headache and fever

characteristics of tension headache

• Bilateral; Over the top of the head, extending to neck

• Varies from diffuse ache to tight, pressing, constricting pain

• gradual

• hours to days

• scalp tenderness, neck pain and muscle tension

• mild-moderate

• stress/anxiety

characteristics of migraine

• usually unilateral

• throbbing; may be preceded by an aura

• sudden

• hours to 2-3 days

• nausea, vomiting

• moderate-severe

• routine physical activity, light, sound

characteristics of sinus headache

• face, forehead, or periorbital area

• pressure behind eyes or face; dull, bilateral pain

• simultaneous with sinus symptoms, including purulent nasal discharge

• days (resolved with sinus symptoms)

• nasal congestion

• mild-severe

• congestion/stooping

when to refer

• Severe headache

• Headache reaching maximum intensity rapidly

• Significant change from usual headache pattern

• Neurologic symptoms: visual changes, seizure, altered mental status, weakness, etc.

• Neck stiffness

• High fever/signs of serious infection

• Suspected secondary headache

• New headache during pregnancy

• Undiagnosed suspected migraine

• Headache persistent despite appropriate self-care

• Medication-overuse headache suspected

• High-risk comorbidity requiring evaluation

what is nonpharmacologic treatment of a heacache

• Keep a headache diary

• Acupuncture

• Physical/Manual therapy

Migraine headache

• Maintain a regular schedule for sleeping, eating, and exercise.

• Stress management

• List of Triggers

what types of headaches are amenable to self care

• tension-type headaches - episodic and chronic

• diagnosed migraine with or without aura

• sinus headache

• cluster headache

• medication overuse headache

what types of headaches should be referred

• cluster headache

• medication overuse headache

• secondary headache

• undiagnosed migraine

• bacterial and viral diseases

pharmacologic treatment

• Acetaminophen(APAP)

• NSAIDS

• Ibuprofen, Naproxen

• Salicylates

• Aspirin (ASA)

acetaminophen

Analgesic (decreases pain) and antipyretic (decreases fever)

Mechanism of action: Produces analgesia through central inhibition of prostaglandin and antipyresis through inhibition of hypothalamic heat-regulating center

Dosage forms: Immediate-release, extended-release, effervescent, dispersible, and chewable tablets; capsules; liquid; suppositories; powder packet

Onset of action ~30 minutes after oral administration

Duration of action ~4 hours after oral administration; increased to 6-8 hours with extended-release formulation

FDA-approved nonprescription uses: Reducing fever and mild-moderate pain

Adverse reactions: • Hepatotoxic in doses >4000 mg/day, FDA limit of 3250 mg/day • Serious cutaneous adverse reactions (rare)

acetaminophen special considerations and dosing

• Use with caution

• Concurrent hepatotoxic drugs

• ≥3 alcoholic drinks/day

• Diagnosed liver disease

• Poor nutrition

• Avoid combination products

Children <12 years of age Weight based-dosing: 10-15 mg/kg Q 4-6 hours PRN Maximum daily dose: 480 mg/dose (max 5 doses) or 2400 mg TDD

Children ≥ 12 years of age 325-1000 mg Q 4-6 hours PRN Maximum daily dose: 4000 mg, FDA max 3250 mg

acetaminophen risk of:

hepatotoxicity

Acetaminophen has been associated with cases of acute liver failure, at times resulting in liver transplant and death. Most of the cases of liver injury are associated with the use of acetaminophen at doses that exceed the maximum daily limits and often involve more than one acetaminophen-containing product

NSAIDS

Mechanism of action: Produced analgesia, antipyresis, and anti-inflammatory effect through reversible inhibition of cyclooxygenase (COX) 1 and 2 enzymes, resulting in decreased production of prostaglandin precursors

Dosage forms Ibuprofen: Immediate-release and chewable tablets; capsules; suspension Naproxen sodium: Immediate-release and delayed release tablets, capsules

Onset of action ~30 minutes after oral administration Duration of action • ~6-8 hours ibuprofen • ~12 hours for naproxen

FDA-approved nonprescription uses: Reducing fever, headache, toothache, muscle ache, backache, arthritis, and menstrual cramps

Adverse reactions: • GI tract: dyspepsia, heartburn, anorexia, and epigastric pain • Other (Rare): Dizziness, fatigue, headache, and nervousness

NSAIDS special considerations and dose

• Use with caution

• ≥3 alcoholic drinks/day

• History of MI, CHF, HTN, or other CV disease

• patients >60 years of age

• Pregnancy

• May be taken with food, milk, or antacids if upset stomach occurs

• Take with full glass of water; suspensions should be shaken thoroughly

• Risk of GI ulceration, perforation, and bleeding

Children <12 years of age

Ibuprofen: Weight based-dosing: 5-10 mg/kg Q 6-8 hours PRN Maximum daily dose: 300 mg/dose (max 4 doses) or 1200 mg TDD Naproxen sodium: Do not use in children <12 years of age

Children ≥ 12 years of age Ibuprofen: 200-400 mg Q4-6 hours PRN; maximum daily dose of 1200 mg Naproxen sodium: 220 mg Q 8-12 hours PRN

NSAIDS increase:

risk for cardiovascular events, especially those with pre-existing cardiovascular conditions or increased risk

• Hypertension, heart failure, and diabetes

NSAIDS may interfere with ______ antiplatelet effect and long term use can be _____

aspirin’s; nephrotoxic

salicylates

Mechanism of action: Produced analgesia, antipyresis,, anti-inflammatory and anti-thrombotic effect through irreversible inhibition of cyclooxygenase (COX) 1 and 2 enzymes, resulting in decreased production of prostaglandin precursors

Dosage forms: Aspirin: Immediate-release, buffered, enteric-coated, film-coated, effervescent, and chewable tablets; suppositories Magnesium salicylate: Tablets

Onset of action: Varies depending on the dosage form

Duration of action: 4-6 hours after oral administration of immediate release; anti-thrombotic effect last ~10 days

FDA-approved nonprescription uses: Reducing fever and relieving mild-moderate pain in headache, muscle pain, toothache, menstrual pain, pain and fever of colds, and minor pain of arthritis

Adverse reactions: • Dyspepsia; Take with food • May cause gastritis and ulceration of the upper GI tract

salicylates examples

Aspirin and Magnesium salicylate Analgesic, anti-pyretic, anti-inflammatory, and anti-thrombotic

NSAIDs examples

Ibuprofen and Naproxen Analgesic, anti-pyretic, and anti-inflammatory

salicylates (aspirin) special considerations an ddose

Special considerations

• Aspirin intolerance (cutaneous and respiratory) may occur

• Contraindicated in patients who have any type of bleeding disorder

• Age >70

• Avoid use in patients with a history of gout

• Reye’s syndrome

Dose

Children <12 years of age

Do not use

Children ≥ 12 years of age

Aspirin: 325-1000 mg Q 4-6 hours PRN

Maximum daily dose of 4000 mg

what is reye’s syndrome

• A rapidly progressive encephalopathy with hepatic dysfunction, which often begins several days after recovery from a viral illness

• Varicella (chickenpox), influenza A or B

• Characterized by vomiting and confusion, rapidly evolving to seizure and coma

• Cause is unknown

• The use of aspirin to treat viral illnesses is has been associated with the syndrome

12 years or younger how is migraine treated

Acetaminophen or Ibuprofen

No Naproxen and Aspirin

12 years or younger how is sinus headache treated

Appropriate decongestant when congestion is present and the patient has no contraindications

12-19 years old how is tension headache treated

Either NSAIDs or Acetaminophen

12-19 years old how is migraine treated

Either NSAIDs or Acetaminophen

12-19 years old how is sinus headache treated

Either NSAIDs or Acetaminophen Add decongestant (phenylephrine)

19 or older how to treat tension headache

Aspirin, NSAIDs, or Acetaminophen

19 or older how to treat migraine

Aspirin or NSAIDs Pt with pre-existing CV conditions – use acetaminophen

19 or older how to treat sinus headache

Aspirin, NSAIDs, or Acetaminophen Add decongestant (phenylephrine)

pregnant how to treat headache

Acetaminophen is preferred. Avoid NSAIDs and aspirin

follow up refer if:

• Symptoms worsen

• Headache pattern changes

• OTC therapy is ineffective

• Medication use becomes frequent

• Medication-overuse headache is suspected

• OTC headache medication

• should not be used for more >3 days per week or >14 days/month,

unless recommended by provider to reduce medication-overuse

headache risk

what is hyperthermia

Malfunctioning of the normal thermoregulatory process, caused by excessive heat exposure and production

what is hyperpyrexia

• >106F (41.1 C)

• Associated with mental and physical sings and symptoms

what is drug fever

• A febrile response to the administration of a medication

• 98.9 F (37.2 C) to 109.0 F (42.8 C )

what is fever

• Defined as a body temperature > 100.0 F (37.8 C), Oral

• An increase in pyrogens stimulates PGE2 (prostaglandin) production, resulting in thermoregulatory set point elevation in the hypothalamus

• Increase in core body temperature

• Most fevers are self-limited

• May be serious with underlying disease

rectal thermometer

Electronic probe thermometer (pen or pacifier[PO])

Gold standard/not preferred

Intrusive Associated with risks Time consuming

use in < 3 months age

axillary thermometer

Electronic probe thermometer (pen or pacifier[PO])

noninvasive

not as reliable large variations

oral thermometer

Electronic probe thermometer (pen or pacifier[PO])

not appropriate for children under 3 years old

temporal thermometer

Infrared thermometer

Rapid, noninvasive More sensitive than tympanic for detecting fever in infants

Appropriate for >3 years old

tympanic thermometer

Infrared thermometer

More accurate than axillary or oral thermometer

Not recommended in <6 months of age

Appropriate for >3 years old

what complications can arise from a fever

• Most uncomplicated fevers are self-limited

• Main goals: comfort + hydration + identify underlying cause

• Febrile seizures may occur in susceptible young children

• Serious complications are unusual at routine fever temperatures

• Hyperpyrexia/hyperthermia requires urgent evaluation

what are exclusions for self treatment for fever

< 3 months of age with rectal temperature ≥100.4F (38.0 C)

>3 months of age with rectal temperature ≥104.0F (40.0 C) or equivalent

Severe symptoms of infection that are not self-limiting

Risk of hyperthermia (temperature >106F)

Impaired O2 utilization in pulmonary or cardiac disease

Impaired immune function (cancer, HIV)

CNS damage (head trauma, stroke)

<2 years of age with fevers that persists >24 hours

>2 years of age with fevers that persists >3 days with or without treatment

Children with history of febrile seizures

Children who displays any of these symptoms:

• Spots or rash

• Sleepy, irritable, or hard to wake up

• Vomiting and cannot keep down fluids; refuses to drink any fluids

• Repeated diarrhea

• Stiff neck

fever non pharmacologic treatment

• Fluid Replacement

• Children: 30-60 mL/ hour

• Adult 60-120 mL/ hour

• Lightweight clothing

• Removal of excessive blankets

• Maintain a comfortable room temperature (~68°F/20°C)

• Not recommended

• Ice water bath

• Alcohol sponge bath

fever pharmacologic treatment

• Acetaminophen(APAP)

• NSAIDS

• Ibuprofen, Naproxen

acetaminophen onset of action and dose

Maximum temperature reduction at 2 hours usual recommended dose

Limit use to 3 days

NSAIDS onset of action and dose

Maximum temperature reduction at ~2 hours at the recommended dose

Do not use in children < 6 months of age

Naproxen sodium: Do not use in children <12 years of age

> 6 months of age

Weight based-dosing: 5-10 mg/kg Q 6-8 hours PRN

Maximum daily dose: 300 mg/dose (max 4 doses) or 1200 mg TDD

Adults

200-400 mg Q 4-6 hours PRN; maximum daily dose 1200 mg

limit use 3 days

what is a fever < 3 months of age

greater than or equal to 100.4 F

what is a fever for 3 months and older

for 3-12 yo less than 104 self care, greater then 104 refer

for older than 12 greater than 104 refer less than 104 self care

should acetaminophen and ibuprofen be routinely alternated

no

pediatric medications are dosed by:

weight