Headache and internal analgesics
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Headache and Internal Analgesics. Headaches. Most common pain complaint 40% of US population have recurrent HA Classifications: Primary HA: 90% of HAs, not associated with underlying illness. Examples: tension, migraine, rebound. Secondary HA: symptom of an underlying condition.

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Headache and Internal Analgesics

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Headache and internal analgesics

Headache and Internal Analgesics


Headaches

Headaches

  • Most common pain complaint

  • 40% of US population have recurrent HA

  • Classifications:

    • Primary HA: 90% of HAs, not associated with underlying illness.

      • Examples: tension, migraine, rebound.

    • Secondary HA: symptom of an underlying condition.

      • Examples: head trauma, substance abuse, vascular defects, bacterial or viral disease


Headaches1

Headaches

  • Four types can treat OTC

    • Sinus headache

    • Tension headache

    • Migraines

    • Rebound headaches

  • OTC treatments

  • Nonpharmacologic treatments


Tension headache

Tension headache

  • 75% of population will experience

  • Due to stress, anxiety, depression, emotional conflicts, fatigue, repressed hostility.

  • Difficult to distinguish from migraine

  • Tight muscles in upper back, head, neck.


Tension headache1

Tension Headache

  • Presentation

    • Location: bilateral, may radiate down to neck &/or shoulders.

    • Quality: Diffuse, pain described as tight or pressing, band constricting head.

    • Severity: Mild to moderate – doesn’t impair daily activities

    • Timing: Gradual onset throughout the day. Triggers.

    • Modifying factors: not usually aggravated by physical activity, environment

    • Associated symptoms: no nausea, vomiting or aura


Migraines

Migraines

  • Occur in 20-25% of US pop.

  • 2 main types: Migraine with aura

    (Classic) and Migraine without aura

    (Common)

  • 4 Phases

    • Prodrome

    • Aura

    • Headache

    • Postdrome

  • Migraines must be diagnosed by a PCP before treating with OTC products!


Phases of a migraine

Phases of a Migraine


Migraines signs and symptoms

Migraines Signs and Symptoms

  • “Common Migraine” Attributes

    • Location: With aura = generally unilateral.

      Without aura = usually generalized

    • Quality: pulsating or throbbing

    • Severity: Moderate to severe

    • Timing: Morning or night

    • Modifying factors: activity, light, sound can make it worse. Lying in a dark room often helps.

    • Associated symptoms: nausea, vomiting, photophobia, phonophobia, tinnitus, light-headedness, vertigo, irritability.

    • Meaning to patient: loss of work, can’t function


Migraine triggers

Migraine Triggers

  • Foods

  • Alcohol

  • Oral contraceptives

  • Menstrual period

  • Stress

  • Fatigue

  • Oversleeping

  • Skipping meals

  • Post-stress


Sinus headache

Sinus headache

  • Due to infection or blockage of the sinuses causing inflammation or distention of the sinus walls

  • Only type of secondary headache that can be self-treated.


Sinus headache1

Sinus headache

  • Signs and Symptoms

    • Location: forehead or perioribital area

    • Quality: pressure behind eyes or face

    • Severity: varies, usually mild to moderate

    • Timing: Pain tends to occur on awakening and can subside gradually after pt is upright for awhile.

    • Modifying factors: Stooping or blowing nose can intensify pain.

    • Associated sx: Nasal stuffiness/discharge, toothache.

    • Setting/hx: persistent pain &/or discharge may be sinus infection and require referral.


Rebound headaches

Rebound headaches

  • Withdrawal

  • Overuse of agents like

    acetaminophen or caffeine.

  • Withdrawal from triptans, opioids, ergotamine formulations

  • Use for 3+ months &/or 15x per month

  • Headache occurs within hours of stopping medication/caffeine


Rebound headache

Rebound Headache

  • Location: varies

  • Quality: dull, diffuse pain

  • Severity: mild to moderate

  • Timing: onset within hours of stopping agent. Duration varies.

  • Modifying factors: taking the agent, increasing dose.

  • Associated sx: Can have restlessness, anxiety, irritability, mood changes, nausea

  • Meaning to patient: needs to take medication/caffeine to avoid severe pain


When to refer

When to Refer

  • Severe head pain

  • Headache that persists for 10+ days

  • Last trimester of pregnancy

  • Children ≤ 7 years old

  • High fever or other signs of serious infection

  • History of liver disease or 3+ EtOH drinks/day

  • Secondary headache

  • Symptoms consistent with migraine but no formal diagnosis


Otc analgesics

OTC Analgesics

  • Acetaminophen

  • Aspirin

  • NSAIDs

    • Ibuprofen

    • Naproxen

    • Ketoprofen

  • Effectiveness varies

    from patient to patient


Acetaminophen

Acetaminophen

  • Pros:

    • Few drug interactions

    • Well tolerated

    • Safe in pregnant women and children ≥ 2 if recommended by MD

    • Effective analgesic and fever reducer

  • Cons:

    • Hepatotoxic

    • Avoid with alcohol

    • Easy to overuse – in many combination products


Aspirin

Aspirin

  • Pros:

    • Effective analgesic, fever reducer, anti-inflammatory.

    • Useful to prevent stroke, MI, colon cancer.

  • Cons:

    • Drug interactions

    • GI bleeding

    • Avoid use with alcohol

    • Reyes syndrome – avoid in children with viral infections

    • Allergies: patients with asthma

    • Caution during pregnancy


Ibuprofen

Ibuprofen

  • Pros:

    • Effective analgesic, fever reducer, anti-inflammatory

    • Safe for children

    • Safe for lactating women

  • Cons:

    • GI bleed, but less than ASA

    • Cross reactivity if allergic to ASA

    • SE: nausea, heartburn, stomach pain, dizziness

    • Caution with alcohol

    • Caution in patients with renal impairment

    • Drug interactions


Naproxen and ketoprofen

Naproxen and Ketoprofen

  • Pros:

    • Similar efficacy as ibuprofen

    • Longer acting then ibuprofen

    • Some people respond better to one agent over another

  • Cons:

    • Dose only down to 12 years old

    • Same warnings as ibuprofen


Treating tension headaches

Treating Tension Headaches

  • Nonpharmacologic

    • Relaxation techniques

    • Massage

    • Hot baths

  • OTC analgesics

    • Acetaminophen 1000 mg NTE 4000 mg/d

    • Aspirin 650 mg NTE 4000 mg/d

    • Ibuprofen 400 mg NTE 1200 mg/d (OTC)

    • Naproxen 220-440 mg NTE 660 mg/d (OTC)

    • Ketoprofen 12.5-25 mg NTE 75 mg/d (OTC)


Treating migraine headaches

Treating Migraine Headaches

  • Nonpharmacologic

    • Ice bag or cold pack applied to forehead/temples

    • Keep HA diary

    • Avoid triggers

  • OTC analgesics

    • Excedrin – combo product, beware of rebound

    • APAP, ASA, NSAIDs

    • Pretreat if onset predictable


Treating sinus headaches

Treating Sinus headaches

  • OTC analgesic with decongestant

  • May need to refer


Treating rebound headaches

Treating Rebound Headaches

  • Nonpharmacologic

    • Slowly taper agent over 8-12 weeks

    • Refer to MD for proper supervision


Cases

Cases . . .


References

References

  • Pennsylvania Neurological Associates, LTD. www.pneuro.com/publications/migraine/

  • Headache Central. Headache patient support site. www.headachecentral.net/ home/foods.asp

    Images

  • Free Migraine Headache and Tension Headache Center. www.headache-doctor.com/

  • Brigham and Women’s Hospital Health information website. healthgate.partners.org/ browsing/browseConten...

  • MSN health website. health.msn.com/ centers/headaches.armx

  • Dr. Joseph M. Smith Medical Library. www.chclibrary.org/ micromed/00067480.html

  • Pakistan online news site. www.dailytimes.com.pk/default.asp?page=story_31-5-2004_pg6_20

  • BBC Health website. www.bbc.co.uk/health/ images/300/headache_man.jpg


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