Chapter 5 - Headache

Question 1

Headache

Answer 1

• Two types: tension (38%) and migraine (10%)
• Sinus headaches are also reported frequently, but may be misidentified migraines
• May be primary (90%) or secondary (10%) headaches

Question 2

Primary Headaches

Answer 2

• Not associated with underlying illness

- EX: chronic/episodic tension headaches, cluster headaches, migraines with or without aura

Question 3

Secondary Headaches

Answer 3

• Symptom of an underlying condition

- Ex: Head trauma, stroke, substance abuse, withdrawal, etc.

Question 4

Tension Headaches

Answer 4

• Aka stress headaches
• Can be episodic or chronic (15+ days/month for 3+ months)
• Manifest in response to stress, anxiety, depression, emotional conflict, etc.
• Episodic - peripheral source
• Chronic - central mechanism to pain
• Similar pathophysiology to migraine

Question 5

Migraine

Answer 5

• Can be with or without aura
• Aura - neurologic symptoms that precede head pain
• Complex interaction of neuronal and vascular factors
• Many triggers
• Can be related to menses in a select few, lack of estrogen and serotonin can cause a similar reaction to start the migraine
• Dysfunction of trigominovascular system causes depolarization that spreads across cerebral cortex
• During headache, stimulation of trigeminal sensory fibers causes release of inflammatory and coagulating factors

Question 6

Sinus Headache

Answer 6

• Infection or blockage of paranasal sinuses
• Causes inflammation and distension of sinus walls
• Pain is localized to facial areas
• Can be difficult to differentiate from migraines without aura
• No N/V or visual disturbances
• Persistent sinus pain and discharge could be indicative of infection and could require medical intervention

Question 7

Medication-Overuse Headache

Answer 7

-Rebound affect after analgesic withdrawal
-Usually using a non-Rx analgesic more than twice a week for 3 or more months
-Headache occurs within hours of stopping medication
Ex: APAP, caffeine, aspirin, some NSAIDs
-Particularly noticeable upon awakening

Question 8

Clinical Presentation of Headache

Answer 8

• Pain severity can vary from not needing to be treated to debilitating
• Shivering and cold temperatures can increase pain in tension-type headaches
• Tension headaches may be accompanied by SOB, constipation, weight loss, fatigue, decreased sexual drive, and menstrual changes
• Aura symptoms: shimmering/flashing areas, blind spots, visual/auditory hallucinations, one-sided muscle weakness, speech difficulty
• Aura symptoms can last up to 30 minutes and headache can last hours to 2 days
• With and without aura symptoms: N/V, photophobia, phonophobia, sinus symptoms, light-headed, aggrivation

Question 9

Headache Treatment Goals

Answer 9

1. Alleviate acute pain
2. Restore normal functioning
3. Prevent relapse
4. Minimize SE
5. Chronic only: reduce headache frequency

Question 10

General Headache Treatment

Answer 10

• Episodic - non-Rx, nonpharmacologic, or a combination
• Usually responds well to APAP, NSAIDs, and salicylates (especially if taken at onset)
• Chronic - limit non-Rx to <3 days/week, taper and eliminate if believed to cause medication-overuse headache
• Physical therapy and relaxation exercises may help chronic headache sufferers
• Take analgesic ahead of time if you anticipate a headache
• Sinus headaches - decongestants and sometimes a combination with a non-Rx analgesic

Question 11

Nonpharmacologic Headache Treatment

Answer 11

• Relaxation exercises and physical therapy for chronic sufferers
• Regular sleeping, eating, and exercise schedules, stress management, biofeedback and cognitive therapy for migraines
• Ice and cold packs to the temples or forehead
• Good diets, magnesium supplements for migraines
• Avoid red wine, aged cheese, artificial sweetners, caffeine, and chocolate for migraines

Question 12

Pharmacologic Headache Treatment

Answer 12

• Select product based on medical history

- May need to additionally treat N/V too

Question 13

APAP - Headaches

Answer 13

• Effective analgesic and antipyretic
• Central inhibition of prostaglandin synthesis
• Onset: 30 minutes
• Duration: ~ 4 hours, 6-8 hours with ER formulation
• Food for mild-moderate, nonvisceral pain
• More stringent dosing in children < 12 y.o.
• Can open capsules and place in a cold beverage or soft food for children
• Potential liver damage if taking > 4g/day chronically
• CI: hypersensitivity, chronic/severe liver disease, G6P dehydrogenase deficiency
• Rare, severe SE: Stevens-Johnson syndrome, epidermal necrosis, SCAR
• Interacts with warfarin (increases INR) and alcohol

Question 14

APAP Poisoning

Answer 14

• BIG problem
• Symptoms: N/V, drowsiness, confusion, stomach pain (not guaranteed to occur)
• Increased ALT and AST, increased bilirubin, jaundice

Question 15

NSAIDs

Answer 15

• Central and peripheral inhibition of COX and prostaglandin synthesis
• Onset: 30 minutes (ibuprofen and naproxen)
• Duration: 12 hours (naproxen) or 6-8 hours (ibuprofen)
• Used for fever and minor pain relief
• Analgesic, antipyretic, and anti-inflammatory
• No changes have been implemented to deal with liquid ibuprofen dosing errors
• Overdoses: minimal symptoms and rarely fatal (GI and CNS effects are most common)
• SE: heartburn, N/V, gastric upset/pain, dizziness, fatigue, weakness
• May be taken with food, milk, or antacids if upset stomach occurs
• Severe SE: rashes, itching, edema, photosensitivity, GI ulcerations, bleeding
• Ibuprofen has significant increased CV risk, making naproxen the safer and preferred option
• *May want to avoid NSAIDs all together with CV disease**
• CI: Renal failure, CHF, renal compromising disease

Question 16

Ibuprofen Interactions

Answer 16

• Digoxin
• Bisphosphonates
• Increases bleeding from inhibition of platelet aggregation

Question 17

NSAID Interactions

Answer 17

• ACEis
• Beta blockers
• Anticoagulants
• Alcohol
• Methotrexate
• Sulfonylureas

Question 18

Salicylates

Answer 18

• Aspirin
• Inhibit prostaglandin synthesis from arachidonic acid by inhibiting COX-1 and COX-2
• Primary peripheral site of action, possibly central too
• Enters CNS, breast milk, and fetal tissue
• EC (absorbed only in small intestine), SR, and buffering (taster absorption but same onset) formulations developed to decrease GI toxicity
• Used for arthritis, rheumatoid disease, temporary relief of pains/aches, mild-moderate musculoskeletal conditions, fever, and thromboembolic events
• SE: dyspepsia (take with food to minimize), gastritis, ulceration (take with PPI to minimize)
• Intolerance is uncommon but can manifest cutaneously or respiratory
• If intolerant, use APAP or non-acetylated salicylates
• Don’t use for post-op pain
• CI: hypoprothrombinemia, Vitamin K deficiency, gout, hyperurecemia, hemophilia, bleeding disorders, peptic ulcer disease
• Avoid in kids with viral infections due to Reye’s syndrome

Question 19

Salicylate Intoxication (Signs and Levels)

Answer 19

• Symptoms: Headache, dizziness, tinitis, sweating, thirst, confusion, N/V, diarrhea
• Mild: < 150 mg/kg
• Moderate: 150-300 mg/kg
• Severe: > 300 mg/kg
• Can cause respiratory alkalosis which progresses to metabolic acidosis

Question 20

Aspirin Interactions

Answer 20

• ACEis
• Beta blockers
• Anticoagulants
• Alcohol
• Methotrexate
• Sulfonylureas
• Valproic acid
• NSAIDs

Question 21

Combination Products - Headache

Answer 21

• Caffeine is commonly used with analgesics for tension headaches and migraines
• Also common to combine with decongestants + APAP/NSAIDs for sinus headaches
• Also some antihistamine + APAP products, but they have limited use due to sedating effects

Question 22

Pharmacotherapeutic Comparison: Aspirin v.s. Nonacetylated Salicylates

Answer 22

• Believed to have equal anti-inflammatory properties

- Aspirin believed to be a superior analgesic/antipyretic

Question 23

Pharmacotherapeutic Comparison: Aspirin v.s. APAP

Answer 23

• Equivalent analgesics

- APAP may not be as effective in some types of pain

Question 24

Pharmacotherapeutic Comparison: Aspirin v.s. NSAIDs

Answer 24

• Ibuprofen is at least as effective as aspirin in treating various types of pain
• NSAIDs preferred for anti-inflammatory actions, aspiring must be maximally dosed for these effects

Question 25

Pharmacotherapeutic Comparison: NSAIDs v.s. APAP

Answer 25

- Both well tolerated - Both can be used for similar pain types - Ibuprofen is a more effective antipyretic - APAP has NO anti-inflammatory properties

Question 26

Pharmacotherapeutic Comparison: Naproxen v.s. Ibuprofen

Answer 26

- Similar efficacy - Similar onset - Naproxen has a somewhat longer duration and safer SE

Question 27

Special Population - Headache

Answer 27

- Consult doctor for 8 y.o. and younger - APAP and Ibuprofen: okay in 2 y.o. + - Naproxen only: okay in 12 y.o. + - Aspirin: Reye's syndrome risk in 15 y.o. and younger and don't use if homeostasis is a concern - APAP: okay to use in preggo, appears in breast milk but only rarely causes rash - NSAIDs: CI in 3rd trimester, compatible in BF - No aspirin during preggo, especially in 3rd trimester, passes placenta and doesn't eliminate from neonate

Question 28

Patient Factors - Headache

Answer 28

- Different dosage forms for diferent needs - Caution in children's dosing to ensure they are receiving correct amounts - Alcoholics - avoid self-treating with non-Rx analgesics - Cross allergic reactions can occur between NSAIDs, APAP, and aspirin (ESPECIALLY NSAIDs and aspirin)

Question 29

Complementary Therapies - Headache

Answer 29

- Butterbun, feverfew, riboflavin, and coenzyme Q10 - common migraine preventatives - Generally ineffective for headaches - Pepperment oil and magnesium also aren't proven effective - Acupunture may be effective for headache

Question 30

Counseling - Headache

Answer 30

- Use appropriate dosing early on in headache's course - Keep log of headache frequency, intensities, and triggers - Continuing/escalating pain can be a serious problem indicator - Explain drug and nondrug measures - Don't chronically use non-Rx analgesics due to medication-overuse headaches - Severe symptoms with headache may indication more severe conditions

Question 31

Follow-up Headache Times

Answer 31

- Episodic: 6-12 weeks - Chronic: 4-6 weeks - Severe: 10 days