Initial Management of Sinus Pressure and Headache in a 61-Year-Old Female
Start with symptomatic treatment using acetaminophen or NSAIDs for pain relief, nasal saline irrigation, and short-term oral pseudoephedrine (not exceeding 3-5 days), while carefully assessing whether this represents true sinusitis or a primary headache disorder masquerading as "sinus headache." 1
Critical First Step: Rule Out Misdiagnosis
The vast majority of patients presenting with "sinus headache" actually have migraine or tension-type headache, not sinusitis. 2, 3
Key diagnostic questions to ask:
- Are symptoms present for fewer than 7-10 days? If yes, this strongly suggests viral rhinosinusitis. 1
- Is there purulent nasal discharge with unilateral facial-dental pain? 1
- Does she have fever with unilateral nasal obstruction following a recent upper respiratory infection? 2
- Is the headache bilateral, pressing/tightening quality, mild-to-moderate intensity? This suggests tension-type headache, not sinusitis. 4
- Is it unilateral, episodic, lasting 4-72 hours with nausea, photophobia, or phonophobia? This suggests migraine. 5, 4
Critical pitfall: Chronic sinusitis is NOT a validated cause of headache unless it relapses into an acute bacterial stage. 5 Studies show 68% of patients diagnosed with "sinus headache" by primary care actually have migraine, 27% have tension-type headache, and only 5% have true sinusitis. 3
Physical Examination Findings to Document
- Check for sinus tenderness on palpation (frontal and maxillary sinuses) 1
- Look for mucosal erythema and purulent nasal secretions 1
- Assess for increased pharyngeal secretions and postnasal drainage 1
- Perform a complete neurological examination to rule out red flags 5
Immediate Symptomatic Treatment (First-Line)
Analgesics:
- Acetaminophen or NSAIDs for pain relief and inflammation reduction 1
Nasal saline irrigation:
- Strongly recommended with minimal adverse effects 1
Decongestants:
- Oral pseudoephedrine for short-term relief of nasal congestion and sinus pressure 1, 6
- Critical limitation: Do not exceed 3-5 days to avoid rebound congestion 1
Supportive measures:
- Adequate hydration and rest 1
- Warm facial packs and steamy showers 1
- Sleep with head of bed elevated 1
When to Consider Antibiotics (NOT First-Line)
Only prescribe antibiotics if she meets criteria for acute bacterial sinusitis: 1
- Symptoms persisting ≥10-14 days without improvement, OR
- Worsening symptoms after initial improvement (double-worsening pattern) 1
If antibiotics are indicated:
Common pitfall: 73% of patients with tension-type headache and 66% with migraine receive unnecessary recurrent antibiotic therapy when misdiagnosed as sinusitis. 3
Red Flags Requiring Urgent Reassessment
Reassess immediately if: 1
- High fever develops
- Severe facial pain worsens
- Neurological symptoms appear (visual changes, diplopia, altered mental status)
- Symptoms persist beyond 10-14 days without improvement 1
If Symptoms Don't Improve: Consider Primary Headache Disorder
For suspected migraine (if headache is unilateral, throbbing, 4-72 hours duration):
- Consider trial of triptans 5
- If headaches occur ≥15 days per month, consider prophylactic treatment with topiramate (evidence-based for chronic migraine) 5
For suspected tension-type headache or facial pain without clear sinusitis:
- Consider trial of amitriptyline 5
- Counsel that sinuses are not involved 5
- Consider neurology referral if first-line treatment fails 5
Imaging Considerations
Do NOT routinely order imaging for uncomplicated presentations. 7
Order CT scan only if: 7
- Symptoms are recurrent or refractory despite adequate treatment
- Considering sinus surgery
- Suspecting complications
Important caveat: Mucosal thickening and sinus abnormalities appear on CT in 40% of symptomatic adults without true sinusitis, so clinical correlation is essential to avoid overdiagnosis. 7