What are the treatment options for sinus headaches related to allergic (allergy) rhinitis?

From the Guidelines

For treating sinus headaches related to allergies, I recommend a multi-faceted approach combining medications and environmental modifications, prioritizing the use of intranasal corticosteroids and intranasal antihistamines as first-line treatments, as supported by the most recent and highest quality evidence from the 2020 European Position Paper on Rhinosinusitis and Nasal Polyps 1. Start with an oral antihistamine like cetirizine (Zyrtec) 10mg or loratadine (Claritin) 10mg once daily to reduce the allergic response. Add a nasal corticosteroid spray such as fluticasone (Flonase) or mometasone (Nasonex), using 1-2 sprays in each nostril once daily, which helps reduce inflammation in the sinus passages, as recommended by the 2017 Joint Task Force on Practice Parameters 1. For immediate relief of sinus pressure and pain, take acetaminophen (Tylenol) 500-650mg every 6 hours or ibuprofen (Advil) 400-600mg every 6-8 hours as needed. Nasal saline rinses using a neti pot or saline spray can physically flush allergens and mucus from the nasal passages, providing additional relief, as suggested by the 2020 European Position Paper on Rhinosinusitis and Nasal Polyps 1. Environmental modifications are equally important:

• Use air purifiers with HEPA filters in your home, especially the bedroom;
• Keep windows closed during high pollen seasons;
• Shower before bed to remove allergens from hair and skin; and
• Regularly wash bedding in hot water. These treatments work together by reducing the allergic inflammatory response that causes nasal passage swelling, mucus production, and sinus blockage, which create the pressure that leads to headache pain. If symptoms persist beyond 7-10 days despite these measures, consult a healthcare provider as you may need prescription-strength medications or further evaluation, as recommended by the clinical practice guideline: allergic rhinitis executive summary 1.

Some key points to consider:

• The combination of an intranasal corticosteroid and an intranasal antihistamine may be recommended for initial treatment of moderate to severe seasonal allergic rhinitis, as suggested by the 2017 Joint Task Force on Practice Parameters 1.
• Nasal irrigation with isotonic saline or Ringer’s lactate is recommended, but there is insufficient data to show that a large volume is more effective than a nasal spray, or that temperature of the solution influences the outcome, as noted in the 2020 European Position Paper on Rhinosinusitis and Nasal Polyps 1.
• Saline irrigation may reduce patient-reported disease severity when compared to no irrigation at up to three months, but no data is available for any outcomes beyond this period, as reported in the 2020 European Position Paper on Rhinosinusitis and Nasal Polyps 1.

Overall, the treatment approach should be individualized based on the severity of symptoms, patient preferences, and the presence of comorbidities, as recommended by the clinical practice guideline: allergic rhinitis executive summary 1.

From the FDA Drug Label

Patients with seasonal allergic rhinitis may find as-needed use of Fluticasone Propionate Nasal Spray, USP (not to exceed 200 mcg daily) effective for symptom control Greater symptom control may be achieved with scheduled regular use. Adult patients may be started on a 200-mcg once-daily regimen (two 50-mcg sprays in each nostril once daily). An alternative 200-mcg/day dosage regimen can be given as 100 mcg twice daily (one 50-mcg spray in each nostril twice daily).

The treatment options for sinus headaches related to allergic rhinitis using fluticasone propionate nasal spray include:

• As-needed use: not to exceed 200 mcg daily
• Scheduled regular use: 200 mcg once daily or 100 mcg twice daily 2 Key points to consider:
• Dosage: the maximum total daily dose should not exceed 200 mcg/day
• Effectiveness: greater symptom control may be achieved with scheduled regular use compared to as-needed use

From the Research

Treatment Options for Sinus Headaches Related to Allergic Rhinitis

• The treatment of allergic rhinitis includes pharmacotherapy, such as oral and intranasal antihistamines, intranasal corticosteroids, oral and intranasal decongestants, oral and intranasal anticholinergics, and leukotriene receptor antagonists 3
• Second-generation oral antihistamines and intranasal corticosteroids are the mainstays of treatment, with practice guidelines recommending intranasal corticosteroids as first-line treatment for moderate to severe allergic rhinitis 3
• A study comparing fluticasone propionate with loratadine found that combination therapy of fluticasone propionate and the oral antihistamine, loratadine, was found to have efficacy comparable with that of intranasal corticosteroid alone 3
• Fluticasone propionate aqueous nasal spray was compared with oral loratadine in patients with seasonal allergic rhinitis, and the results showed that fluticasone propionate improved clinician-rated total nasal symptom scores more than loratadine 4
• Azelastine nasal spray is also an effective and safe treatment for allergic rhinitis, with a rapid onset of action and a prolonged duration of activity, and it has been shown to be as effective as ebastine, loratadine, cetirizine hydrochloride, and terfenadine at symptom reduction 5

Pharmacological Treatment

• H(1)-antihistamines, such as loratadine, block both neural and vascular H(1) receptors and have a clinical effect on symptoms such as nasal itching, sneezing, and rhinorrhea 6
• Intranasal corticosteroids, such as fluticasone propionate, have a long-term anti-inflammatory effect and are effective in reducing nasal congestion and other symptoms of allergic rhinitis 6, 4
• Azelastine hydrochloride is a nasally administered antihistamine that inhibits the production or release of many chemical mediators of the allergic response and has a rapid onset of action and a prolonged duration of activity 5

Combination Therapy

• Combination therapy of fluticasone propionate and the oral antihistamine, loratadine, has been shown to have efficacy comparable with that of intranasal corticosteroid alone 3
• The use of combination therapy may be beneficial for patients with moderate to severe allergic rhinitis who do not respond to single-agent therapy 3