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Pharm301 Topics > Topic 4: headaches > Flashcards

Topic 4: headaches Flashcards

1
Q

What is a headache?

A
  • symptom not a disease state
  • common pain syndrome
  • causes not always obvious (mixed headaches can occur)
  • careful diagnosis required
  • consider patient feelings
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2
Q

What are the types of primary headaches?

A
  • migraine (classic or common)
  • tension headache (episodic or chronic)
  • cluster headache
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3
Q

What are the types of secondary headaches?

A
  • head trauma (acute or chronic post-traumatic)
  • medication overuse headache (rebound)
  • sinus headache
  • associated with vascular disorders or withdrawal (subdural hematoma)
  • tumour
  • infection (meningitis, abscess)
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4
Q

What do we need to rule out with headaches?

A
  • -medication overuse headache
  • eye strain
  • glaucoma
  • meningitis
  • subarachnoid haemorrhage
  • temporal arteritis
  • raised intracranial pressure
  • depression
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5
Q

How can eye strain be ruled out?

A

close work, frontal headache

-refer to optometrist for routine eye check

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6
Q

How can glaucoma be ruled out?

A
  • frontal/orbital headache with pain in the eye
  • sometimes (but not often) the eye appears red and painful
  • blurred vision, cloudy cornea
  • Patient may notice haloes around the vision
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7
Q

How can meningitis be ruled out?

A
  • Severe generalised headache associated with fever
  • patient is obviously ill
  • neck stiffness
  • Kernig’s sign test comes back positive
  • Laterally purpuric rash
  • difficult to diagnose early
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8
Q

What does suspected meningitis look like?

A

Child who has difficulty placing the chin on the chest

  • looks and feels unwell
  • has a headache and temperature above 38.9 degrees

refer urgently to A&E as patient can decline rapidly

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9
Q

How can subarachnoid haemorrhage be ruled out?

A
  • patient experiences very intense and severe pain in the occipital region
  • nausea and vomiting often present
  • often described as the worst headache they have ever had
  • extremely unlikely to present in pharmacy, but if this occurs, refer urgently!!
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10
Q

How can temporal arteritis be ruled out?

A
  • Temples are inflamed and become tender to touch
  • may be visibly thickened
  • unilateral pain
  • patient generally unwell with fever, myalgia, general malaise
  • scalp tenderness also possible, especially when combing the hair
  • common in elderly (especially women)
  • requires prompt treatment with oral CS as retinal artery can be compromised, leading to blindness.
  • Refer urgently!!!
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11
Q

How can raised intracranial pressure be ruled out?

A
  • many conditions cause this (space occupying lesions such as brain tumour, haematoma, abscess)
  • headache symptoms are varied ranging from severe chronic pain to intermittent moderate pain
  • pain can be localised or diffuse, and more severe in the morning with gradual improvement over next few hours
  • coughing, sneezing, bending and lying down worsens pain
  • nausea and vomiting are common
  • neurological symptoms evident over a prolnged period of time (drowsiness, confusion, lack of concentration, difficulty with speech, paraesthesia
  • patients with recent history (last 2-3 months) particuarly decreased consciousness and vomitting- refer urgently!!
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12
Q

How can depression be ruled out?

A
  • loss of appetite, weight loss, decreased libido, sleep disturbances, constipation
  • recent changes to patient’s social circumstances e.g. loss of job
  • refer to GP to determine if patient has depression
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13
Q

How can medication overuse headache be diagnosed?

A
  • daily or near daily headaches which are dull and nagging
  • medication history essential, should refer to GP
  • treat by stopping all analgesia for a number of weeks (requires careful planning)
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14
Q

How is MOH defined?

A
  • headache on > 15 ays/month
  • regular medication use for >3 months with intake on either

> 15 days/month of simple analgesics
or >10 days/month of ergotamine, 5HT agonist (triptan), opioid combination analgesic

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15
Q

What are the signs of meningitis in babies and toddlers?

A
  • fever, cold hands and feet
  • floppy, listless, unresponsive
  • refusing food
  • difficulty to wake, drowsy
  • vomiting
  • spots/rash, pale, blotchy skin
  • rapid breathing or grunting
  • fretful, dislikes being handled
  • unusual cry, moaning
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16
Q

What are the signs of meningitis in children and adults?

A
  • fever, cold hands and feet
  • stomach cramps and diarrhoea
  • comiting
  • spots/rash
  • drowsy/difficult to wake
  • confusion and irritability
  • stiff neck
  • severe muscle pain
  • photophobia
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17
Q

When should headaches be referred?

A
  • new or severe headaches in patients >50 years
  • young children (<12 years)
  • headache associated with trauma or injury
  • first, worst or different from usual headache (could be thunderclap, severe headache of more than 4 hours, atypical or prolonged aura in migraines
  • suspected ADR
  • headache lasting longer than 2 weeks or becoming worse over time
  • pain within the eye
  • pain exacerbated by exertion, coughing or bending
  • pain unresponsive to analgesics
  • assoc clumsiness, drowsiness, visual disturbances or vomiting, neck stiffness, seizures
  • symptoms of a cluster headache
  • nausea/vomiting but with no other symptoms of a migraine
  • neurological symptoms, esp. change in consciousness
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18
Q

What is a tension headache?

A

-episodes lasting for 30 minutes to 7 days
-headache with at least 2 of the following characteristics:
bilateral
pressing or tightening (non pulsating)
mild-mod intensity
not aggravtated by routine physical activity
not assoc. with nausea or vomiting
photophobia or phonophobia may be present (but not both)
headache not caused by other conditions

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19
Q

What causes a tension headache?

A
  • muscle contraction
  • not fully understood.
  • not caused by other conditions like pyrexial illness or medication overuse
  • can be triggered by stress or other factors like sleep disruption
  • affects 40-90% of western countries
  • prevalence higher in women
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20
Q

What are the complications of a tension headache?

A
  • medication overuse headache
  • impaired sleep
  • reduced energy levels
  • well being affected
  • impaired work/social functioning (rare)
  • use of NSAIDs can lead to peptic ulcer
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21
Q

How should a tension type headache be diagnosed?

A

-exclude symptoms of other secondary causes

at least TWO of

  • usually bilateral
  • asoc with pressing/tightening but non pulsating quality
  • not aggravated by routine physical activity
  • mild-mod intensity

BOTH of the following:

  • not assoc with nausea/vomiting/other symptoms
  • either photophobia or phonophobia but not both

tension type headache may also radiate to or arise from the neck, or be stress related

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22
Q

What are the common differential diagnosis’ with tension headache?

A
  • migraine without aura (can coexist with tension headache)
  • MOH (aggravation of prior headache which is usually tension type or migraine and often coexists
  • pain referred from a source in the neck and perceived in one or more regions of the head and/or face
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23
Q

How can tension type headaches be managed?

A

-analgesics for episodic use:
NSAIDs
Paracetamol (less effective)
Opiods (increases risk of MOH)

  • physical therapy - massage, stretching of neck muscles
  • Spinal manipulation (some evidence)
  • Behavioural techniques (stress reduction with exercise)
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24
Q

When would a tension headache be referred?

A

if it is chronic.

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25
Q

What is a migraine?

A

-primary episodic headache disorder characterised by
episodic severe headaches
commonly (but not always) unilateral
often described as throbbing or pulsating
associated with symptoms like photophobia, phonophobia, nausea and vomiting

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26
Q

What causes a migraine?

A
  • change in blood flow with some invovlement of 5HT3 receptors
  • broadly classified into aura (classical migraine 25%-33% of patients) and without aura (common migraine 75% of patients)
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27
Q

What are the 4 phases of a migraine?

A
  1. Prodrome - change in mood or behaviour (yawning, food cravings)
  2. aura
  3. headache
  4. resolution - drained, lethargic after pain subsides
28
Q

What are the implications of reduced gastric motility after a migraine attack?

A

-impaired absorption of analgesics, therefore combination products e.g. metoclopramide and paracetamol or S/L prochlorperazine available

29
Q

What causes migraines?

A
  • not fully understood
  • some genetic component
  • more common in women
30
Q

What is the diagnostic criteria for migraines without aura?

A

A: at least FIVE attacks fulfilling criteria B-D

B: attacks lasting 4-72 hours

C: headache which has at least 2 of the following:

  • unilateral location
  • pulsating quality (varying with heartbeat)
  • mod or severe pain intensity
  • aggravation by or causing avoidance of routine physical activity

D: At least ONE of the following during the headache:

  • nausea and/or vomiting
  • photophobia and phonophobia

E: not attributed to another disorder

31
Q

How do migraine attacks differ in children?

A

shorter lasting
headache commonly bilateral
GI disturbance is more prominent

32
Q

What are the characteristics of migraine in children?

A
  • affects 5-10% of children
  • refer all children < 12 or those with newly diagnosed or differnt to previous occurrences
  • affects male and female equally until puberty
  • recurrent abdominal pain with minimal headache
  • can be bilateral and shorter (1 hour)
  • refer for neurological examination with severe attacks
  • treat with simple analgesics and behaviour intervention
33
Q

When should migraines be referred?

A
  • not previously diagnosed
  • first migraine in patients > 50 years old
  • women taking OC and experiencing migraine for the first time or it as worsened
  • first time aura in women on combined OC
  • migraines increasing in frequency
  • > 3 severe migraines per month
  • children < 12 years
34
Q

How are migraines managed?

A
  • systematic approach is recommended:
    1. symptomatic NSAIDs early in the attack
    2. specific anti migraine drugs like triptans - do not take too early
    3. combination therapies like naproxen and sumatriptan

paracetamol - limited evidence alone

NSAIDs - ibuprofen, aspirin, diclofenac

Combination analgesics - opiods associated with limited additional benefit

  • aspirin/paracetamol/ibuprofen plus codeine
  • paracetamol + codeine + doxylamine (mersyndol)
  • aspirin + paracetamol + codeine (Pirophen)

headache diary

35
Q

What are the more migraine specific products? - pharmacist only

A
  • prochlorperazine (buccastem) - sublingual which bypasses delayed absorption
  • paracetamol + metoclopramide (paramax)
  • sumatriptan, rizatriptan, zolmitriptan
36
Q

What are the benefits of a headache diary?

A

-record intensity and site of pain, any spreading of pain, associated symptoms
-timing and frequency of attacks
relieving factors
-other factors like persons’s general health between attacks, the level of anxiety and concern the attacks cause, and more than one type of headache present

for a minimum period of 8 weeks

37
Q

What should the patient be informed of for a migraine?

A

-treat at first sign of attack
ensures adequate absorption as gastric emptying reduced
find what works and stick to it.
-rest in a quiet darkened room
-avoid triggers (foods like cheese, chocolate, caffeine, preserved meats, stress, irregular sleep, citrus fruit)

  • headache diary to identify triggers and monitor success
  • prophylaxis to be initiated with >3 migraines per month.
38
Q

What is a cluster headache?

A
  • characterised by recurrent attacks of ONE SIDED pain in or around the eye or temporal region
  • assoc with signs of autonomic dysfunction on the same side
  • attacks of pain usually last for 15-180 minutes, described as the most severe pain known and tend to recur at the same time each day, often waking the person shortly after falling asleep
39
Q

What are signs or symptoms of autonomic dysfunction?

A
  • rhinorrhea or nasal congestion
  • red eye and/or lacrimation
  • facial or forehead sweating or flushing
  • constriction of the pupil and/or ptosis
  • eyelid oedema
  • sense of fullness in the ear
40
Q

What causes cluster headaches?

A
  • not fully understood

- somehow involves the hypothalamus: disturbance causes reflex activation of autonomic system

41
Q

What causes pain in a cluster headache?

A
  • not known
  • suggested that vasodilation of blood vessels compresses surrounding tissues or obstructs venous outflow of the cavernous sinus
42
Q

How can an attack be triggered in a cluster period?

A
  • by drinking alcohol
  • breathing in fumes from volatile substances
  • being in a warm environment
43
Q

What is the prevalence of cluster headaches?

A
  • approximately 0.2%
  • estimated to be 2.5-7.2x more common in men than women
  • episodic custer headache is 6x more common than chronic cluster headache
44
Q

What are the symptoms of a cluster headache?

A

-same time each day as clusters or bouts for 6-12 weeks
-usually unilateral:
frontal, behind eyes, or temporal
severe eye pain
conjunctivitis and nasal congestion
worsens on lying down
patients tend to be agitated and pacing
50% of patients can be wakened by nocturnal symptoms
can last 10min - 3 hours
not usually assoc with nausea
family history is uncommon

45
Q

How often do patients experience cluster headaches?

A

usually 1-3 headaches per day for weeks to a few months, then remission

46
Q

Should patients be referred?

A

yes, as OTC medications are not effective

patients should also avoid alcohol for the cluster

47
Q

What is the criteria to be diagnosed with a cluster headache?

A

BOTH of:

  • unilateral location
  • severe to very severe pain around and/or above eye and/or temple

AT LEAST ONE of:

  • conjunctival infection and/or lacrimation
  • nasal congestion and/or rhinorrhoea
  • eyelid oedema
  • foreead and facial sweating
  • constricted pupil and/or
  • dropping of eyelid
  • restless or agitation

^same side of face as the pain

at least 5 attacks: from one attack every other day up to 8 attacks a day

48
Q

Who does a sinus headache affect?

A

-not restricted to specific age group or gender

49
Q

What are the symptoms of a sinus headache?

A
  • persistent headache above or below eyes that could be getting worse (more commonly below or behind eyes)
  • dull pain initially one side but can move to other side and become more severe as condition worsens
  • frontal/forehead headache, facial pain, tender to touch
  • worsened by lying down or bending forewards, or moving eyes side to side
50
Q

What is the typical history of a sinus headache?

A

-usually follows a cold or history of nasal congestion

51
Q

What other medications should be taken aware of when treating sinud headache?

A
  • blood pressure medications.

- decongestants not suitable in blood pressure

52
Q

How can sinus headache be treated?

A

decongestants:
oral (e.g. phenylephrine)
topical (e.g. oxymetazolinem xylometazoline)

analgesics

53
Q

When should sinus headaches be referred?

A
  • getting worse
  • not responding to OTC treatment
  • coloured mucous (indicates infection and need antibiotics)
54
Q

What are the advantages of using NSAIDs to treat headaches?

A
  • lack additive potential
  • analgesic at low doses and anti-inflammatory at higher doses
  • can be used in tension headache and migraine
  • ibuprofen is associated with less GI irritation than aspirin
55
Q

what are the disadvantages of using NSAIDs?

A
  • degree of blockage of the COX enzymes vary
  • inhibits production of protective prostaglanding in GIT
  • not suitable for pregnancy, breastfeeding, asthamtics
  • caution in renal compromise, patietns over 65, children, history of peptic ulcer/GI bleeds, anticoagulant treatment
56
Q

What drugs interact with NSAIDs?

A
  • anticoagulants -increased effect
  • lithium -increased effect
  • diuretics -antagonises effect
  • ACE and ARBs- antagonises effect and increased risk of renal impairment and hyperkalaemia
  • phenytoin - increased effect
  • also interacts with herbal supplements known to possess antiplatelet therapy: gingko, garlic, ginger, bilberry, dong quai, fever few, ginseng, turmeric, meadowsweet, willow
57
Q

What is the advantage of using paracetamol to treat headaches?

A
  • antipyretic and analgesic action
  • acts peripherally
  • few side effects at recommended dose
58
Q

What are the disadvantages of using paracetamol to treat headaches?

A
  • no anti-inflammatory action
  • prolonged use may enhance warfarin activity
  • metoclopramide and domperidone may enhance paracetamol effect by increasing absorption
  • accidental overdose a a result of duplication of therapy
  • caution in reduced liver function, liver disease, heavy alcohol use, malnourishment
59
Q

What are the FDA label changes on paracetamol

A
  • alcohol warning ( no more than >3 drinks/day)
  • warning on liver damage on inner and outer containers
  • highlight paracetamol on label
  • warning about use with other paracetamol containing products
  • warning to speak to doctor if on warfarin or have liver disease
60
Q

What are the advantages with using opioids to treat headaches?

A

-prevent pain signal being conducted to the brain

61
Q

What are the disadvantages with using opioids to treat headaches?

A
  • the only OTC opioid is codeine
  • it is only allowed OTC in combination with other analgesics
  • no evidence of enhanced analgesic effect at some OTC doses
  • can cause constipation and liable to misuse
62
Q

What are the combination analgesics available for OTC use?

A

paracetamol + codeine (Panadeine, Codral pain relief, Panadeine plus)

ibuprofen + codeine (Nurofen plus)

aspirin, paracetamol and codeine (Pirophen)

63
Q

When are combination analgesics used to treat headaches?

A

-when single ingredient products fail

64
Q

What are the disadvantages with using combination analgesics to treat headaches?

A

-may lead to patient confusion with what they are taking and increase risk of drug interactions

65
Q

What are examples of analgesics combined with other therapeutic groups?

A

Combinations with caffeine (panadol extra)

aspirin + antacids + citric acid + sodium bicarbonate (Alka-Seltzer)

paracetamol + codeine phosphate + doxylamine succinate (Mersyndol)

paracetamol + diphenhydramine (Panadol Night)

paracetamol + metoclopramide (Paramax)

66
Q

Which medicines are pharmacist only medicines?

A 
Mersyndol
Nurofen plus (30s)
Panadeine (40s)
Panadeine plus (40s)
Panafen plus (30s)

these are not more than 5 days supply, larger packs require Rx

67
Q

What details need to be taken to sell a pharmacist only medicine?

A
  • name and address of person purchasing
  • name of medicine and quantity
  • name of pharmacist

under notes: can record who the medicine is for.

Pharm301 Topics (8 decks)

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