Wk 28 - CNS + MSK OTC Flashcards
Give examples of types of headaches
- Migraine
- Tension headache
- Sinusitis
- Cluster headaches
- Temporal arteritis
- Trigeminal neuralgia
- Chronic daily headache
- Medication overuse
What is a migraine?
- Complex neurological condition
- Severe/moderate headache
- Throbbing + pulsating
What are the key feature that support the diagnosis of migraines?
- Nausea + vomiting
- Photophobia
- Phonophobia
- Disability
What are the causes of a migraine?
Vasodilation of blood vessels in brain
Outline the main classifications of migraines
- Migraine w/ aura
- Migraine w/o aura
- Chronic migraine
- Menstrual migraine
Give examples of migraine w/ aura
- Typical aura
- Hemiplegic migraine
- Migraine w/ brainstem aura
- Ocular
- Silent
Outline the features of migraine w/o aura
- Recurrent headache
- Attacks last 4-72 hrs
- Unilateral, pulsating, mod/severe
- Aggravated by physical activity
- Association w/ nausea, vom, photophobia + phonophobia
- Relief from lying in darkened room
- No neurological symptoms
Outline the features of migraine w/ aura
- Transient, unilateral
- Visual, sensory + other CNS symptoms that develop gradually
- Occurs 5-20 mins before headache
- Prodromal + post-dromal phases occur
- Neurological symptoms precede headache
- More common in women
Visual aura
- Flashing lights
- Scotoma
- Zigzag lines (photopsia)
Sensory aura
- Unilateral tingling or numbness in lips, fingers, face + hands
- Difficulty in speaking (dysphasia)
What is the ICHD-3 diagnostic criteria for migraine w/o aura?
- > 5 attacks fulfilling 3 criteria
- Headache lasting 4-72 hrs
2/4:
- Unilateral
- Pulsating
- Mod/severe pain
- Aggravated by physical activity
During headache at least 1 present:
- Nausea and/or vom
- Photophobia + phonophobia
What is the ICHD-3 diagnostic criteria for migraine w/ aura?
> 2 attacks fulfilling 3 criteria
1/more:
- Visual
- Sensory
- Speech
- Motor
- Brainstorm
- Retinal
At least 3:
- At least 1 aura symptom gradually over 5 mins
- 2/more aura symptoms
- Each symptom lasts 5-60 mins
- 1 unilateral
- 1 +ve
- Aura accompanied w/in 60 mins of headache
Give an example of a diet trigger for migraine
- Crash diet
- Irregular meals
- Cheese
- Chocolate
- Red wine
- Tyramine containing foods
Give an example of an environmental trigger for migraine
- Smoking
- Bright light
- Screen use
- Strong smell
Give an example of an psychological trigger for migraine
- Depression
- Anxiety
- Stress
- Anger
Give an example of medicinal triggers for migraine
- HRT
- COC
Give other examples of triggers for migraine
- Menstruation
- Shift pattern
- Menopause
Give treatment options OTC for acute migraine
- Simple analgesia
- Anti-emetic
- Migraine specific treatment: triptans or 5HT1 agonist
Give examples of simple analgesia for migraines
- Paracetamol
- Ibuprofen
- Aspirin
Use early in attack to avoid gastric stasis
Give examples of anti-emetics used for migraines
Gastric stasis slowed in migraine (red med absorption)
- Migraleve pink: codeine, paracetamol + buclizine
- Buccastem M buccal: prochlorperazine 3mg - previously diagnosed migraine + adults
How do serotonin 5-HT1 agonists or triptans work to reduce migraines?
- Imitate 5-HT
- 5-HT causes dilated blood vessels to constrict
- Included 1st line along simple analgesia + anti-emetic in mod/severe migraine
- Red pain w/in 2 hrs
- Red photophobia + phonophobia
Give examples of triptans
- Almotriptan
- Naratriptan
- Sumatriptan
- Zolmitriptan
What is the criteria to supply sumatriptan (imigran)?
- 18-65
- Migraine diagnosed by doc/pharmacist
- Established pattern of migraine w//w/o aura (5/more over year)
- Simple analgesic ineffective
Outline the cautions for sumatriptan use
- SSRI/SNRI
- St Johns wort
- COC
- Heart disease risk factors
What are the contraindications of sumatriptan?
- Under 18, over 65
- Pregnant + breastfeeding
- 3/more cardiovascular risk factors
- Aged 50 + over + experiencing migraine attack for 1st time
- 1st ever migraine attack w/in previous 12 months
- Fewer than 5 migraine attacks in past
- Don’t respond to treatment
- Headache on 10/more days per month
- COC
- 4/more attacks per month
- Migraine lasting over 24hr
Outline how to take sumatriptan
- One 50mg tablet
- Taken asap - start of headache + not start of aura
- 2nd dose taken 2 hrd after 1st if symptoms back - only if headache responded to 1st dose
- Don’t take more than 2 in 24hrs
- Don’t take more than 2 for same attack
When should sumatriptan be considered as a preventative treatment?
- Migraine attacks have sig impact on QoL
- Acute treatments are contraindicated or ineffective
- Person is risk of MOH due to frequent use of acute drugs (amitriptyline, propranolol, topiramate)
Give counselling point for a migraine
- Keep headache diary to identify triggers
- Immediate use of simple analgesia
- Dark + quiet env
- Good sleep hygiene
- Diet + fluid intake
- COC
- Cold compress
What is tension type headache?
- Most common type of headache
- Recurrent episodes of headache that are bilateral
- Pressing/tightening band around head (non-pulsating)
- Mild to moderate
- Relationship to neck w/ pain into/from neck
- Mild nausea
- Relieved by simple analgesics
What are the different types of TTH?
- Episodic: fewer than 15 days each month
- Chronic: more than 15 days each month + has ft of episodic TTH
What causes TTH?
- Anxiety
- Screen time
- Depression
- Poor posture
- Poor sleep
- Stress
- Muscular tightness
What are the treatments for TTH?
- Simple analgesics: paracetamol, ibuprofen
- Syndol tabs: codeine, paracetamol, doxylamine + caffeine
- Syndol headache relief: codeine, paracetamol + caffeine
- Avoid codeine prods
Give counselling advice for TTH
- Lifestyle adjustments
- Alleviate stress
- Check sleep hygiene
- Attention to anxiety/depression
- Advice on posture
- Exercise
- Red use of screens
- Avoid codeine
- Acupuncture
When should you refer when experiencing a headache
- Migraine w/ COC
- Headache w/ associated high temp
- Frequent migraine/treatment failure
- Severe headache of >4hrs
- Suspected ADR
- Associated drowsiness, unsteadiness, visual disturbance or vomiting
- Associated neck stiffness
- Suspected injury/trauma
- Under 12
What are the different types of MSK pains?
- Myalgia from injury, infection, cramp
- Bone pain: fracture, infection, tendon pain from sprain, strain or inflammation
- Joint pain: RA/OA/Gout
- Bursitis
- Fibromyalgia: pain in tendons, muscles + joints
- Nerve compression pain: put pressure on nerves (carpal tunnel syndrome)
Low back pain
- 60% people experience
- Pain in lumbosacral area of back btw bottom of rib + top of legs
- Usually due to trauma or musculoligamentous strain
- Acute resolve w/in 6 wks
Give counselling advice for lower back pain management
- Stay active, avoid bed rest (leads to loss of muscle strength + inc stiffness)
- Inc physical activities over few days or wks
- Relaxation red tension
- Local heat/ice pack
Pain analgesia for lower back pain
- Offer NSAID first line: ibuprofen 400mg TDS
- Paracetamol not enough
- If NSAID not tolerated or ineffective offer codeine
Other than pain analgesia, what can be used to manage lower back pain?
Topical NSAIDs
- Less systemic absorption
- Ibuprofen gel: ibuleve
- Diclofenac gel: voltarol
Rubefacients: heat rubs
Cooling sprays
What is a sprain?
- Stretch/tear of ligament
- Result of joint being forced suddenly outside usual range
- Symptoms: pain round affected joint, tenderness, pain weight bearing
- Ankles, knees, wrists + thumbs
What is a strain?
- Stretch/tear of muscle fibres and tendon
- Stretched beyond limit + forced to contract too strongly
- Symptoms: muscle pain, inflammation, spasm
- Foot, hamstring + back
What is the management for a strain/sprain?
- Oral analgesia: paracetamol/NSAIDs + price
- Oral NSAIDs: ibuprofen OTC
- Topical NSAID
What are the red flags for MSK?
- Severe arthritis
- Back pain w/ abnormal urination
- Back pain radiating to leg
- Suspected fracture
- Head injury
- Treatment failure
- Suspected adverse drug reaction
What is insomnia?
- Unsatisfactory sleep
- Difficulty in sleeping, difficulty maintaining sleep, early wakening results in impaired daytime functioning or wellbeing
- Associated w/ inc age
What are the common complaints of daytime effects in patients w/ insomnia?
- Fatigue
- Tiredness
- Lack of energy
- Irritability
- Red work performance
- Difficulty conc
Give physical causes of insomnia
- Pain
- Nasal congestion
- COPD
- Pregnancy
Give physiological causes of insomnia
- Circadian rhythm disorders
- Poor sleep hygiene
Give psychological causes of insomnia
- Stress
- Bereavement
Give psychiatric causes of insomnia
- Anxiety
- Depression
- Dementia
Give pharmacological causes of insomnia
- Stimulants
- Steroids
- Decongestants
- Thyroxine
Outline the classifications of insomnia
- Transient (days)
- ST (4wks)
- Chronic (>4wks - refer)
Give examples of non-pharmacological treatment for insomnia
- Sleep hygiene
- Regular sleep schedule
- Avoid napping
- Caffeine avoided after midday + nicotine, alcohol + large meal w/in 2 hrs of bedtime
- Exercise during day, avoid close to bedtime
- Avoid clock watching
- CBT
- Relaxation techniques
Give examples of relaxation techniques for insomnia
- Relaxation before bed
- Regular daily exercise but avoid w/in 4 hrs of bedtime
- Stress management
- Acupuncture
Give examples of sedative antihistamines
- Diphenhydramine
- Promethazine
Diphenhydramine
- Nytol original
- Nytol one a night
- Recommend no longer than 7 consecutive nights (SPC 14 nights)
- Not for under 16
- S/e: anticholinergic, hangover effect
- Contraindications: Prostatic hypertrophy, closed angle glaucoma, pregnancy + breast feeding
Promethazine
- Sominex
- Phenergan (10mg + 25mg)
- HL: 8-12hrs (longer acting + more sedative
- No longer than 7 consecutive nights
- Not for under 16
- S/e: anticholinergic, hangover effect
- Contraindications: Prostatic hypertrophy, closed angle glaucoma, pregnancy + breast feeding
What are complementary therapy for insomnia?
- Herbal sleep aids: valerian root extract, hops, passion flower, jamaica dogwood, nytol herbal
- Aromatherapy: lavender/camomile oil
- Nasal plaster
Give examples of red flags for insomnia
- Suspected depression
- Chronic issue (>4 wks)
- Children <16
- Associated physical conditions
- Suspected alcohol/drug dependence
