Headache in Patients with Sella Disease: Clinicomorphological Predictors of Secondary Headache and the Outcome of Endoscopic Transphenoidal Surgery


Maria Joseph, MBBS/MD1; Raquel Alvarado, PhD¹; Ann McCormack, FRACP, MBBS, PhD^2,3; Benjamin Jonker, FRACS, MBBS^4,5,6; Mark Winder, FRACS, MBBS⁴; Richard J. Harvey, FRACS, MD, PhD^1,7

1. Rhinology and Skull Base Research Group, Applied Medical Research Centre, University of New South Wales, Sydney, Australia 
2. Department of Endocrinology, St Vincent’s Hospital, Sydney, Australia 3. Hormones and Cancer Group, Garvan Institute of Medical Research, Sydney, Australia 
4. Department of Neurosurgery, Saint Vincent’s Hospital, Sydney, Australia 
5. Institute of Academic Surgery and Department of Neurosurgery, Royal Prince Alfred Hospital, Sydney, Australia 
6. Brain and Mind Centre, University of Sydney, Camperdown, NSW 2050, Australia Camperdown, Sydney, NSW, Australia 
7. Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia

Objective

Sella pathologies are frequently found as a result of imaging performed to investigate headache. However, both headache and incidental sella lesions are common in the general population.This fosters a complex diagnostic question: are incidental sella pathologies coincidental to primary headache or causing secondary headache? Hence, this study prospectively examined the prevalence, phenotype, burden and predictive factors of secondary sella-related headache in patients with radiologically confirmed sella pathologies and the efficacy of transphenoidal surgical intervention.  

Methods

Patients undergoing surgical resection of a sella tumour were consecutively recruited and defined as having headache or not at baseline with headache phenotype characterised using validated questionnaires (HARDSHIP, EUROLIGHT). Headache severity was assessed at baseline and 6-months postoperatively using HIT-6 and MIDAS questionnaires. Tumour characteristics were defined using radiological, endocrine and histological factors.  

Results

Of the 60 participants (62% female, 47.1±18.6 years), 63% possessed headache at baseline. HIT-6 scores were higher in younger participants (R2=-0.417, p=0.010), smokers (63.31±7.93 vs 54.44±9.21, p=0.006), those with family headache history (68.13±7.01 vs 54.94±9.11, p=0.003), dural invasion (55.70±12.14 vs 47.18±10.15, p=0.027) and sphenoid sinus invasion (58.87±8.97 vs 51.29±10.97, p=0.007). Postoperative HIT-6 and MIDAS scores improved more in patients with higher baseline headache severity scores (HIT-6: R2=-0.682, p<0.001, MIDAS: R2=-0.880, p<0.001) and in those with dural invasion (MIDAS: -53.00±18.68 vs 12.00±17.54, p=0.003).  

Conclusions

Headaches are common in patients with pituitary pathology. However, surgical intervention is most effective in patients with severe headache at presentation and MRI evidence of dural invasion.