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/ www.pneuro.com/publications/migraine/ Headache Central. Headache patient support site. www.headachecentral.net/ home/foods.asp www.headachecentral.net/ home/foods.asp Images Free Migraine Headache and Tension Headache Center. www.headache- doctor.com/www.headache- doctor.com/ Brigham and Women’s Hospital Health information website. healthgate.partners.org/ browsing/browseConten... healthgate.partners.org/ browsing/browseConten... MSN health website. health.msn.com/ centers/headaches.armxhealth.msn.com/ centers/headaches.armx Dr. Joseph M. Smith Medical Library. www.chclibrary.org/ micromed/00067480.htmlwww.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