Transillumination of the Sinuses. When sinus tenderness or other symptoms suggest sinusitis, this test can at times be helpful but is not highly sensitive or specific for diagnosis. The room should be thoroughly darkened. Using a strong, narrow light source, place the light snugly deep under each brow, close to the nose. Shield the light with your hand. Look for a dim red glow as light is transmitted through the air-filled frontal sinus to the forehead.

Absence of glow on one or both sides suggests a thickened mucosa or secretions in the frontal sinus, but it may also result from developmental absence of one or both sinuses.

Ask the patient to tilt his or her head back with mouth opened wide. (An upper denture should first be removed.) Shine the light downward from just below the inner aspect of each eye. Look through the open mouth at the hard palate. A reddish glow indicates a normal air-filled maxillary sinus.

Absence of glow suggests thickened mucosa or secretions in the maxillary sinus. See p. 681 for an alternative method of transilluminating the maxillary sinuses.




Quality and Severity




Tension Headaches


Migraine Headaches

("Classic migraine" in contrast to "common migraine" is distinguished by visual or neurologic symptoms during the half hour before the headache.)

Toxic Vascular Headaches due to fever, toxic substances, or drug withdrawal

Dilatation of arteries outside or inside the skull, possibly of biochemical origin; often familial

Dilatation of arteries, mainly inside the skull

Usually bilateral; may be generalized or localized to the back of the head and upper neck or to the frontotemporal area

Typically frontal or temporal, one or both sides, but also may be occipital or generalized. "Classic migraine" is typically unilateral.


Mild and aching or a nonpainfUl tightness and pressure

Throbbing or aching, variable in severity


Fairly rapid, reaching a peak in 1-2 hours

Variable: hours or days, but often weeks or months

Several hours to 1-2 days

Aching, of variable severity


Depends on cause

Cluster Headaches


One-sided; high in the nose, and behind and over the eye

Steady, severe

Abrupt, often 2-3 hours after falling asleep

Roughly 1-2 hours

Headaches With Eye Disorders

Errors of Refraction (farsightedness and astigmatism, but not nearsightedness)

Acute Glaucoma

Probably the sustained contraction of the extraocular muscles, and possibly of the frontal, temporal, and occipital muscles

Sudden increase in intraocular pressure (see p. 148)

Around and over the eyes, may radiate to the occipital area

In and around one eye

Steady, aching, dull Gradual


Steady, aching, often severe

Often rapid

Variable, may depend on treatment

Blanks appear in these tables when the categories are not applicable or are not usually helpful in assessing the problem.


Associated Symptoms

Factors That Aggravate or Provoke

Factors That Relieve

Convenient Categories of Thought

Often recurrent or persistent over long periods

Often begins between childhood and early adulthood. Typically recurrent at intervals of weeks, months, or years, usually decreasing with pregnancy and advancing age

Depends on cause

Symptoms of anxiety, tension, and depression may be present.

Often nausea and vomiting. A minority of patients have preceding visual disturbances (local flashes of light, blind spots) or neurologic symptoms (local weakness, sensory disturbances, and other symptoms).

Depends on cause

Sustained muscular tension, as in driving or typing; emotional

May be provoked by alcohol, certain foods, or tension. More common premen-strually. Aggravated by noise and bright light

Possible massage, relaxation

Quiet, dark room; sleep; sometimes transient relief from pressure on the involved artery, if early in the course

Fever, carbon monoxide, hypoxia, withdrawal of caffeine, other causes

Depends on cause

The two most common kinds of headache

Vascular headaches

Typically clustered in time, with several each day or week and then relief for weeks or months

Unilateral stuffy, runny nose, and reddening and tearing of the eye

During a cluster, may be provoked by alcohol


Eye fatigue, "sandy" sensations in the eyes, redness of the conjunctiva

Prolonged use of the eyes, particularly for close work

Rest of the eyes

Variable, may depend on treatment

Diminished vision, sometimes nausea and vomiting

Sometimes provoked by drops that dilate the pupils

Face pains

(table continues next page)

TABLE 5-1 ■ Headaches (Continued)




Quality and Severity




Headaches With Acute Paranasal Sinusitis

Trigeminal Neuralgia

Mucosal inflammation of the paranasal sinuses and their openings

Mechanism variable, often unknown

Usually above the eye (frontal sinus) or in the cheekbone area (maxillary sinus), one or both sides

Cheek, jaws, lips, or gums (second and third divisions of the trigeminal nerve)

Aching or throbbing, Variable variable in severity

Sharp, short, brief, Abrupt lightninglike jabs; very severe

Often several hours at a time, recurring over days or longer

Each jab is transient, but jabs recur in clusters at intervals of seconds or minutes

Giant Cell Arteritis




Postconcussion Syndrome

Chronic inflammation of the cranial arteries, cause unknown, often associated with polymyalgia rheumatica

Bleeding into the subdural space after trauma, followed by slow accumulation of fluid that compresses the brain

Mechanism unclear

Localized near the involved artery (most often the temporal, also the occipital); may become generalized


May be localized to the injured area, but not necessarily

Aching, throbbing, or burning, often

Gradual or rapid Variable

Steady, aching


Gradual onset weeks to months after the injury

Within a few hours of the injury

Often depends on surgical intervention

Weeks, months, or even years


Subarachnoid Hemorrhage

Brain Tumor

Infection of the meninges that surround the brain

Bleeding, most often from a ruptured intra-cranial aneurysm

Displacement of or traction on pain-sensitive arteries and veins or pressure on nerves, all within the skull



Varies with the location of the tumor

Steady or throbbing, Fairly rapid very severe

Very severe, "the Usually abrupt.

worst of my life" Prodromal symptoms may occur

Aching, steady, Variable variable in intensity

Variable, usually days

Variable, usually days

Often brief severe


Associated Symptoms

Factors That Aggravate or Provoke

Factors That Relieve

Convenient Categories of Thought

Often recurrent in a repetitive daily pattern: starting in the morning (frontal) or in the afternoon (maxillary)

Pain may be troublesome for months, then disappears for months, but often recurs. It is uncommon at night.

Recurrent or persistent over weeks to months

Progressively severe but may be obscured by clouded consciousness

Tends to diminish over time

A persistent headache in an acute illness

A persistent headache in an acute illness

Local tenderness, nasal congestion, discharge, and fever

Exhaustion from recurrent pain

Tenderness of the adjacent scalp; fever, malaise, fatigue, and anorexia; muscular aches and stiffness; visual loss or blindness

Alterations in consciousness, changes in personality, and hemiparesis (weakness on one side of the body). The injury is often forgotten.

Poor concentration, giddiness or vertigo, irritability, restlessness, tenseness, and fatigue

Fever, stiff neck

Nausea, vomiting, possibly loss of consciousness, neck pain

May be aggravated by coughing, sneezing, or jarring the head

Typically triggered by touching certain areas of the lower face or mouth, or by chewing, talking, or brushing teeth

Mental and physical exertion, straining, stooping, emotional excitement, alcohol

Nasal decongestants


Face pains

Consider these three in older adults.

Headaches following head trauma

Acute illnesses with very severe headaches

Often intermittent, but progressive

Neurologic and mental symptoms and nausea and vomiting may develop.

May be aggravated by coughing, sneezing, or sudden movements of the head

An underlying concern of patient and clinician alike

TABLE 5-2 ■ Vertigo

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