Pain Management Flashcards
A patient presents to the pharmacy with a headache. What are the RED FLAGS that require REFERRAL?
-serious headache
-middle age (>40) to elderly
-severe/abrupt/sudden onset
-progressive severity or increased frequency (worst headache, or first)
-significant changes in pattern of headache
-stiff neck, focal signs, reduced consciousness
-fever, appears sick
-occurs during exercise, after sex, middle of sleep causing awakening
-syncope
Drugs of choice for tension headaches
acetaminophen or NSAIDs
Signs/symptoms of a tension headache? Cause of tension headache?
pressure pain, wanes.
no nausea or vomiting.
-tightness around the head/band, non-pulsating
-typically both sides or on top of head
Signs/symptoms of a migraine
throbbing
unilateral
+nausea/vomiting
common in AM
affects QoL, interrupts ADLs
Triggered by: light, smell, noise, food, physical activities, emotional stress, diet, menstruation
Drugs of choice for migraines
MILD - ibuprofen 400-800 mg q6h or ASA 650 mg-1300 mg Q4h
Mod-Severe: nsaids, triptans, dihydroxy ergot alkaloids
Non pharm options for migraine treatment
apply ice, sleep, rest in dark room, noise-free room
Signs/symptoms of a cluster headache
-series of SHORT, cyclical pattern or clusters
-excruciating pain
-nocturnal awakening
-occur in clusters, bouts lasting weeks to months, then remission
-unilateral (around or behind the eye, forehead, temple or upper cheek)
Drugs of choice for cluster headaches
Prophylaxis: verapamil at high doses 240-960 mg/day
2nd option: lithium
Symptomatic Tx: DHE (dihydroergotamine), SC sumatriptan, or corticosteroid
Alternate therapy for treatment of headaches
biofeedback (hypnosis)
relaxation therapy
CBT
psychotherapy
acupuncture or nerve block
psychotherapy (family dr), psychologist, psychiatrist or neurologist
Migraine with Aura Diagnostic criteria
aura symptoms: visual flashing/spots/light or loss of vision, facial weakness, pricking feeling or numbness, speech aphasia or dysarthria, tinnitus, vertigo, ataxia, or reduces consciousness
Migraine without Aura diagnostic criteria
duration: 4-72 hrs
-2 or more of the following: unilateral, moderate-severe, aggrevated by daily activities
-nausea or vomiting + photo/phonophobia
Red flags in MIGRAINES (SNNOOP10)
S-systemic symptoms: fever, wt loss, rash, joint pain
N- neoplasm of brain, metastasis
N- neurological: reduced consciousness, altered vision, stiff neck
O- onset: sudden, max intensity within seconds-mins
O- older age > 50 y/o
P10:
1. Pattern changes (freq+severity)
2. Postural headache: when sitting/standing. goes away when lying down.
3. Precipitated by cough/sneeze
4. Papilledema
5, Progressive headache
6. Pregnancy or postpartum + new onset HA
7. pain in eye + tearing/nose congestion/facial pain
8. post-traumatic migraine
9. pathology of immune system
10. painkiller overuse
Common AEs of Triptans
Chest tightness
Fatigue
N/V
Dizziness
Throat symptoms
Sumatriptan dosage forms
Tablet
Intranasal IMITREX 5-20 mg. (1 spray in 1 nostril per dose. repeat in 2 hrs prn. max 40 mg/day)
SC
Contraindications of sumatriptan
cardiac-like symptoms: ischemic heart disease (angina, MI), HTN, pregnancy, basilar or hemiplegic migraine
T/F - Maxalt (rizatriptan) tablet and MLT wafer have the same bioavailability.
true
Limit the use of triptans to max ___ days per 1 month
10
Patient C picked up triptans for her migraine. How would you counsel her to take it if the migraine returns after her first dose?
IF partial response or symptoms return, repeat dose in 2 hours. No more than 200 mg in a 24-hr period (4 hrs if nara or frovatriptan)
When should you consider trying a different triptan?
After treating with the first triptan for 3 separate attacks and still not effective
Which drug has a black box warning?
Combination drug: sumatriptan succinate+naproxen sodium (Suvexx) - CV events, GI events, risk in pregnancy (avoid if > 20 weeks)
Contraindications of NSAIDs
Renal - CrCl < 30
uncontrolled CHF
active GI ulcer, GI bleeding, inflammatory bowel disease (Chron’s)
ASA Triad: asthma, nasal poly and ASA intolerance
When should a patient be referred following a sports injury?
if symptoms persist > 14 days of trying OTC analgesics
Non-pharm approach to sports injuries
RICE - rest, ice (15-20 mins for 4+ times per day for 48 hrs or longer), compression, elevate
Which bodily injuries require immediate medical attention?
eyes, head, nosebleed
Drug tx for sports injuries (Acute)
ASA or NSAIDs for short period
A patient came to the hospital with a knee sprain. He also just had surgery and was diagnosed with DVT. What should be avoided?
Avoid the full RICE method - ice and compression leads to stasis. Its ok to just do rest and elevation of limbs.
1st line drug for patients with migraine + pregnancy
Treatment: acetaminophen, AVOID nsaids in 3rd trimester
migraine prophylaxis for patients who are pregnant
Mg, Propranolol, nadolol, metoprolol, amitriptyline, nortriptyline.
which drugs should be avoided in pregnancy in treatment of migraines?
triptans
topiramate (cleft-palate)
What is medication overuse headache?
headache frequency = > 15 days per month, in a patient with pre-existing headache disorder
AND
Overuse of medications:
- > 10 days/month of: ergots, triptans, combo analgesics, opioids
- > 15 days/month of non-opioid analgesics (nsaids, acetaminophen)
-typically when pts have regular overuse for more than 3 months
How to prevent medication-overuse headaches
- limit use of meds to < 10 days, or < 15 days (nsaids/ acetaminophen)
-initiate prevention of migraine therapies like beta blockers if pt has frequent headaches
What can trigger a tension headache?
stress, fatigue, eye strain, lifestyle (dehydrates, sleep, caffeine), hormones, weather changes. NOT physical activity.
Frequency of tension headache
infrequent = <1 day/month
frequent = 1-14 times in over 3 months
chronic: hours to days
Characteristics of TTH (tension-type headaches)
location: bilateral
not pulsating
yes pressing/tightening
mild-mod severity
daily activities do not aggravate it
prophylactic therapy for TTH
1st line: amitriptyline or nortriptyline
2nd line: venlafaxine, mirtazapine
what can trigger cluster headaches?
alcohol, strong smells, bright light, high altitude
drug interactions with triptans
MAOi (except ele-, fravo- and naratriptan)
caution with SSRI, SNRIs- serotonin syndrome
MAO-A inhibitors(moclo, phenelzine, tranyl) + triptans = Category X DDI.
MAO-B (seleg, rasagel) inhibitors are Category C. (Triptans considered safe with MAO-b i are ele, fravo, and nara)
Zolmitriptan- avoid with cyp1a2 inhibitors (ex. fluvoxamine, cimetidine)
Almotriptan- avoid CYP3A4 inhibitors. And SSRI/SNRI (ser synd)
Frovatriptan- propranolol increases concentration of fravo by 50-60% (reduce dose of fravo)
which triptan has the longest half life?
frovatriptan - 26 hours
which drug is the best option to PREVENT MENSTRUAL MIGRAINE ATTACKS ?
frovatriptan - give 5-7 days before menstrual period
which triptan is used for migraine in children?
almotriptan
which triptan is available as ODT?
zomig (zolmatriptan) = don’t need water, dissolves on tongue. faster onset. repeat in 2 hrs if headache returns.
max 2 doses within 24 hour period
maxalt - rizatriptan - used for breakthough pain
which triptan is a good option for patients who experience migraine and vomiting?
rizatriptan
Any priming required for sumatriptan intranasal spray?
no shaking or priming needed
which triptan has the fastest onset?
SC sumatriptan; most efficacious for severe migraine attacks.
-take at first sign of headache or aura
-if after first dose there is no relief, do not us 2nd dose for the same headache.
Patient was taking sumatriptan oral pills. It was helping but she is experiencing nausea and vomiting. What is an alternative option?
Sumatriptan intranasal spray - a good option for n&v
Patient took sumatriptan and is breastfeeding. After how long can she resume breastfeeding?
After triptan dose, avoid breastfeeding for 24 hours. Theoretical risk to baby: irritability, poor feeding, change in HR and blood vessel constriction.
in headaches, why don’t we use DHP-CCBs (amlodipine/nifedipine)?
they cause VASODILATION = exacerbates migraines or reduce efficacy of triptans (which cause vasoconstriction), or in cluster headaches, vasodilation increases blood flow to hypertensive regions and trigger more attacks.
Risk factors for slow back pain
-age: 45-64
-greater height
-climbing stairs often
-stress
-heavy work demand
-poor relation with co-workers
A patient comes to the pharmacy complaining about lower back pain. While you do an assessment, what are the RED FLAGS you should look out for?
-age > 50
-previous cancer history
-unexplained wt loss
-no improvement after 1 month of tx
-cauda aquina syndrome
-epidural abscess
-herniated nucleus pulposus
-spinal fracture or compression fracture
-spinal osteomyelitis
What are some self care tips to treat low back pain?
-avoid unnecessary bed rest
-be active, avoid aggravating activities like heavy lifting, twisting
-premature physiotherapy
-exercise only as tolerated
-hot compress can relieve pain (short term relief)
-insufficient evidence to recommend cold packs
which antidepressant is indicated for lower back pain?
duloxetine
use of muscle relaxants
short-term use for acute pain
ex. baclofen or cyclobenzaprine
AEs of baclofen
CNS depression
monitor / caution in opioid, BZD, TCA and antihypertensives
DDIs with cyclobenzaprine
Drug structure = similar to TCAs. AVOID with MAOi, TCAs
-Increased risk of seizurs with: tramadol
-SSRIs
-CYP1A2 inhibitors (cyclo is a metabolite)
-QT prolonging drugs
potency sequence of opioids from most to least
- fentanyl
- hydromorphone
- oxycodone
- morphine
- tapentadol
- tramadol
- codeine
- meperidine
how to switch from one opioid to another?
- calculate total daily dose of opioid 1
- calculate the morphine equivalent dose of new opioid
- reduce new opioid dose by 25-50%
What is the point of converting to the LOWER dose of a new opioid?
to avoid overdose
Max dose of morphine equivalent in chronic non-cancer pain
90 Mg of Morphine equivalent daily
Initial doses for chronic non-cancer pain?
less than 50 MME daily
