C (7) Headache

Headache Types

• Primary vs. secondary

• Medication-overuse headache

• Tension

• Migraine

• Sinus

Headache Types

Primary headache:

not associated with an underlying illness.

Headache Types

Secondary headache:

headache is a symptom/manifestation of another condition.

Headache Types

Most headaches appropriate for self-treatment:

• Tension-type

• Previously diagnosed migraine

• Sinus headache

Headache Types

Tension Headache - topics we discuss?

• Triggers:

• Episodic vs. Chronic

Headache Types

Tension Headache - Triggers:

• Emotional conflicts - Stress/Anxiety/Depression

Headache Types

Tension Headache: Episodic vs. Chronic

Episodic

• <15 days/month

• Pain associated with the peripheral nervous system

Chronic

• 15+ days/month for ≥3 months

• Stimulus associated with the central nervous system

Headache Types

In community practice, the major way to distinguish episodic vs. chronic tension headache is…

how often the headaches occur.

Headache Types

Migraine - what topics we cover?

• Pathophysiology

• triggers

  • tracking?

Headache Types

Migraine - Pathophysiology

trigeminal nerve activated in CNS → neuronal inflammation → pain.

Headache Types

Migraine - triggers

“Students Hate Cramming At Midnight, Bro.” 😭

• S = Stress / fatigue

• H = Hypoglycemia / skipping meals → think Hungry

• C = Caffeine

• A = Alcohol

• M = Menstrual cycle

• B = Barometric pressure changes

Food can also trigger (come back if time):

• Red wine

• Aged cheese

• Aspartame

• MSG

Headache Types

Migraine - tracking?

keep headache diary → find triggers → avoid triggers

Headache Types

Sinus Headache - topics we discuss?

Pathophysiology

Headache Types

Sinus Headache - Pathophysiology

MUCUS (in sinus cavity) → PRESSURE → PAIN

And treatment idea:

Drain mucus → ↓ pressure → ↓ headache.

Headache Types

Medication-Overuse Headache - topics we discuss

• what it is

• treatment

Headache Types

Medication-Overuse Headache - what it is?

Medication-overuse headache = too much analgesic use → rebound headache

• >2 days/week for ≥3 months = suspect medication-overuse headache.

• Stop the analgesic → headache can come back/worsen

• Take the analgesic again → headache may improve → clue that overuse is causing it

Headache Types

Medication-Overuse Headache - treatment?

Medication-overuse headache → STOP → REBOUND → REFER → LIMIT

• STOP analgesic for ≥1 month

• REBOUND: headaches may get worse during withdrawal

• REFER: may need provider/prescription treatment

• LIMIT: OTC analgesics to ≤3 days/week to help prevent recurrence

Distinguishing Headache Types

CHART

Distinguishing Headache Types

Aura:

visual warning (lights/halos) that comes BEFORE the migraine

Self-care

topics we discuss

• Exclusions for self-care

• Nonpharmacologic treatment

• Pharmacologic Treatment

Refer?

1. NUMBERS — say this like a chant

“7 pain, 10 days, 8 kid, 3 drinks, 104 fever.”

• 7–10/10 pain

• >10 days

• <8 years

• ≥3 drinks/day

• >104°F

2. NON-NUMBERS — only 5 buckets

PATTERN

• First/worst

• Getting worse

PATIENT

• Liver disease

• Cancer/HIV

• PREGNANCY

  • New headache

  • Last trimester

SCARY

• Serious infection

• Stiff neck

• Neuro changes → vision, seizure, mental status

TYPE

• Secondary headache → refer

  • Exception = sinus

• Migraine not previously diagnosed → refer

Self-care

Nonpharmacologic Therapy - overview

• Nonpharmacologic Therapy…

  • for Tension headache

  • for Migraine

  • Other options:

  • Professor's food-trigger examples:

Self-care

Nonpharmacologic Therapy - Tension headache

• Relaxation

• Massage/Physical therapy

Self-care

Nonpharmacologic Therapy - Migraine

Maintain regular:

• Sleep

• Eating

• Exercise

Self-care

Nonpharmacologic Therapy - Other options:

AVOID triggers + DARK/ICE + STRESS control + MAGNESIUM prevention

Headache-Specific Pharmacologic Treatment

Tension

• Any of the OTC analgesic classes discussed can be effective.

• take at onset of pain for best effect.

Headache-Specific Pharmacologic Treatment

Migraine

• REFER = Undiagnosed migrain

• OTC analgesic = take EARLY → aura/first pain

• Triptans = abortive treatment → stop an active migraine

• Migraine prevention drugs = recognize the list, not heavy memorization (COME-BACK)

  • Beta blocker

  • TCA

  • CCB

  • Divalproex

  • Topiramate

  • Gabapentin

Headache-Specific Pharmacologic Treatment

Sinus

• Sinus headache → decongestant for cause + analgesic for pain

• Know the 2 decongestants:

  • Oxymetazoline

  • Pseudoephedrine

OTC ANALGESIC - ADULTS

OTC ANALGESIC

Naproxen

• may take 2 tablets for the first dose, then remaining tablet 8–12 hours later

• max 3 × 220 mg = 660 mg/day.

EXAM ALERT- In self-care cases, use the…

self-care limits, not prescription-strength limits.

OTC ANALGESIC - PEDS

OTC ANALGESIC

Pediatric Dosing - what is dosing based on?

Prefer weight-based dosing over age-based dosing.

OTC ANALGESIC

main differences between pediatric vs. adult dosing?

• Pediatric ibuprofen interval differs from adult:

  • Pediatric: q6–8h

  • Adult/self-care: q4–6h

• APAP interval stays q4–6h.

PRACTICE / READING ASSESSMENT

Question: What is an appropriate weight-based dose of acetaminophen for a 6-month-old child weighing 15 lb, expressed as a measurable mL dose?

• 15 lb ÷ 2.2 = 6.82 kg

• APAP = 10–15 mg/kg

• Dose range ≈ 68–102 mg

• APAP concentration = 160 mg/5 mL = 32 mg/mL

• Approximate volume range = 2.1–3.2 mL

• Syringe-measurable dose selected by professor = 2.5 mL

✅ Correct answer: 2.5 mL

🚨 EXAM ALERT: For the first exam, professor expects you to recall the Tylenol concentration 160 mg/5 mL. She said it would be supplied on later comprehensive exams.

📝 PRACTICE / READING ASSESSMENT — 20-lb Child

Question: What would be the most appropriate acetaminophen suppository product for a patient weighing 20 lb?

Calculation:

• 20 lb ÷ 2.2 ≈ 9 kg

• 10–15 mg/kg

• Dose range ≈ 90–136 mg

✅ Professor selected Children's FeverAll 120 mg suppository because 120 mg falls within the weight-based range.

She specifically explained:

• 80 mg is below the range → underdosing.

• Avoid doses above the range because of toxicity risk.

📝 PRACTICE / READING ASSESSMENT — Teething

Question: What would you recommend for teething pain in a 5-month-old infant weighing 15 lb?

The complete original answer choices are not fully recoverable from the supplied sources.

Professor discussed:

• Two ibuprofen/Advil choices → eliminate because patient is <6 months.

• Children's Tylenol 10 mg/kg q4–6h

• Children's Tylenol 10 mg/kg q6–8h

✅ Correct: Children's Tylenol 10 mg/kg q4–6h

Why:

• Ibuprofen cannot be used before 6 months.

• APAP interval remains q4–6h in children.

Acetaminophen

topics overview

1. Mechanism/Kinetics

2. Adult/Pediatric Formulations to Recognize

3. Maximum Dose

4. Hepatotoxicity

5. Interactions

Acetaminophen

Mechanism:

• CENTRAL (CNS) → ↓ prostaglandin synthesis

• PERIPHERAL (body tissues) → ↓ pain impulses/signals

• Extensive hepatic(liver) metabolism

Acetaminophen

Kinetics:

• Oral onset ≈ 30 minutes

• IR duration listed on PowerPoint: 4 hours

• ER: 6–8 hours

Acetaminophen

Adult Formulations to Recognize

• Regular strength = 325 mg → q4–6h

• Extra strength = 500 mg → q4–6h

• Arthritis / ER = 650 mg → q8h

Acetaminophen

Pediatric Formulations to Recognize

• Peds APAP liquid: Infant = Children = 160 mg/5 mL → use weight-based dosing.

• Suppositories come in different strengths

Acetaminophen

Pediatric Formulations: → Choose the dose based on the

child's weight, not simply whether the package says infant/children.

Acetaminophen

Pediatric Formulations: Professor Counseling for Suppositories

• Remove the suppository from the plastic/foil protective wrapper before rectal insertion.

• Suppositories can be useful when a young child cannot reliably swallow liquid or spits medication out.

Acetaminophen

Maximum Dose

• Before 2011: 4000 mg/day

• Tylenol manufacturer reduced self-care max:

  • Regular Strength → 3250 mg/day = 10 × 325 mg

  • Extra Strength → 3000 mg/day = 6 × 500 mg

• Prescription combination products are no longer to contain >325 mg APAP per dose/unit.

Acetaminophen

PROFESSOR EMPHASIS: Know ________ mg/day for self-care.

3000–3250

Acetaminophen

Toxicity

Hepatotoxicity:

Acetaminophen

Hepatotoxicity: More conservative dosing/avoidance may be needed with: - skip

• Liver disease

• ≥3 alcoholic drinks/day

• Other hepatotoxic drugs

• Poor nutritional intake

Acetaminophen

Toxicity: Adverse Effects

• Leading cause of acute liver failure in the U.S. according to the slide.

• Common:

  • stomach upset

  Stop/seek care:

  • yellow skin/eyes

  • bloody stool/vomit

  • abnormal bruising/bleeding

  • allergic reaction

Acetaminophen

Interactions

Alcohol = BAD for liver
Warfarin = APAP still BEST choice

What OTC meds are NSAIDs?

• ibuprofen

• naproxen

NSAIDs

topics we cover?

• Mechanism/Kinetics

• Brands/Concentrations

• Drug-Interactions/Cautions

• Toxicity

  • GI Toxicity

    • risk factors

    • warning signs

  • Cardiovascular Risk

  • Kidney Function

NSAIDs

Mechanism

• Central + peripheral inhibition of COX
  → ↓ prostaglandin synthesis

• Eliminated primarily through kidneys

NSAIDs

Kinetics

NSAID onset = 30 min
Naproxen = last 12 h
Ibuprofen: adult 4–6, kid 6–8

NSAIDs

Adult Formulations- skip

IBU = Advil/Motrin = 200–400 q4–6
NAP = Aleve = 220 q8–12; may take 2 first

NSAIDs

Pediatric Formulations

Ibuprofen liquids = DIFFERENT concentrations → Infant 50/1.25; Children 100/5

NSAIDs

Toxicity

GI/GUT → bleed
HEART → MI/stroke/BP/HF
KIDNEY → ↓ blood flow → damage

NSAIDs

Toxicity: Adverse Effects

Common:

• stomach upset → take with food

Stop:

• severe stomach pain

• bloody stool/vomit

• abnormal bruising/bleeding

• allergic reaction

NSAID

Drug Interactions/Cautions

• NSAID + anticoagulant → ↑ bleeding → avoid; use APAP instead

• Aspirin 81 mg = antiplatelet/CV protection, NOT pain relief

• Aspirin analgesia starts around 325 mg

• If ASA 81 mg + NSAID must both be used:
  ASA ≥30 min BEFORE OR ≥8 hr AFTER the NSAID

What combination drug we talk about?

APAP + Ibuprofen Combination

APAP + Ibuprofen Combination

• APAP 250 mg

• Ibuprofen 125 mg

• 2 caplets q6h

• Max 6 caplets/day

APAP + Ibuprofen Combination

Main counseling issue

less dosing flexibility + higher risk of dosing mistakes.

Salicylates

What drugs under this?

•  aspirin

• magnesium salicylate

Salicylates

topics we cover?

• Mechanism/Kinetics

• Formulations/Brands

• Toxicity

  • Intoxication

  • GI Effects

  • Reye Syndrome

Salicylates

Mechanism/Kinetics

• Inhibit COX-1 and COX-2
  → inhibit prostaglandins

• Renally excreted.

Salicylates

Formulations:

• Enteric coated - protects stomach, delays absorption, delays pain relief.

• Buffered - intended to absorb faster, but pain relief isn’t meaningfully faster

• Sustained release

Salicylates

Brands

• Bayer → aspirin

• Ecotrin → aspirin

• St. Joseph → low-dose aspirin

• Doan's → magnesium salicylate

⭐ Aspirin dosing for analgesia received greater emphasis than magnesium salicylate because magnesium salicylate is less commonly used.

Salicylates

Toxicity

• same as NSAIDS PLUS:

• Intoxication: TINNITUS = hallmark, hyperventilation

• Reye syndrome: avoid aspirin/salicylates in patients <18, especially around viral illness.

Salicylates

Toxicity: Adverse Effects

Common:

• stomach upset

Stop:

• severe stomach pain

• bloody stool/vomit

• abnormal bruising/bleeding

• allergic reaction

Aspirin

What topics we cover?

• Intolerance

• Drug/Disease Interactions

Aspirin

Intolerance

• Aspirin allergy → skin + breathing reaction

  • NO ibuprofen/naproxen as well

  • use APAP or magnesium salicylate instead

Aspirin

Drug/Disease Interactions

• SAME AS NORMAL NSAIDS: Aspirin + NSAIDs/anticoagulants/alcohol/corticosteroids → ↑ bleeding risk

• Gout → avoid aspirin for pain because aspirin can ↑ uric acid and worsen gout

Combination Products

• Migraine/tension headache → caffeine combo

• Pain keeping patient awake → Tylenol PM = APAP + diphenhydramine (Sleep)

• Sinus headache/congestion → analgesic + pseudoephedrine (sinus)

Agent Comparison

APAP = not anti-inflammatory

NSAIDs = strongest inflammation control
- Aspirin/NSAIDs = similar pain relief
- Naproxen = longer acting than ibuprofen

SPECIAL POPULATIONS

• Children

  • Ibuprofen ≥6 months

  • Naproxen ≥12 years

  • Aspirin ≥18 years

  • APAP = no comparable age cutoff on this slide

• Elderly → APAP

• Pregnancy/Lactation

  • APAP = preferred/appropriate option if needed

  • NSAIDs = avoid in 3rd trimester

    • Naproxen = avoid during lactation

    • Aspirin = avoid pregnancy + lactation

• Renal impairment

  • Use caution with NSAIDs + salicylates

Pediatric Counseling

• use Weight-based dosing→ syringe → concentration concentration

• APAP infant + children concentrations = SAME

• Ibuprofen infant + children concentrations = DIFFERENT

• Avoid alternating APAP + ibuprofen routinely because it can cause dosing errors

SKIP - OPTIONAL

Adult Counseling / When to Stop

All analgesics

• Know the maximum daily dose

• Do NOT self-treat headache >10 total days

• Limit analgesics to ≤3 days/week to reduce medication-overuse headache

Adult Counseling / When to Stop

specific analgesics

APAP

Common:

• Stomach upset

Stop therapy for:

• Yellow skin/eyes

• Bloody stool/vomit

• Abnormal bruising/bleeding

• Allergic reaction

NSAIDs

Common:

• Stomach upset → take with food/milk

Stop for:

• Severe stomach pain

• Bloody stool/vomit

• Abnormal bruising/bleeding

• Allergic reaction

Salicylates

Common:

• Stomach upset

Stop for:

• Severe stomach pain

• Bloody stool/vomit

• Abnormal bruising/bleeding

• Allergic reaction