Headache and Internal Analgesics

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Headache and Internal Analgesics
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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

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Headaches

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

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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.

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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 doesnt 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

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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!

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Phases of a Migraine
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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, cant function

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Migraine Triggers

• Foods
• Alcohol
• Oral contraceptives
• Menstrual period
• Stress
• Fatigue
• Oversleeping
• Skipping meals
• Post-stress

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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.

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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.

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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

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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

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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

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OTC Analgesics

• Acetaminophen
• Aspirin
• NSAIDs
• Ibuprofen
• Naproxen
• Ketoprofen
• Effectiveness varies
• from patient to patient

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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

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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

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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

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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

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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)

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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

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Treating Sinus headaches

• OTC analgesic with decongestant
• May need to refer

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Treating Rebound Headaches

• Nonpharmacologic
• Slowly taper agent over 8-12 weeks
• Refer to MD for proper supervision

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Cases . . .
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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 Womens 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/d
  efault.asp?pagestory_31-5-2004_pg6_20
• BBC Health website. www.bbc.co.uk/health/
  images/300/headache_man.jpg