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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
Headaches
Four types can treat OTC Sinus headache Tension headache Migraines Rebound headaches
OTC treatmentsNonpharmacologic treatments
Tension headache
75% of population will experience Due to stress, anxiety, depression,
emotional conflicts, fatigue, repressed hostility.
Difficult to distinguish from migraineTight muscles in upper back, head, neck.
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
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!
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
Foods Alcohol Oral contraceptives Menstrual period Stress Fatigue Oversleeping Skipping meals Post-stress
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 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 headachesRebound headaches
WithdrawalOveruse of agents like
acetaminophen or caffeine. Withdrawal from triptans, opioids,
ergotamine formulations Use for 3+ months &/or 15x per monthHeadache occurs within hours of stopping
medication/caffeine
Rebound HeadacheRebound 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
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
AcetaminophenAspirinNSAIDs
Ibuprofen Naproxen Ketoprofen
Effectiveness varies
from patient to patient
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
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
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
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
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
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 Rebound Headaches
Nonpharmacologic Slowly taper agent over 8-12 weeks Refer to MD for proper supervision
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