What can help alleviate symptoms of sinus pressure headache in a patient, potentially with a history of allergies?

Management of Sinus Pressure Headache

For sinus pressure headache, start with acetaminophen or ibuprofen for pain relief, combined with saline nasal irrigation, and reserve antibiotics only for confirmed acute bacterial sinusitis with severe symptoms (fever >38°C, purulent discharge, severe unilateral pain, and "double sickening"). 1

Initial Assessment: Is This Really Sinusitis?

Most patients who believe they have "sinus headaches" actually have migraine or tension-type headache, not sinusitis. 1, 2

Key distinguishing features to identify true sinusitis:

• Nasal congestion AND purulent (colored) nasal discharge are required for sinusitis diagnosis 1
• Unilateral facial pain with fever >38°C suggests bacterial infection 1, 3
• Symptoms lasting >10 days without improvement or worsening after initial improvement ("double sickening") indicate possible bacterial sinusitis 1
• Bilateral frontal headache with clear nasal discharge is more likely migraine or tension headache, not sinusitis 2

Common pitfall: Up to 42% of patients with primary headache disorders are mistakenly diagnosed with sinusitis. 1 If the patient has throbbing unilateral headache with photophobia, phonophobia, or nausea, this is migraine—not sinusitis. 2, 4

First-Line Symptomatic Treatment (For All Patients)

Regardless of whether infection is present, these measures provide relief:

• Acetaminophen or ibuprofen for pain and fever relief 1, 5, 6
• Saline nasal irrigation to remove mucus and reduce congestion 1, 7
• Oral decongestants (pseudoephedrine) to relieve nasal congestion 1
• Topical decongestant sprays for no more than 3 days to avoid rebound congestion (rhinitis medicamentosa) 1
• Adequate hydration, rest, warm facial packs, steamy showers, and sleeping with head elevated 8, 3

Nasal steroid sprays can reduce symptoms but require 15 days of use for benefit, with modest effect (number needed to treat = 14). 1 Side effects include headache, nasal itching, and nosebleeds. 1

When to Use Antibiotics

Antibiotics are NOT needed for:

• Symptoms lasting <10 days (viral rhinosinusitis/common cold) 1
• Post-viral rhinosinusitis without severe features 1

Antibiotics ARE indicated for acute bacterial rhinosinusitis when ≥3 of these are present:

• Purulent (discolored) nasal discharge 1, 3
• Severe unilateral facial pain 1, 3
• Fever >38°C 1, 3
• Elevated inflammatory markers (ESR/CRP) 1
• "Double sickening" (worsening after initial improvement) 1, 3

First-line antibiotic choice: Amoxicillin with or without clavulanate for 5-10 days. 1 For severe symptoms with fever and facial tenderness, prefer amoxicillin-clavulanate 875 mg/125 mg twice daily for 10 days due to coverage of β-lactamase-producing organisms. 3

Watchful waiting is an acceptable alternative: Most patients improve naturally without antibiotics. Only 10-15 out of 100 patients benefit from antibiotics compared to placebo. 1 You can provide a prescription but instruct the patient to fill it only if symptoms worsen or fail to improve after 7 days. 1

What NOT to Do

• Do NOT routinely use antihistamines or oral steroids for sinusitis—they have side effects without proven benefit 1
• Do NOT use antibiotics for post-viral cough—the cause is not bacterial 8
• Do NOT use newer-generation antihistamines for post-viral rhinosinusitis—they are ineffective 8
• Do NOT perform imaging for straightforward acute sinusitis—reserve CT scans for treatment failures, suspected complications, or recurrent episodes 3

If Allergic Rhinitis is Contributing

Many patients with recurrent "sinus pressure" actually have allergic rhinitis triggering their symptoms. 1, 9, 10

Identify allergic rhinitis by:

• Nasal itching, sneezing, clear watery rhinorrhea, and eye symptoms 1
• Seasonal pattern or exposure-related symptoms (pets, dust) 1
• Symptoms starting before age 20 1

Treatment for allergic rhinitis:

• Second-generation oral antihistamines (preferred over first-generation due to less sedation) for sneezing, itching, and rhinorrhea 1
• Intranasal corticosteroids are most effective for nasal congestion 1
• Leukotriene receptor antagonists can be added but are less effective than intranasal steroids 1
• Allergen avoidance measures and immunotherapy for patients with inadequate response to medications 1

When to Refer or Escalate

Consider specialist referral if:

• Symptoms persist beyond 3 weeks despite appropriate treatment 7
• Recurrent episodes (>2 per year) suggesting underlying immune deficiency or structural abnormality 7, 2
• Unilateral symptoms suggesting structural problem, polyps, or tumor 1
• Need for evaluation of allergic triggers or immunotherapy 1, 7

For persistent symptoms after 3 weeks: Switch to high-dose amoxicillin-clavulanate (90 mg/kg amoxicillin component, maximum 2g every 12 hours) for 10-14 days, add nasal corticosteroids, and consider CT imaging to evaluate for anatomical abnormalities or complications. 7

Post-Sinusitis Persistent Cough

If cough persists after sinusitis resolves, treat with first-generation antihistamine-decongestant combination (the anticholinergic properties reduce secretions). 8 Most patients improve within days to 2 weeks. 8 Avoid antibiotics for post-viral cough. 8