OTC Scenarios

Question 1

Patient presents with:

• Pain spread across the back along the top of the pelvis/vertically on one side of the spine
• Pain radiating to buttock or thigh, restricting movement and causing patient to adopt a posture leaning forward or to one side

What do you recommend?

Answer 1

Diagnosis:

• Simple back pain: soft tissue injury
• Patient has strained spinal muscles/ligaments e.g. lumbago; low back pain and fibromyalgia; widespread muscle pain/weakness
• Usually from twisting or lifting

Treatment:

• Analgesia (paracetamol, paracetamol + ibuprofen, cocodamol)
• Heat therapy: heat pad or hot water bottle
• Remain as active as possible (only bed rest in sciatica)
• Avoid bending or stooping, lifting or sitting on low chairs (allow time for back to recover)
• Increase frequency of physical activity upon improvement
• Stay at work or return to work as soon as
• Self-limiting: 90% acute attacks usually resolved in 6 weeks, should be better in a few days

Question 2

Patient presents in pharmacy with the following. Recommend suitable product.

• Back pain
• In LOWER back, radiates down one leg (as far as foot)
• Pain can be intense and burning
• Pain is constant and WORSENED by movement
• Patient limps and unable to flex hip very far; making sitting and climbing stairs uncomfortable
• Gait (manner of walking) is stiff and awkward
• Patients hold themselves rigid to avoid movement

Answer 2

Diagnosis:
- Trapping of nerve root
- Usually sciatic nerve from slipped vertebral disc (sciatica)
(pressure on sciatic nerve causes radiating pain)
- Risk factors: age (herniated discs/bone spurs), obesity (stress on spine), prolonged sitting, diabetes

Treatment:

• Analgesia (paracetamol, paracetamol + ibuprofen, cocodamol)
• REST (bed rest) initially, but aim to remain as active as possible e.g. walking/stretching = strengthen back muscles
• Heat therapy: heat pad or hot water bottle
• Avoid bending or stooping, lifting or sitting on low chairs (allow time for back to recover)
• Increase frequency of physical activity upon improvement
• Stay at work or return to work as soon as
• Usually self-limiting, improving within 6 weeks

Question 3

Patient presents with back pain. What should you ask?

Answer 3

Who? The patient? Their child?
What? are the symptoms? (red flag if:
- backache not related to movement,
- upper back pain not obviously due to muscle or ligament strain,
- associated w/other symptoms of illness,
- associated with neurological symptoms e.g. tingling/numbness in feet,
- bowel or bladder problems, severe pain at night,
- cyclical low-back pain in middle to second half of menstrual cycle
How? long has it gone on for? (red flag if unresponsive to 7 day treatment with OTC products)
Actions taken? (as above)
Medications - existing?

Question 4

How are injuries such as: sprain/strain/fracture/dislocation/bruising treated?

Answer 4

Rest
Ice
Compression
Elevation

• Oral analgesics: paracetamol, NSAIDs and aspirin
• Topical analgesics (e.g. Ibuprofen gel, Voltarol (diclofenac sodium)
• Topical rubefacients (e.g. salicylates; aspirin cautions, nicotinates e.g. Transvasin

Question 5

Patient presents with ‘toothache’. Advise & recommend.

Answer 5

WWHAM
W- Who?
W- What symptoms? e.g. dental caries (decay), dental abscess (pus forming in/above tooth), pericoronitis (inflammation around crown of partially erupted tooth), dry socket, gingival recession
H- How long? Not self-limiting, referral to dentist always
A- actions? Analgesics give symptomatic relief until dental assessment/treatment e.g. paracetamol/ibuprofen
M- medications.

• Dental pain is caused by inflammation of pulp or periodontal membrane of a tooth; rich nerve supply in both

Question 6

Patient presents with a ‘headache’. Advise and recommend.

Answer 6

WWHAM
W- WHO?
W- WHAT are the symptoms?

TTH:

• pain often at base of skill, but can be over top of head to eyes.
• Bilateral (frontal/occipital; front and back)
• Dull pain; like a ‘band’ - pericranial muscle contraction (membrane covering outer surface of skull)
• Triggered by tension/anxiety/fatigue
• Most common

Chronic Daily Headache:

• Type of tension headache
• Present morning to night
• Ache/dull throbbing pain
• Patients take simple/combination pain relief on more than 3 days a week

Vascular Headache; Migraine:

• Two of: throbbing/pulsating pain, moderate to severe intensity, unilateral (one sided), aggravated by movement
• And one of: nausea and/or vomiting, photophobia AND phonophobia (sensitive to light/sound)
• Can have aura symptoms before pain: perceptual disturbances e.g. strange light, unpleasant smell, confusing thoughts/experiences
• Triggered by certain foods/stress

Cluster Headache:
- Men in 20s 
- M/F ratio 6:1
- Steady intense unilateral orbital boring pain
>>> REFER

Traction Headache (e.g. meningitis):
- Eye strain (spasm/fatigue of ciliary and periorbital muscles of eye)
- Glaucoma
- Neuropathic pain from shingles
- Temporal arteritis (mostly OAPs); inflammation of arteries in/around scalp
- Referred pain from jaw
- Muscle strain and pulled ligaments in neck or upper back
»> REFER

Red Flags:

• Sudden onset ‘first’ headache
• Worst ever headache (may be subarachnoid haemorrage)
• Late onset new headache (>40 years)
• Headache w/stiff neck
• Headache w/stiff neck OR rash in under 12’s
• Progressively increasing headache
• Headache w/drowsiness, unsteadiness, visual disturbances or vomiting

H- HOW long for?

TTH:
- Few hours to several days

CDH:
- Occurs at least 15 days of the month, > 4 hours per episode

Migraine:

• Attacks last 4 to 72 hours
• Recurrent (menstrual cycle, regular times e.g. weekend)

Cluster Headache:

• Lasts 10 minutes to 3 hours
• Same time each day
• 50% experience night time symptoms

Traction Headache/Red Flags:
- Sudden onset ‘first’ headache
- Late onset new headache (>40 years)
»> REFER

A - ACTION taken?
M - MEDICINES, other?

Treatment:
Simple headache:
- NSAIDs/aspirin
- Paracetamol 
- Compound analgesics

Migraine:

• NSAIDs/aspirin
• Paracetamol
• Compound analgesics
• Sumatriptan (e.g. Imigran Recovery)
• Prochlorperazine (Buccastem-M)

Question 7

A patient comes in and asks for sumatriptan for their migraine. Counsel and advise.

Answer 7

Who - Is it for you?
What - Symptoms; is it a headache or a migraine?
How long have you have these symptoms?
Actions taken? Paracetamol/ibuprofen/combination analgesia already tried.
Medicines? (Is patient on SSRI/MAOI/Moclobemide/St John’s Wort/other vasoconstrictor migraine treatments e.g. Ergotamine/Methysergide? - AVOID Sumatriptan if so)

Sumatriptan counselling:

• What age are you? (18 - 65 only)
• Do you experience aura? (can be with or without)
• Is patient pregnant/breastfeeding?
• Do you have existing medical conditions e.g. CVS/hypertension/peripheral vascular disease/liver or kidney disorder/neurological conditions inc. epilepsy? (probably find out in medications)
• CVS risk?
• Concurrent migraine treatment?

Taking Sumatriptan:

• Take one 50mg tablet at onset
• Second tablet may be taken after a minimum of 2 hours if migraine RECURS; cannot take 2 tablet for the same migraine attack (attacks last 4 to 72 hours)
• Max TWO tablets in 24 hours
• Side effects are mild and short-lived

Watch out for:

• If attack lasts longer than 24 hours
• Attacks become more frequent
• Symptoms change
• Patient has four or more attacks per month
• Patient does not completely recover between attacks
• Patient is over 50 and having first migraine attack