Headache (HA), Fever, and Musculoskeletal (MSK) Pain

Analgesics (reduce pain) and Antipyretic (reduce fever)

• All inhibit COX centrally and peripherally, ↓ prostaglandin (PGE2) synthesis.

• Acetaminophen (APAP), Non-steroidal anti-inflammatory drugs (NSAIDS0, Salicylates (Ibuprofen, Naproxen), Non-salicylates (Aspirin [ASA], Magnesium salicylate).

• Lowers fever and inflammation.

Acetaminophen (APAP)

• Mainly central COX inhibition, NOT ANTI-INFLAMMATORY!!!

• Brand Name: Tylenol

• Uses: pain + fever, NOT INFLAMMATION!

• Onset & Duration (takes ~30 min to work): lasts 4hr

• Minimum Age for OTC Use: >2 years

• Bigggest Safety Concern: Hepatotoxicity (liver damage)

  • Warnings: liver warning, allergy alert for serious skin reactions.

• Max Dose: 4,000 mg/day (4 g/day). Consider <2 g/day or avoid in liver disease, SEVERE ALCOHOL USE DISORDER!

• Overdose —> poison control/ED —> Acetylcysteine most effective within 8hr

What is the APAP pediatric dose for oral suspension?

Oral suspension 160 mg/5mL

What is the pediatric dosing (<12 years) for APAP?

10-15 mg/kg q4-6hr, do NOT exceed 5 doses/day

What are key drug interactions w/Acetaminophen?

Alcohol (hepatotoxicity/liver damage), liver disease, warfarin (INCREASES INR)

What are the names of non-salicylates NSAIDs?

Ibuprofen, Naproxen

Ibuprofen

• Brand Names: Motrin, Advil

• Use: pain, fever, anti-inflammatory

• Onset (takes ~30 min to work) and Duration: lasts 4hr

• Minimum Age for OTC Use: Fever >6 months; heart-attack >2 years

• Biggest Safety Concerns: GI/CV/Renal (GI/cardiovascular/kidney)

  • GI: dyspepsia (indigestion) most common.

    • Stomach bleeding warning risk factors: ulcer history, anticoagulant, other NSAIDs, >3 alcoholic drinks/day, age >60 yrs.

    • CV: INCREASES heart-attack, heart failure, hypertension, stroke in those with CVD. (IF HAVE CVD, DON’T TAKE IBUPROFEN IF IT’S OTC AND NOT A RX)

    • Renal: LOWER renal blood flow. Don’t take if they have renal disease or heart failure.

• Max Dose: 1,200mg (OTC treatment)

What is the dosing for Ibuprofen for infant and chidl?

• Doses:

  • Infant —> 50mg/1.25mL

  • Child —> 100mg/5mL

What are the interactions with Ibuprofen?

Low dose of aspirin (ASA); separate the 2 by 30 min

Naproxen Sodium

• Brand Name: Aleve

• Use: pain, fever, anti-inflammation, anti-platelet effects (reversible)

• Onset (takes ~30 min to happen) and Duration: lasts up to 12hr

• Minimum Age for OTC Use: >12 years

• Biggest Safety Concern: GI/CV/Renal

• Biggest Safety Concerns: GI/CV/Renal (GI/cardiovascular/kidney)

  • GI: dyspepsia (indigestion) most common.

    • Stomach bleeding warning risk factors: ulcer history, anticoagulant, other NSAIDs, >3 alcoholic drinks/day, age >60 yrs.

    • CV: INCREASES heart-attack, heart failure, hypertension, stroke in those with CVD. (IF HAVE CVD, DON’T TAKE IBUPROFEN IF IT’S OTC AND NOT A RX)

    • Renal: LOWER renal blood flow. Don’t take if they have renal disease or heart failure.

What are the names of salicylate NSAIDs?

Aspirin and Magnesium Salicylate

Aspirin (ASA)

• Uses: pain, fever, inflammation, anti-platelet (IRREVERSIBLE)

• Onset (takes ~30 min to happen) and Duration: lasts 4-6hr

• Minimum Age for OTC Use: avoid in children and teens unless provider directed.

• Biggest Safety Concern: bleeding; Reye syndrome

  • Reye Syndrome: AVOID in children and teens

  • Not recommended to take to prevent cardiovascular disease (CVD)

• Aspirin Tolerance: asthma + nasal polyps (~10% of people with asthma)

• Enteric coating/buffering reduce local irritation but NOT the risk of serious GI bleeding (systemic effect)

Magnesium Salicylate

• Brand Names: Doan’s

• Uses: pain, anti-inflammation

• Onset (takes ~30 min to happen) and Duration: lasts 6hr

• Minimum Age for OTC Use: avoid in children and teens unless provider directed.

• Biggest Safety Concern: magnesium accumulation in renal impairment; Reye syndrome

  • Reye Syndrome: AVOID in children and teens

What are key interactions with NSAIDs/salicylates?

Interacts with anti-coagulants, anti-platelets (avoid anything that INCREASES bleeding risk)

Combination Products: Caffeine and Decongestant

• Caffeine: analgesic adjunct can trigger migraine and cause withdrawal headache.

• Decongestant + analgesic: sinus headache.

• Counsel: CHECK EVERY PRODUCT FOR DUPLICATE INGREDIENTS! (ask a patient what they’re taking)

How long can patients self-treat?

• Pain (oral analgesics): 10 days

• Fever: 3 days

• Headache: <3 days/week (<14 days/month)

• Using counterirritants, topical lidocaine: 7 days

• Topical diclofenac: up to 7 days to work; stop at 21 days

Special Populations

Pregnancy

APAP (Tylenol) is preferred. AVOID NSAIDs in pregnancy!

Breastfeeding

APAP compatible; ibuprofen preferred NSAID. AVOID NSAIDs.

Children

APAP or Ibuprofen is safest; naproxen <12

Renal impairment, HF, CVD, anticoagulants, GI bleeding/ulcers, true ASA allergy, taking daily ASA

REfer or use APAP

What headaches can you treat?

Tension-type, migrane, sinus

Tension-type (stress) Headache

• Chronic episodic, frequent episodic

• Characteristics: bilateral, band-like, gradual onset

• Can you treat with self-care? Yes.

Migrane (±aura)

• Characteristics: with or w/o aura, pulsating, neck pain, stiffness, fatigue, cravings, photophobia/phonophobia

• Can you treat with self-care? Yes, if already diagnosed with having migraines

Sinus Headache

• Characteristics: face/forehead/behind eye pain, lasts as long as sinus symptoms are present.

• Can you treat with self-care? Yes, decongestant + analgesic