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. 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!

Phases of a Migraine

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 Sinus headaches

OTC analgesic with decongestantMay need to refer

Treating Rebound Headaches

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

Cases . . .

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