The patient should receive naproxen to treat his headaches, which meet criteria for migraine without aura. Episodes of migraine without aura typically last between 4 and 72 hours if untreated. Two of four pain features are necessary for the diagnosis to be made: unilateral location, throbbing quality, moderate to severe intensity, and worsening with physical activity. Either nausea or a combination of photophobia and phonophobia also is required. Patients with this diagnosis commonly report sinus pressure or drainage with these episodes, which often leads to the incorrect diagnosis of sinus headache. Common triggers include stress, hormonal or weather changes, alterations in sleep or meal patterns, or strong light, noise, or odor stimuli. Neurologic examination findings are normal. Evidence-based guidelines suggest that NSAIDs (such as naproxen), triptans, and dihydroergotamine are effective therapy for this type of acute migraine but that NSAIDs are preferred as initial treatment because of their greater cost-effectiveness.

In the context of a stable pattern of headaches that meets the criteria for migraine, CT of the head in unnecessary. Similarly, the headache pattern described by this patient—weekly headache episodes lasting 6 to 8 hours—is incompatible with an acute or chronic sinus pathology, which makes CT of the sinuses also unlikely to add any useful information.

Pseudoephedrine is effective in alleviating sinus congestion but has no role in the treatment of migraine. Headache is a relatively late-appearing and minor symptom of acute sinusitis; major symptoms include facial pain, purulent discharge, fever, and hyposmia, none of which this patient reports.