Rhinologists have long cautioned about removal of the middle turbinate, though exenteration of the ethmoid labyrinth including the middle turbinate has shown the structure can be sacrificed. The middle turbinate can be removed in the crowded nose often with septoplasty and partial inferior turbinectomy, to improve the nasal airway. A vasoactive middle turbinate which engorges and compresses against an often deviated nasal septum gives rise to the “four finger headache” patient for whom middle turbinectomy, often with septoplasty, is helpful. Point cocainization of the compressed site helps prognosticate the good candidate for surgical relief. Patients with purulent sinusitis have been excluded from the study. Results have been good to excellent with no long-term adverse sequelae. There has been no crusting, drying, or infection as a result of our middle turbinectomies. Careful patient selection is critical.