Headache, Fever, and Musculoskeletal Injuries Review

What types of headaches are there?

Tension type, sinus, migraine, and medication overuse

Where is a tension type headache located?

Bilateral, over top of the head, extending to base of skull

What is the nature of a tension type headache?

Varies from diffuse ache to tight, pressing, constricting pain

What is the onset of a tension type headache?

Gradual

What is the duration of a tension type headache?

Minutes to days

What are some non-headache symptoms of a tension type headache?

Scalp tenderness and neck or muscle pain

Where is a migraine headache located?

Usually unilateral

What is the nature of a migraine headache?

Throbbing and sometimes preceded by aura

What is the onset of a migraine headache?

Sudden

What is the duration of a migraine headache?

Hours to days

What are some non-headache symptoms of a migraine headache?

Nausea

Where is a sinus headache located?

Face, forehead, and periorbital area

What is the nature of a sinus headache?

Pressure behind eyes or face, dull, bilateral, and worse in the morning

What is the onset of a sinus headache?

Simultaneous with sinus symptoms

What is the duration of a sinus headache?

Days

What are some non-headache symptoms of a sinus headache?

Nasal congestion

What is a medication overuse headache?

Results from rebound effect after withdrawal of an analgesic

What is a medication overuse headache associated with?

Analgesic use more than twice weekly for ≥3 months

Does a medication overuse headache require a medical referral?

Yes

What are some exclusions to self care for headaches?

Severe head pain, rapid onset of maximum pain, concerning change in headache pattern, persisting for 10 days with or without treatment, occurring >15 days per month for 6 months, third trimester of pregnancy, new headache during pregnancy, individuals <8 years of age, high fever or signs of serious infection, neck stiffness, history of liver disease or ≥3 alcoholic drinks/day, association with underlying pathology, migraine symptoms with no previous migraine diagnosis, neurological changes, and high risk comorbid conditions

Which populations are excluded from self care for headaches?

Individuals <8 years of age, pregnant women in their third trimester, individuals who have a new headache during pregnancy, and individuals who have a history of liver disease or drink ≥3 alcoholic drinks/day

What are some non-pharmacologic therapies for tension type headaches?

Relaxation exercises and physical therapy (stretching and strengthening head and neck muscles)

What are some non-pharmacologic therapies for migraine headaches?

Maintaining a regular schedule (sleeping, eating, exercise), stress management, ice or cold pacs applied with pressure to forehead or temple areas, and avoiding light, noise, trigger foods, and hunger/low blood sugar

What are the treatment goals for headaches?

Alleviate acute pain, restore normal functioning, prevent relapse, and minimize side effects

When is the best time to take medications for migraine headaches?

Medications work best when taken during aura (as applicable) or at the onset of symptoms

What recommendation is best to prevent medication overuse headache?

Limit OTC analgesic use to <3 days per week or <14 days per month

What treatment therapy is best for a sinus headache?

Concomitant use of a decongestant and nonprescription analgesic

When should a patient follow up for a headache?

Headache persists for >10 days or headache worsens despite self treatment

When should a patient follow up for chronic headaches after HCP diagnosis?

After 4-6 weeks of management

When should a patient follow up for episodic headaches after HCP diagnosis?

After 6-12 weeks of management

What is the average body temperature?

97.5-98.9ºF (36.4-37.2ºC)

What is body temperature regulated by?

Hypothalamus and neurons in skin and CNS

What are pyrogens?

Fever producing substances

What are exogenous pyrogens?

Toxins and microbes

What are endogenous pyrogens?

Immune cytokines

What are prostaglandins?

Hormone produced and released in response to pyrogens and elevate body temperature set in the hypothalamus

What is the definition of a fever with oral thermometers?

≥99.5ºF

What is important to note with oral thermometers?

Wait 20-30 minutes to use after eating/drinking

What is the definition of a fever with rectal thermometers?

≥100.4ºF

What are some things to note with rectal thermometers?

Preferred in children and is most reliable

What is the definition of a fever with axillary thermometers?

≥99.3ºF

What is important to note with axillary thermometers?

Least reliable

What is the definition of a fever with tympanic thermometers?

≥100ºF

What is the definition of a fever with temporal thermometers?

Varies with age

How do you convert the reading for an oral thermometer to a rectal or tympanic thermometer?

Add 1 degree

How do you convert the reading for an oral thermometer to an axillary thermometer?

Subtract 1 degree

What are some exclusions to self care for fevers?

Individuals >3 months old with rectal temp ≥104ºF, individuals <3 months old with rectal temp ≥100.1ºF, severe symptoms of infection, risk for hyperthermia, impaired oxygen utilization, impaired immune function, CNS damage, children with a history of febrile seizures, patients >2 years old with fevers that 3 days without treatment, and patients <2 years old with fevers that last >24 hours

What excludes patients >3 months old for self care of fevers?

Rectal temperature ≥104ºF

What excludes patients <3 months old for self care of fevers?

Rectal temperature ≥100.1ºF

What excludes patients >2 years old for self care of fevers?

Fevers that last >3 days without treatment

What excludes patients <2 years old for self care of fevers?

Fevers that last >24 hours

What symptoms exclude children from self care of fevers?

Development of spots or rash, refusing fluids, very sleepy, irritable, or difficult to wake, vomiting, cannot keep fluids down, repeated diarrhea, and stiff neck

How much fluid replacement is recommended for children?

Increase by 30-60 mL (1-2 oz) per hour

How much fluid replacement is recommended for adults?

Increase by 60-120 mL (2-4 oz) per hour

What are some non-pharmacologic therapies for fevers?

Fluid replacement, wearing lightweight clothing, removing blankets, maintaining a comfortable room temperature, and body sponging/bathing (limited effectiveness)

What is the treatment goal for fevers?

Alleviate discomfort of fever rather than treating to a specific body temperature

What are some counseling points for self care of fevers?

Do not use pharmacologic therapy (antipyretics) for more than 3 days without direction or further evaluation of a healthcare provider

When should patients follow up and see a healthcare provider for fevers?

If the fever persists for >72 hours and additional symptoms develop (e.g.., stiff neck, severe headache, sore throat, severe ear pain, unexplained rash, repeated vomiting/diarrhea)

Should parents alternate between APAP and ibuprofen?

No because this may increase the risk of medication errors and/or side effects

What is myalgia?

Muscle pain

What are signs of myalgia?

Possible swelling

What is the onset of myalgia?

Acute or gradual depending on cause

What is tendonitis?

Inflammation/injury of tendons surrounding joints

What are signs of tendonitis?

Warmth, swelling, and erythema

What is the onset of tendonitis?

Often gradual, possibly acute depending on cause

What is bursitis?

Inflammation/injury to the bursa located within joints

What are signs of bursitis?

Warmth, swelling, erythema, and possible crepitus

What is the onset of bursitis?

Acute with injury

What is a sprain?

Stretching or tearing of a ligament

What are signs of a sprain?

Swelling and bruising

What is the onset of a sprain?

Acute with injury

What is a strain?

Hyperextension of a muscle or tendon

What are the signs of a strain?

Swelling and bruising

What is the onset of a strain?

Acute with injury

What is osteoarthritis?

Gradual softening and destruction of cartilage

What are signs of osteoarthritis?

Possible join swelling and narrowing of joint space

What is the onset of osteoarthritis?

Years

What are some exclusions to self care for musculoskeletal injuries?

Severe pain, pain lasting >10 days, pain persisting >7 days after treatment with a topical analgesic, increase in intensity or change in character of pain, pelvic or abdominal pain, accompanying signs of infection, nausea, vomiting, visually deformed joint, abnormal movement, weakness/numbness in limb(s), suspected fracture, pregnancy, <2 years of age, and back pain associated with loss of bowel and/or bladder control

What are non-pharmacologic therapies for musculoskeletal injuries?

RICE: rest, ice, compression, and elevation; heat; stretching, massaging, and adequate hydration; TENS; chiropractor; physical therapy; acupuncture; and Epsom salt baths

When is heat advised as a non-pharmacologic therapy?

Osteoarthritis to increase blood flow, reduce muscle spasm, and alleviate stiffness

When is heat not advised as a non-pharmacologic therapy?

For noninflammatory cases only, do not administer to injured or inflamed areas

How should heat be applied as a non-pharmacologic therapy?

Apply in 15-20 minute increments 3-4 times daily

What are the treatment goals for musculoskeletal injuries?

Decrease intensity of pain, decrease duration of pain, restore function of the affected area, prevent rein jury and disability, and prevent acute pain from becoming chronic persistent pain

What are some over the counter oral analgesic options for musculoskeletal pain?

APAP (which can be used for inflammatory pain including osteoarthritis) and NSAIDs (better for inflammatory pain)

How long should over the counter oral analgesics be used for self care of musculoskeletal pain?

10 days

When should patients follow up after self care of musculoskeletal pain?

If pain persists >10 days (excluding osteoarthritis) and symptoms do not improve ≥7 days

What are some key considerations for topical analgesics?

Do not use concurrently with heat. Monitor for changes in skin condition. Do not apply to wounded, broken, or irritated skin. Avoid eyes, inside of nose, mouth, or genitals.

How should ice be applied as a non-pharmacologic therapy?

Apply in 15-20 minute increments 3-4 times daily. Continue until swelling subsides (usually 1-3 days).

How should elevation be used as a non-pharmacologic therapy?

Elevate the injured area at or above heart level 2-3 hours/day (if possible)

What is the mechanism of action of acetaminophen (APAP)?

Central inhibition of prostaglandin synthesis

What is the black box warning with APAP?

Hepatotoxicity

What are some counseling points with APAP?

Adhere to max daily dose recommendations. Check other medications that may contain APAP.

What is the recommended dosing of IR APAP for adults (>12 years)?

325-1000 mg every 4-6 hours as needed

What is the recommended dosing of ER APAP for adults (>12 years)?

650-1300 mg every 8 hours as needed

What is the recommended dosing of APAP for children (<12 years)?

10-15 mg/kg every 4-6 hours as needed

What is the maximum dosing of APAP for children (<12 years)?

480 mg/dose with 5 doses/day (2400 mg) OR 75 mg/kg/day

What is the maximum daily dosing of APAP for acute use or under HCP supervision?

≤4000 mg/day

What is the maximum daily dosing of APAP for chronic use or without HCP supervision?

≤3000 mg/day

What is the maximum daily dosing of APAP for patients with liver disease, using other hepatotoxic drugs, poor nutritional intake, on warfarin, or ≥3 alcoholic beverages daily?

≤2000 mg/day

When should patients stop taking APAP?

If patients develop nausea, vomiting, drowsiness, confusion, or abdominal pain