Sinus Migraine Medication
Critical Clarification: "Sinus Migraine" is Usually Misdiagnosed Migraine
Up to 90% of self-diagnosed "sinus headaches" are actually migraines, and true rhinosinusitis rarely causes significant headache. 1 Patients with nasal congestion, facial pressure, and headache who attribute symptoms to "sinus problems" almost always meet diagnostic criteria for migraine and should be treated accordingly. 1
First-Line Treatment: NSAIDs
Start with NSAIDs as first-line therapy for mild-to-moderate migraine attacks presenting as "sinus headache." 2, 3
- Ibuprofen 400-800 mg, naproxen sodium 500-825 mg, diclofenac potassium, or aspirin 1000 mg have the strongest evidence 2, 3, 4
- Take medication as early as possible when pain is still mild for maximum efficacy 2, 3
- Acetaminophen 1000 mg is less effective and should only be used if NSAIDs are contraindicated 2
- Combination therapy (aspirin 250 mg + acetaminophen 250 mg + caffeine 65 mg) is effective for mild-to-moderate attacks 3, 5
Second-Line Treatment: Triptans
If NSAIDs fail after 2-3 attacks, escalate to triptans for moderate-to-severe migraine. 2, 3
- Sumatriptan, rizatriptan, naratriptan, or zolmitriptan are all effective options 2, 3
- Intranasal sumatriptan 5-20 mg is particularly useful when nasal congestion mimics sinus symptoms 3
- Triptans work best when taken early during the attack while pain is still mild 2
- Combine triptan with fast-acting NSAID (naproxen sodium, ibuprofen, or diclofenac) to prevent relapse and improve efficacy 2, 3
Adjunctive Antiemetic Therapy
Add metoclopramide 10 mg or prochlorperazine 10 mg 20-30 minutes before analgesics to enhance absorption and provide synergistic pain relief, even without vomiting. 3, 6
- Antiemetics overcome gastric stasis during migraine attacks 3
- Metoclopramide and prochlorperazine provide direct analgesic effects beyond treating nausea 3
Third-Line Options for Refractory Cases
If all triptans fail after adequate trials (no response in ≥3 consecutive attacks) or are contraindicated: 2
- CGRP antagonists (rimegepant, ubrogepant, zavegepant) are newer alternatives 2, 3
- Dihydroergotamine (DHE) intranasal or injectable for severe attacks 2, 3
- Lasmiditan (ditan class) has comparable efficacy to triptans but causes temporary driving impairment 2
Critical Medication-Overuse Headache Prevention
Limit acute medications to no more than 2 days per week to prevent medication-overuse headache (MOH), which creates a vicious cycle of daily headaches. 2, 3
- MOH occurs with NSAIDs used ≥15 days/month or triptans used ≥10 days/month 3
- If using acute medications more frequently, initiate preventive therapy immediately 3
What NOT to Use
Avoid opioids and butalbital-containing compounds as they have questionable efficacy, high dependency risk, and cause rebound headaches. 2, 3
Do not use decongestants (pseudoephedrine) for migraine as they do not address the underlying neurogenic pain mechanism and may worsen symptoms. 7
When to Consider Preventive Therapy
Start preventive therapy if: