phmd 202b headache and fever

how much of the population has had a headache in the past year?

50% of the population

• 70% tension, 1-3% chronic

• 10% migraine

• sinus congestion

  • over use of analgesics

tension headaches

• bilateral; diffuse ache, tightening, pressing, constricting

• mild-moderate; if chronic: 15+ in a month for 3 months but can also be episodic

• gradual, usually 30min-7days

• mostly in 40’s; increases with education and higher ratio in females!

  • b/c caused by stress and anxiety!

• scalp tenderness, neck pain + muscle tension

migraine headaches

• usually unilateral; throbbing and pulsating

• moderate-severe, sudden

• 4-72h and caused by physical activity, light, and sound

• genetic!: up to 70% have family history

• may be severely debilitating: nausea, vomiting, aura

• 2 main forms:

  • migraine with aura: preceded by visual symptoms

  • migraine without aura: more common than with aura

sinus headaches

• face, forehead, or periorbital area; pressure behind eyes or face, dull and bilateral pain

• mild-severe

• simultaneous w/ sinus symptoms

• can last for days (usually resolves with sinus symptoms)

• nasal congestion and nasal discharge; blowing nose can make it worse

• may look like a migraine headache without aura; no visual disturbance, nausea, vomiting!

• if there is persistent pain/discharge → can indicate infection so refer!

sinuses are full! → cant drain successfully → so if you try to drain, you reduce swelling → lowers pressure → so pain

medication overuse headache

• timing is related to when meds are stopped

• can occur with OTCs and prescription products

• withdrawal effect of the drug is the opposite of its pharmacological effect

what are the possible treatment options for a tension headache?

nonopioid analgesics: acetaminophen

NSAIDs: aspirin, ibuprofen, and naproxen

stress reduction, relaxation, message, exercise, new job or supervisor, new spouse/partner

what are some examples of migraine headache triggers?

food that contains:

• tyramine (aged cheeses, Chianti wine)

• nitrates (cured meat products)

• phenylethylamine (chocolate)

• MSG (chinese food, canned soup)

• aspartame (diet sodas, artificial sweeteners)

• yellow food coloring

drugs:

• analgesics (excessive use or withdrawal)

• caffeine (excessive use or withdrawal)

• cimetidine

• cocaine

• estrogens (oral contraceptives)

• nitroglycerin (dilates blood vessels)

emotions: stress, anticipation, anxiety, depression, excitement, frustration

changes in temperature/weather: too hot, cold, dry, wet, windy

what are some possible treatments for migraine headaches?

***should have medical diagnosis to confirm if migraine***

if NSAID is taken when migraine starts, it can stop the HA; or if trigger is known

many prescription meds available

use ice packs on neck!

alternative treatments: butterbur, feverfew, riboflavin, coenzymes Q10, magnesium (preventatives)

what are some treatment options for a sinus headache?

oral or topical decongestant (pseudoephedrine, oxymetazoline)

can use OTC analgesics for pain

how would you treat a medication overuse headache?

most likely requires medical supervision!!! so refer!

longer-term taper, prescription meds may be needed!

if it is from OTC meds, can recommend that they slowly lower their dose of medication

fever

SYMPTOM!!!!!

• hypothalamus regulates temperature, increases in response to pyrogen

• temperature greater than 100F

• very common in kids, more than in adults (20x) → most common cause of ER visits in kids under 15 years

• must identify underlying cause but most are are caused by microbial infections

  • pathogen causes an increase in body’s set point (bugs trigger immune cytokines and prostaglandins (E), resetting the hypothalamus set point)

what are the different ways you can take temperature?

rectal, oral, armpit, forehead

DONT TOUCH PATIENT → take temp in the middle of the head with the laser thermometer

hyperthermia

malfunction of the hypothalamus in response to heat exposure or excessive production

treat differently than fever

can be induced by drugs! → if suspected all drugs should be stopped, can take 1-3 days for temperature to normalize, and then reintroduce drugs one at a time

hyperpyrexia

temperature greater than 106F

potential for mental and physical signs

can be from a fever or hyperthermia

what drugs can be used to treat a fever?

acetaminophen, NSAIDs, aspirin, magnesium salicylate

KNOW DOSING (adult and kid), APPROPRIATE USAGE, WARNINGS AND CAUTION

acetaminophen

analgesic and antipyretic

MOA is uncertain

rectal levels are about half of oral levels

if hepatotoxicity: 4gm daily max

if regular drinker (more than 2 a day): 2gm max

NSAIDs

ibuprofen: shorter time (6-8h), but less GI issues, possibly more cardiac effects

naproxen: works longer (up to 12h), but more GI issues

MOA: COX inhibition leading to inhibition of prostaglandin synthesis

analgesic, antipyretic, anti inflammatory

may cause cardiac effect! and with prolonged use GI effects!!!!!! (GI BLEEDS)

always take with food

reversible inhibition of platelet fxn

aspirin (salicylates)

for arthritis (osteo + rheumatoid), fever, pain (muscular)

irreversible inhibition of platelet function

low dose, baby, 81mg for cardiac prevention

asthma, nasal polyps and respiratory reaction

fecal occult blood test (stop 3 days before)

surgery (stop 6-8h before)

how would you treat a pregnancy patient for headaches?

acetaminophen: considered safe during pregnancy, crosses the placenta but generally well tolerated by both mother and fetus; also compatible with breastfeeding

NSAIDs: NOT RECOMMENDED during the 3rd trimester b/c of potential adverse effects on labor and fetal cardiovascular system → limited to situations where potential benefit justifies risk

how would you treat an elderly patient for headaches?

IF THIS IS SUDDEN ONSET, NOT NORMAL FOR THIS ELDERLY PATIENT REFER!!!!!

salicylates and NSAIDs: increased risk for adverse effects like GI tox, HTN, and renal effects

acetaminophen: safest alternative!!

how would you treat children for headaches?

acetaminophen and ibuprofen: both considered safe for children 2yrs+ for pain relief

naproxen: children 12yrs+

avoid aspirin in children and teenagers : increase risk of Reye’s syndrome

what is an alternate therapy for treatment of headaches?

caffeine! used as an adjunct for tension-type and migraine HAs

may also have analgesic properties

what is the maximum daily of acetaminophen for adults?

4000mg (325-1000mg q4-6h)

what is the maximum daily of ibuprofen for adults?

1200mg (200-400mg q4-6h)

what is the maximum daily of naproxen for adults?

660mg (220mg q8-12h)

what medications can you use to treat a fever?

antipyretics! (ibuprofen, acetaminophen)

use in pts that have underlying problems like heart/lung disease or general discomfort

takes about 2h to work! (try not to alternate! stick to one or the other)

dont use antipyretics as prophylaxis before vaccines

dont take for longer than 3 days at a time

what are some examples of nonpharmacologic therapy for fevers?

fluid intake: helps to prevent dehydration during fevers

sponging or baths: limited effectiveness and can induce discomfort or shivering

• if using tepid water it can help dissipate heat but not routinely recommended to temps below 104F

wear lightweight clothing, maintain comfortable room temperature, drink sufficient fluids to replenish losses!