What is the treatment and differential diagnosis for a 26-year-old female with headache, bilateral frontal and maxillary sinus tenderness, and photophobia for 2 days, with an unremarkable neuro exam?

Clinical Assessment and Differential Diagnosis

This patient most likely has migraine rather than acute bacterial sinusitis, and should be treated with migraine-specific therapy rather than antibiotics. 1, 2

Key Diagnostic Considerations

The presence of photophobia is a critical distinguishing feature that strongly suggests migraine rather than acute bacterial rhinosinusitis (ABRS). 3, 4 While sinus tenderness is present, several factors argue against bacterial sinusitis:

• Duration of only 2 days makes bacterial sinusitis unlikely, as ABRS typically requires symptoms persisting ≥10-14 days without improvement 5, 1
• Photophobia is not a feature of sinusitis but is a hallmark symptom of migraine 6, 3
• The bilateral nature of symptoms is more consistent with migraine than with acute sinusitis, which is typically unilateral when bacterial 5

Primary Differential Diagnoses

Most Likely: Migraine with Autonomic Features

• Up to 68% of patients diagnosed with "sinus headache" actually have migraine 2
• Nasal congestion and facial pressure can occur with migraine due to vasodilation of nasal mucosa as part of the vascular event 3
• The photophobia strongly supports this diagnosis 6, 3

Less Likely: Viral Rhinosinusitis

• Symptoms present for fewer than 7-10 days strongly suggest viral etiology 1
• Viral rhinosinusitis does not require antibiotics 5, 1

Unlikely: Acute Bacterial Rhinosinusitis

• Would require purulent nasal discharge (anterior and/or posterior, often unilateral) and symptoms persisting beyond 10-14 days 5, 1
• Acute bacterial sinusitis rarely causes photophobia unless complicated 5

Consider: Tension-Type Headache

• Can present with bilateral frontal headache and facial tenderness 5
• However, photophobia is less typical 2

Red Flags Requiring Urgent Imaging

This patient requires immediate CT imaging with contrast if any of the following develop:

• Severe headache with meningeal signs 5
• Periorbital edema or erythema 5
• Visual changes, proptosis, or abnormal extraocular movements 5
• Altered mental status or focal neurologic findings 5
• Severe pain preventing sleep 5

These signs suggest orbital or intracranial complications requiring hospitalization and parenteral antibiotics 5

Recommended Treatment Approach

First-Line Treatment (Migraine Protocol)

Initiate migraine-specific therapy immediately:

• Sumatriptan 50-100 mg orally for acute migraine treatment 6
• NSAIDs (ibuprofen or naproxen) for pain relief and anti-inflammatory effect 5, 1
• Acetaminophen as alternative analgesic 1

Supportive Measures

• Adequate rest and hydration 5, 1
• Darkened, quiet environment (given photophobia) 6
• Nasal saline irrigation for symptomatic relief of nasal congestion 1
• Warm facial compresses 5, 1

When to Consider Antibiotics

Antibiotics are NOT indicated at this time because:

• Symptoms have been present for only 2 days (not the required 10-14 days) 5, 1
• No documented purulent nasal discharge 5
• Photophobia suggests migraine rather than sinusitis 3, 4

Antibiotics should only be considered if:

• Symptoms persist ≥10-14 days without improvement 5, 1
• Symptoms worsen after initial improvement (double worsening) 5, 1
• Purulent unilateral nasal discharge develops 5
• High fever with severe unilateral facial pain develops 5

If antibiotics become indicated, first-line therapy is:

• Amoxicillin-clavulanate for 7-10 days 5, 1
• Alternative: Cefuroxime-axetil or cefpodoxime-proxetil 5

Follow-Up Plan

Reassess in 3-5 days to determine treatment response 5, 1

Instruct patient to return immediately if:

• Severe worsening of headache 5, 1
• Development of periorbital swelling, visual changes, or eye movement abnormalities 5
• High fever develops 5, 1
• Neurological symptoms emerge 5

Common Pitfall to Avoid

The most common diagnostic error is misdiagnosing migraine as "sinus headache" and treating with unnecessary antibiotics. 3, 4, 2 Studies show that 66-73% of patients with migraine or tension-type headache receive inappropriate recurrent antibiotic therapy when misdiagnosed with sinusitis. 2 The presence of facial pressure and tenderness does not confirm sinusitis—these symptoms commonly occur with migraine due to autonomic involvement. 3