Headache and Musculoskeletal Flashcards
estimate of 1/3 of non rx analgesic use is for
headaches
primary headache
not associated with underlying illnesses (90% of headaches)
examples of primary headaches
episodic and chronic tension-type, migraine, cluster, medication over-use headaches
secondary headaches
symptom of underlying condition
examples of secondary headaches
head trauma, stroke, substance abuse or withdrawal, bacterial and viral diseases, and craniofacial disorders
tension-type headaches
manifests in response to stress, anxiety, depression, emotional conflicts, etc.
episodic tension-type
peripheral pain source
chronic tension-type
central mechanism, occurs at least 15 days/month for at least 6 months
migraine
complex interaction of neuronal and vascular factors involving dysfunction of the trigeminovascular systems. stimulation of the trigeminal sensory fibers in the large cerebral and dural vessels resulting in inflammation, vasodilation, and activation of platelets and mast cells
T/F a medical diagnosis is not needed to self treat migraines
false
sinus headache
infection or blockage of paranasal sinuses causing inflammation of the sinus walls
medication-overuse headache
results from rebound effect after withdrawal of an analgesic that has been used more than two times a week for more than three months and occurs within hours of stopping the agent
agents associated with medication-overuse
APAP, NSAIDs, aspirin, caffeine, triptans, opioids, butalbital, and ergotamine
treatment goals for headache
- reduce severity and alleviate acute pain
- restore normal functioning
- prevent relapse
- minimize side effects
exclusions for self treatment of headache
- severe head pain
- headache longer than 10 days
- last trimester of pregnancy
- < 8 years of age
- high fever or signs of infection
- history of liver disease or consumption of three or more drinks/day
- secondary headache
- no diagnosis of migraine
non pharm treatment
- relaxation exercises, physical therapy
- maintain regular schedule for sleeping, eating, and exercise
- ice packs
- diet - restrict foods that are triggers
- avoid triggers
APAP indication
fever or mild to moderate pain
MOA of APAP
central inhibition of prostaglandin synthesis via inhibition of COX-1 isoenzyme. Inhibits prostaglandins from sensitizing nociceptors that are initiating pain impulses
T/F APAP has anti-inflammatory benefits
false
onset of action for APAP
30 minutes, duration is 4 hours
1 cause of acute liver toxicity
APAP
adult dose of apap
325-500mg q4-6hr
apap max dose at one time
1000mg
apap max dose per day
4000mg/day
apap max dose for elderly
less than or equal to 3000mg/day
apap max dose and warfarin use
less than or equal to 2000mg/day
apap max dose with alcohol use
less than or equal to 2000mg/day
apap children dose
10-15mg/kg q4-6hr (max dose 5 per day)
liquid: 160mg/5mL
adverse effects for apap
rash, generally well tolerated
precautions for apap
underlying liver dysfunction, more than 3 drinks/day
overdose for apap
more than 3 grams per day
antidote for apap overdose
N-acetylcysteine or activated charcoal
toxic single dose of apap
10-15g
fatal single dose of apap
20-25g
MOA of NSAIDs
reversible inhibition of COX 1 and 2 enzyme which causes central and peripheral inhibition of prostaglandin synthesis which inhibits prostaglandins sensitize nociceptors to initiate pain impulses
NSAIDs are used as
analgesic, antipyretic, and anti-inflammatory
duration of action for ibuprofen
6-8 hours
duration of action for naproxen
8-12 hours
adult dose of ibuprofen
200 to 400mg q6-8 hr
max OTC dose of ibuprofen
1200mg/day
ped dose of ibuprofen
5-10 mg/kg q6-8hr
liquid 100 mg/5mL
oral drops 40mg/1mL
max dose ped of ibuprofen
max 40/mg/kg/day; max 4 doses
naproxen adult dose
220-440mg q 8-12 hours
naproxen max adult dose
660mg/day
naproxen ped dose
not for < 12 years
naproxen max dose in elderly
440mg/day
common adverse effects of nsaids
dyspepsia, N/V, heartburn, and abdominal pain
nsaids cause damage to the GI mucosa in two ways
- direct acidic damage to the GI mucosa
2. inhibition of GI prostaglandins synthesis that lines the smooth muscle of the GI tract
boxed warning for nsaids
increased risk of CV events (MI and stroke), risk increases with duration of use, higher dose, and patients with CVD risk factors
nsaids contraindicated in
treatment of pain in the setting of a CABG or in patient who has undergone CABG
1 cause for acute renal failure
nsaids
GI bleeding risk factors
- older than 60
- history of peptic ulcer or GI bleed
- other medications w/ GI bleed risk
- alcohol use
- high dose of nsaids
pregnancy recommendations
apap recommended
drug interactions w nsaids
aspirin, anticoagulants, antihypertensive, nephrotoxic drugs
combo products w aspirin
asa with caffeine, and apap (Excedrin)
powder formulation of salicylates
BC powder or goody powder
non-acetylated salicylates
doans, nuprin, momentum
non-acetylated salicylates vs. aspirin
same anti-inflammatory effect but NA is less superior as analgesic/antipyretic
moa of aspirin
- irreversible central and peripheral inhibition of COX 1 and 2
- inhibits platelet aggregation
aspirin inhibits COX 1 at
low doses (81-325mg)
aspirin inhibits COX2 at
higher doses (anti-inflammatory drug)
onset of aspirin
1-2 hours
duration of aspirin
4-6 hours
aspirin metabolized by
plasma
adult dosing of aspirin
325-1000mg q4-6hr
doses 0f 4-6g for anti-inflammatory
aspirin dosing for CV protection
81-325
max otc dose for aspirin
4000mg/day
max dose aspirin for children
not for <16 years
fda says 19
adverse effects of aspirin
dyspepsia, nv, heartburn, abdominal pain
aspirin contraindicated in
patients with bleeding disorders and in children
other precautions of aspirin
h/o of gout or hyperuricemia, bleeding disorder, renal dysfunction
toxicity of aspirin
headache, dizziness, tinnitus, dim vision, mental confusion, drowsiness, sweating, thirst, nv, diarrhea
drug interactions w aspirin
warfarin, nsaids, corticosteroids, alcohol, antihypertensive
delayed onset muscle soreness
begins > or equal to 8 hours after repeated unaccustomed eccentric muscle contraction and is associated with delayed-onset muscle soreness which can last for days
myalgia
can result from systemic infections (flu, virus), chronic disorders, medications
strains
caused by stretching or tearing of muscle or tendon. movements that cause a strain involve twisting or pulling. can be caused by acute injury or chronic
strain injury of the muscle is caused by
eccentric contraction of the muscle while the muscle is lengthening
tendons can become strained when
their stretch capacity is exceeded
tendonitis
inflammation of tendon which results from acute injury or from chronic overuse of a body part (carpal tunnel), can also be caused by medications (fluoroquinolones)
bursitis
inflammation of the bursa (fluid filled sacs located b/t joint spaces) generally from acute injury to the joint or over-repetitive action, which can be worsened at any movement of the structure adjacent to bursa
sprains
caused by excessive stretching or partial/complete tearing of ligaments. typically occur during physical activity
low back pain
fifth most likely reason for physician visit; most patients recover within a few days or weeks; considered chronic if longer than 3 months
muscle spasm
involuntary muscle contractions; muscle cramps are prolonged muscle spasms that produce painful sensation
osteoarthritis
gradual softening and destruction of cartilage between bones; often referred to as degenerative joint disease and is considered a chronic condition
osteoarthritis is caused by
genetic, metabolic, and environmental factors; heavy physical activity, repetitive movement, and lifting of heavy weights can aggravate condition
treatment goals for muscles
- decrease the intensity and duration of pain
- restore function of affected area
- prevent reinjury and disability
- prevent acute pain from becoming chronic
exclusion for self treatment of musculoskeletal disorders
- severe pain (> 6/10)
- pain that lasts more than 10 days
- pain that continues > 7 days after treatment with topical analgesic
- increased intensity or change in character of pain
- pelvic or abdominal pain
- signs of infection
- visually deformed joint, abnormal movement, weakness in any limb, numbness, or suspected fracture
- pregnancy
- < 2 years
- back pain and loss of bowel or bladder control
non pharm for muscles
RICE and continue for 48-72 hours
R in rice
rest area for 1-2 days
I in rice
ice asap, should not be applied for greater than 15-20 min and applied 3-4 times daily
C in rice
compression with elastic support - wrap point most distal from injury and decrease tightness as your rap toward injured area
E in rice
elevate injured area at or above level of heart for 2-3hours a day
heat for muscles only in
non-inflammatory condition
must be 48 hours after injury for 15-20 min 3 to 4 times daily
thermacare moa
topical heat wrap that alleviates pain by increasing blood flow, reducing muscle spasm, and improving stiffness
kinds of thermacare wraps
back, hip, neck, knee, wrist and hand, shoulder, and lower abdomen
how long to apply thermacare
up to 8 hours (remove before if pain, itching or burning)
transcutaneous electrical nerve stimulation (TENS)
therapy for sore, aching muscles, joint pain/ or chronic intractable pain
TENS moa
alteration of pain transmission and increase in production of natural endorphins
TENS use
15-30 min up to 3 times daily
avoid TENS use in
use with internal or attached medical devices
pharm treatment for muscles
nsaids and apap or topical analgesics
types of topical analgesics
local analgesic, anesthetic, antipruritic
topical analgesics used for
temporary relief of minor aches/pains of muscles and joints
apply topical analgesics
up to 3-4 times daily for up to 7 days
moa of counterirritants of topical analgesics
pain relief through nerve stimulation and psychological component of smell, warmth, and coolness
methyl salicylate products
bengay and flexall
rubefacient
‘hot’ action
safety considerations of methyl salicylate products
- caution if sensitive to aspirin
- avoid in children
- avoid wrapping or heating area
methyl nicotinate products
aspercreme heat pain relieving gel, bengay ultra strength relieving patch, icy hot, mineral ice, jointflex pain relieving cream
if apply methyl nicotinate over large areas
can cause hypotension
camphor in low concentrations
(.1-3%) depress cutaneous receptors
examples of counterirritants of topical analgesics
methyl salicylate, methyl nicotinate, camphor, menthol, capsaicin/capsicum
camphor in high concentrations
(3-11%) stimulates nerve endings
safety considerations for camphor
keep away from children; ingestion can cause CNS toxicity, seizures, and respiratory depression; infants can have respiratory collapse if applied to nostrils
menthol in low concentrations
(<1%) depresses cutaneous receptor response (anesthetic)
menthol in high concentrations
(>1.25%) stimulates response (counterirritant)
safety considerations of menthol
asthma exacerbation possible; enhances permeability of other topicals
capsaicin products
capzasin, zostric, icy hot
capsaicin is extracted from
hot chili peppers (warmth)
moa of capsaicin
depletes substance P at the nerve ending, which is released in response to stress and injury
- elicits a feeling of warmth initially then burning and tingling sensation
t/f capsaicin is effective in relieving pain but not inflammation
true
applying capsaicin
regularly 3-4 times daily for 14 days - 6 weeks
topical anesthetics
lidocaine (used every 6-8 hours, max 3 applications in 24 hours)
