a neurologist and not an expert in sinuses, infections of the same, an allergist, or an ID specialist (unless we're talking about infections of the brain and spinal cord). HOWEVER, when it comes to the pathology of things going on in the sinuses and headaches the following is given to be the party line.

1. SINUSITIS as well as pathologies of the sinuses (chronic mucosal thickening, osteomas, sinoliths, continuous drainage, allergic sinus reactions, etc.) are believed to cause a grand total of 0.5-1% of all headache problems (be they mild, severe, or in between). Furthermore, the term "sinus headache" or headaches CAUSED by either sinus infection, sinus drainage, or other pathology such as mucoceles, cysts, osteomas, angiomas, etc. are (by headache specialists) THE MOST ERRONEOUSLY OVERDIAGNOSED ENTITIES. We know this through the numerous series and studies performed on patients with "diagnosed sinus infections" treated with rounds of antihistamines, antibiotics, and surgeries for all sorts of relief measure from drilling holes, to cauterizations, etc. and note the most marginal CURATIVE RESULTS possible when the strictest of criteria in order to diagnose sinus infections or sinusitis are NOT USED.

OSTEOMAS on the other hand are benign tumors which when found in the nasal passages and sinues CAN BE THE SOURCE of chronic and mild headaches when they are small. As they grow and enlarge and especially if they become more invasive either into the bone or break through into other structures can cause PROGRESSIVE HEADACHES and can result as well in the development of SINUS SWELLING and infections based upon OBSTRUCTIONS of the nasal passages. This certainly can be the cause of headaches (worsening over time) and these headaches are clearly relieved by surgery. However, as time goes on and osteomas grow they usually are associated with not just headaches and sinus drainage but also obvious and significant facial and orbital swelling. Is that happening in your girlfriend? If not, then, I doubt that the osteoma is a significant factor at this time....BUT it certainly worth taking note of and watching as things evolve and if in fact, headaches begin showing a worsening in either intensity, frequency, or both, and if it seems that sinus symptoms of either drainage or obstruction are getting worse then, there is much more justification for surgically removing them.

In short, I believe that the description of an ongoing viral illness within the sinuses is difficult for me to embrace but even if that were true it would not be considered a viable source of headache pain unless the infection were ACUTE and fulminantly acive in terms of causing large volume drainages in short amounts of time. One way to test the theory is to do a simple forward flexion maneuver at the hips. If the pain and pressure of a frontal sinus region becomes decidedly worse (usually within 5 seconds of bending over) causing a significant headaches of a throbbing or pulsating type usually in the frontal to frontotemporoparietal regions which then, subside as quickly when coming to the erect position then, the diagnosis of a sinus based headache is much more justified.

An aside....I am not sure what you mean when you say that a CT scan RULED OUT a viral infection of the sinuses. There is nothing specific seen on a CT scan which can distinguish between viral vs. any other type of sinus infection or even allergy. What one sees in a case where acute sinus pain is the cause of headaches are we are referred to as AIR/FLUID levels. In the absence of such a radiographic finding then, it is highly unlikely that sinus drainage or infection can be the cause of any type of headache.

So bottom line is:

1. I think it is possible that your girlfriend's headaches could be due to an osteoma or even a sinolith. In fact, depending on the location of this sinolith...headache could be the ONLY PRESENTING SYMPTOM for it in the sphenoid sinus though obstruction of the nasal and sinus passages also occurs but because of the degree of isolation of the sphenoid sinus in the cranium headache is the most clinically important symptom.

2. Chronic sinusitis in you with mucosal thickening etc? Sorry, no can agree with that for all the reasons I stated before. We simply do not have the evidence to demonstrate that people with chronic mucosal thickening has any relationship to headaches....quasi proof of that is the fact that your headaches began 6-8 months ago while your mucosal thickening has been in progress for years and has likely PLATEAUED...in other words the only reason for headaches to occur in such a scenario would be if the mucosas KEPT ON THICKENING....but it doesn't.....

Write back with some more comments on what I've said. Do you have an osteoma as well somewhere?

---

Brief Answer:
Proceed with caution when considering ENT's cause List

Detailed Answer:
Good morning. I know you are very focused on finding the cause to these headaches. I'm assuming from all of this diligence that prior to 8 months ago you never had ANY HEADACHES that you can recall of a similar daily nature, true? You've not yet said (nor have I asked) what medication you have been trying as of 8 months ago for your dull, aching, nagging, CHRONIC DAILY HEADACHES? I know it's been suggested that you take daily paracetamol or equivalent such as acetaminophen or aspirin, etc.

First of all, I will caution you against taking more than 15 doses in a month of medications which are considered abortive for headaches such as all the over the counter preparations you choose to name. That would include paracetamol and its equivalents. That number changes to 10 doses per month MAXIMUM of prescription medications for headaches on the order of triptans (Imitrex, Maxalt, Zomig) or narcotics/opiates such as Tramadol, Percocets, Butalbital, Fiorcet, Fiorinal, etc. Going beyond the numbers I've written places you at risk for what the XXXXXXX Headache Society and the International Headache Society term MEDICATION OVERUSE HEADACHES. These are headaches which are secondary to the overuse of analgesics designed to be taken for headaches on an AS NEEDED basis but themselves can cause headaches if overused according to the definition above.

Therefore, Question #1 I have for you is whether or not as of 8 months ago to the present you are taking any OTC or prescription medications for the purpose of alleviating the headaches and if so, do you take more than 15 doses of these medications (if simple analgesics) or more than 10 doses of more complex prescription meds as described above, in a month's time?

If your answer to my question is YES then, there is a CHANCE that some percentage of your headaches (I can't tell you exactly the number) could be due strictly to the overuse of whatever you're taking to treat the headaches. I can tell you that I never like recommending daily analgesic medication to any headache patient for these reasons. However, it is a very common practice for doctors to tell patients it's OK to do so....problem is, "It's not OK by guidelines and recommendations" but so be it..

If your answer to my question is NO then, point clarified and we can clearly discard any notion that the use of analgesics are the cause of any of your headaches.

Next point-- ENT results of "slight sinusitis, deviated septum, and septal spur" would make me proceed cautiously as to considering the cause of these headaches as being due to any of them. First of all, you know my position on the sinusitis....and you also know that MY position on the relationship between "slight" and "chronic" sinusitis is really not MY notion so much as it is the position of those who research, teach, and publish this material. When looking at the data, the patients, and all other causes of headache combined, we have found that the radiographic diagnoses (and often the clinical diagnoses) of chronic sinusitis is not considered to be a significant risk factor when discussing the genesis or persistence of headaches. We believe that other causes should be sought and addressed. The proof is in the pudding in your case. I believe you've been through (at this point) several rounds of Neti pot uses, allergy and other medication regimens and I'd like to tell me the overall NET EFFECT that this has all had on your headaches that you've had for 8 months?

Furthermore, let's examine the deviated septum and septal spur. Can the ENT specialist tell you whether those entities developed either at the time or just before the development of your headaches? If they cannot then, again I would be very cautious at ascribing a cause/effect relationship because those entities are actual PHYSICAL CHANGES to the architecture of your nasal and perhaps sinus passages. If they were the true culprits or significant contributors to your headaches then, THEY MUST HAVE DEVELOPED just ahead of or at the time of the headaches. Does that make sense to you?

Therefore, Question #2 for you is whether you can recall having any reason to have suffered a deviated septum as of 8 months ago? Strong forceful blow to the face? Concussion to the head? Fall? Get into a fight? If the answer is YES then, I guess you forgot to tell me about some critical piece of information which could easily explain what's going on in terms of frontal and vertex headaches as you've been describing. Case closed.....LOL......But somehow, I am going to guess that's NOT THE CASE....and you have not suffered any such injuries that could in and of themselves be considered not just enough to deviate your septum but cause a mild form of TRAUMATIC BRAIN INJURY which in and of itself (no deviated septum or septal spur necessary) can cause headaches of the type you're describing.

So, if you've not suffered any such traumatic injuries to deviate your septum in the last 8-10 months that would imply that your septal deviation (as severely as the doctor wishes it to be) existed before your headaches...long before your headaches and would not likely be either the cause or a significant contributor to the present complaints. Can I make the same argument for the Septal spur? Heck, don't even know what one of them things are to tell you the truth...but I would first want to know how big it is? Does it obstruct your breathing? Does it obstruct nasal or sinus drainage? Where exactly is this thing located? Can I see a picture of it? How does a septal spur come about in a 26 year old? Old injury? New Injury? Spontaneously? Is it as a result of chronic allergies, chronic colds, chronic something?

See all the questions I would want to ask if it were MY SEPTAL SPUR?

The issue I think you need to be cautious about is that if you concede to any of those as being the root cause or significant contributing factors to your headaches then, you also must accept the proposed solution which the ENT doctors may suggest to you which would likely not be medical anymore after you fail the fluticasone (which I believe you've already done) and the Neti Pot...and that's surgical. I will tell you that in my headache practice of 12 years thusfar (not including 4 years of training before practice) I only recall a handful of patients, meaning about 5...maybe a few more than that but not many....who have clearly told me that headaches were absolutely relieved with surgery to their nasal passages or sinuses to fix such things such as deviated septae, nasal polyps, septal growths/spurs/calcifications, and osteomas. In those same few who were also suffering from nasal or sinus drainage...drilling holes and perforating the sinuses surgically did relieve their constant drainage problems and subsequently their headaches. Of all the rest who are in my headache clinic and have been surgerized in these ways, there has been NO BENEFIT and in some cases, worsening of their situation since now there are additional portals of entries and communications that have been opened where infections, allergens, and other foreign bodies (flies, mosquitos, LOL) have access which precipitate problems.

Bottom line as far as I'm concerned is that you should treat the theory of those as the causes very very lightly right now until it is clear that nothing else can be at work here such as chronic daily headaches either due to a medication overuse syndrome as I described above (if applicable) or tension type headaches (which DOES NOT IMPLY that you are just simply stressed out or suffering psychological problems)....headaches that simply come on which we CALL TENSION TYPE...unfortunate term that we need to get away from since people misinterpret the meaning....and which often times has very nebulous or even UNFINDABLE causes....but they do happen.

If you were in my headache clinic here's how I would work this out...I would give you a headache diary or log....have you fill it out for 30 days, keeping track of a number of parameters having to do with the headaches and the most salient features of these headaches from a symptomatic point of view. We would then, sit down, analyze these logs and put a diagnosis down for the headaches. We will have searched and discovered (if they exist) triggers, precipitants, as well as things you do to IMPROVE THE HEADACHES, shut the pain down, make it better. We would examine other things often overlooked which contribute to daily headaches such as sleep habits, social habits (i.e. ingestion of caffeine, alcohol, etc.), presence or absence of nightmares, flashbacks, etc. etc. Do you suffer from any comorbid conditions such as depression, PTSD, OCD (I think you may have a little of the "O" part...but that's not a strict diagnosis cuz I'm not a psychiatrist....I'm just sayin').

After going through that exercise which takes about 30 days we would embark upon a treatment plan...which may or may not involve the use of medications. I would even entertain the possibility of the ENT suggestions by looking at the films, having them interpreted by a radiologist specifically for grade and severity of the septal spur as well as its location and then, look to see if there weren't a way of confirming or denying the hypothesis that any of those structural changes or defects you have could be causing the headaches.

That would be the real WORKUP for discarding OTHER causes of headaches.....and that type of workup is not commonly done in the real world because as you can imagine it takes time on both the patient's part as well as the doctor's part. And everybody is rush, rush, rush...."just give me the best medicine...." Hey, if it were only that simple. In my opinion, I'm a pretty modern type of guy and I practice using high technology and games as a neurologist with my patients. I used to be the only resident in training using a NEWTON.....any idea what that even is? I be you don't...look it up....it was the forerunner of the ipad...20 years ago! LOL....

BUT, as modern as I consider myself and as forward thinking as I consider myself....I also am coming to believe more and more with time that there is actually is NO SUBSTITUTE for a tedious and exhaustive search for the cause of a headache (if it can be found) by going through the steps...no shortcuts, no dramatic or drastic decisions regarding surgeries, laser treatments, corruguator muscle removals, etc. etc. unless we have absolutely ruled out everything thing else and found that none of our standard (and even nonstandard) treatments work.

Finally, because I really don't want you to ask your employer for time off work to continue reading this treatise....but I understand the thought process of why you are very focused on finding a common thread between you and your girlfriend in terms of her headaches. I really do not know anything about your girlfriend's headaches other than what you've said and we've already treated that issue. But I can't comment any further on her headaches related to hers until I would have the opportunity to nail her with the same plethora of questions as I've asked you and reviewed her specifics. Just because 2 individuals (whether they live together, are in the same family, work in the same place) develop similar headaches doesn't mean the etiology is the same. Again, I hear what you're saying but I think that to this point the best I can say is that she's got headaches SIMILAR TO YOURS but she also has other potential causes that you don't (save for the septal spur..whatever that is with respect to her OSTEOMA)....I DO NOT BELIEVE that you nor she are suffering from the same chronic viral infection causing the same headaches.

Oh, and finally (I lied in the previous paragraph when I said I was wrapping it up)....WILL THIS GO AWAY? I don't know....I need a diagnosis first of these headaches which would come from a 30 day log....wanna come to XXXXXXX Ohio and we'll do it! LOL..... BUT, in my experience I can't think of someone your age whose headaches could not be improved or even eliminated so long as the proper workup was done, unnecessary/irreversible procedures were avoided unless absolutely necessary, and that the patient was compliant with recommendations and strategies employed. In those cases (all that I can remember to date) we have been successful at either significantly improving if not terminating their headaches.

Dude....could it be something as simple as just marrying your girlfriend? Let's not go there! LOL.....

So, now we're ready for the wrap up.

Since this represents your 3 question in this series I am going to ask that you please CLOSE THIS QUERY out, evaluate all of my answers with a HIGH STAR RATING if you feel they are deserving, provide some written feedback so that management keeps throwing me the peanuts....and then, YOU MAY REOPEN another set of questions if you'd like to continue this conversation and give me more updates or information as you acquire it through your journey because of course, I am interested in knowing what you find out....just be judicious with the decisions you make to search for the cause and then, the treatments to these headaches and don't things without being as certain as certain can be that it's going to result in positive outcomes.

Or, come to XXXXXXX OH for a weekend....I have office hours on Saturdays and we'll do a face to face which is generally more effective than these sorts of meetings. You can bring your scans, lab reports, medical reports, and we'll have a good time sorting it through, I'll give you the logs, explain them to you, and then, you'll be on a plan to get this done!

Cheers!

The query has required a TOTAL of 221 minutes of physician specific time to read, research, and compile a return envoy to the patient.

---