From the Guidelines
Prednisone should not be used as a first-line treatment for sinus drainage, especially in patients with a history of migraines, due to its potential to trigger headaches and other significant side effects. For a patient with migraines, I would recommend starting with more conservative options first, such as:
- Saline nasal irrigation (using a neti pot or saline spray)
- Intranasal corticosteroids like fluticasone (Flonase) 1-2 sprays per nostril daily
- Antihistamines if allergies are contributing
- Decongestants such as pseudoephedrine may help temporarily but should be used cautiously 1. If these measures fail and symptoms are severe, a short course of prednisone (typically 20-40mg daily for 5-7 days) might be considered, but with careful monitoring for potential side effects, including mood changes, insomnia, increased blood pressure, and elevated blood sugar 1. It's essential to address any underlying causes of the sinus drainage, such as allergies, infections, or anatomical issues, rather than just treating symptoms. A healthcare provider should evaluate the patient to determine the most appropriate treatment approach, taking into consideration the patient's history of migraines and potential interactions with other medications 1.
From the Research
Sinus Drainage and Migraine
- The patient's history of migraine is relevant when considering treatment for sinus drainage, as symptoms referable to the sinus area are frequently reported during migraine attacks 2.
- However, the idea that sinusitis can trigger migraine is misplaced, as the whole symptom complex is vascular and coexisting nasal congestion is due to vasodilation of the nasal mucosa that is sometimes part of the vascular event 3.
Treatment Options
- There is no evidence to suggest that prednisone is a suitable treatment for sinus drainage in patients with a history of migraine.
- Nasal irrigations, in various forms, are a widely used and accepted means of treatment of the symptoms of chronic rhinosinusitis and other sinonasal disease processes 4.
- Budesonide nasal irrigation has been shown to be effective in improving symptoms of allergic rhinitis, and may be a viable treatment option for patients with sinus drainage and migraine 5.
Diagnosis and Misdiagnosis
- Sinus headaches are uncommon, and the International Headache Society classification is robust in qualifying the term sinus headache 3.
- The majority of patients with a history of self-described or physician-diagnosed "sinus" headache are actually diagnosed with migraine-type headache 2.
- It is essential to consider migraine in the differential diagnosis of patients with recurrent headaches without fever or purulent discharge, even if they present with sinus-area symptoms 2.