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Headache and Internal Analgesics

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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  1. Headache and Internal Analgesics

  2. 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

  3. Headaches • Four types can treat OTC • Sinus headache • Tension headache • Migraines • Rebound headaches • OTC treatments • Nonpharmacologic treatments

  4. 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.

  5. 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

  6. 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!

  7. Phases of a Migraine

  8. 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

  9. Migraine Triggers • Foods • Alcohol • Oral contraceptives • Menstrual period • Stress • Fatigue • Oversleeping • Skipping meals • Post-stress

  10. 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.

  11. 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.

  12. 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

  13. 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

  14. 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

  15. OTC Analgesics • Acetaminophen • Aspirin • NSAIDs • Ibuprofen • Naproxen • Ketoprofen • Effectiveness varies from patient to patient

  16. 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

  17. 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

  18. 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

  19. 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

  20. 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)

  21. 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

  22. Treating Sinus headaches • OTC analgesic with decongestant • May need to refer

  23. Treating Rebound Headaches • Nonpharmacologic • Slowly taper agent over 8-12 weeks • Refer to MD for proper supervision

  24. Cases . . .

  25. 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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