Headache, Fever, & Musculoskeletal Injuries

Abbreviation for HCP,PCP,PMH

HCP→ Health care provider

PCP→ Primary care provider

PMH→ Past medical history

Tension-Type Headache

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

Nature→ Varies: diffuse ache to tight pressing, constructing pain

Onset→Gradual

Duration→ Minutes to days

Non-headache symptoms→ Scalp tenderness, neck or muscle pain

Migraine headache

Location→ Usually unilateral “one side.”

Nature→ Throbbing sometimes preceded by aura

Onset→ Sudden

Duration→ Hours to days

Non-headache symptoms→ Nausea

Sinus Headache

Location→ Face, forehead, periorbital area

Nature→ Pressure behind eyes or face, dull, bilateral, worse in morning

Onset→Simultaneous with sinus symptoms

Duration→ Days

Non-headache symptoms→ Nasal congestion

Exclusions To Self Care

• Severe head pain

• rapid onset of maximum pain

• Concerning change in headache pattern (first or worst, gradual escalation over months)

• Persisting for 10 days ± treatment

• Occur> 15 days per months for 6 months

• Third trimester of pregnancy

• New headache during pregnancy

• Age< 8 years

• 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

• Neurologic changes (seizures, vision changes, altered mental status )

• High risk comorbid conditions (cancer, HIV)

Non-pharmacologic therapies for Tension

• Relaxation exercise

• Physical therapy-stretching and strengthening head and neck muscles

• Chronic headaches- headache log to document triggers, frequency, intensity, duration, response to treatment

  • Headache diary :> 8 weeks, frequency, duration, related symptoms, precipitating factors, medications used for relief, menstruation scedule

Non-pharmacologic therapies for Migraine

• Maintaining regular schedule: sleeping, eating, exercise

• stress management

• Ice or cold packs applied with pressure to forehead or temple areas

• Avoiding triggers foods, hunger/low blood sugar

• Avoiding light, noise and other triggers

• see headache diary above

Treatment goals headache

• Alleviate acute pain

• restore normal functioning

• prevent relapse

• minimize side effects

General treatment approach headaches

• Limit OTC analgesic use to < 3 days per week OR < 14days per month (prevent medication overuse headache)

• For migraines, medications work best when taken during aura (as applicable) or at the onset of symptoms

• Sinus headaches respond well also to decongestants

  • Concomitant use of a decongestant + nonprescription analgesic helps relieve sinus headache pain.

• When to follow up:

  • Headache persists>10 days

  • Headache worsens despite self-treatment

  • After HCP (health care provider) diagnosis/follow-up:

  • Chronic headaches- after 4-6 weeks of management

  • Episodic headaches- after 6-12 weeks of management

Fever Pathophysiology

• Average body temperature

  • 97.5-98.9 F (36.4-37.2 C)

  • Common core body temp= 98.6F (37)

• Body temperature is regulated by the hypothalamus and neurons in skin and CNS

• Pyrogens- fever producing substances

  • exogenous: toxins, microbes

  • endogenous: immune cytokines

• Prostaglandins- produced and released in response to pyrogens and elevate body temperature set in the hypothalamus

Oral

• Mouth

• wait 20-30 min to use after eating/drinking

Rectal the gold standard

• rectum

• preferred in children most reliable

Axillary

• armpit

• least reliable

Tympanic

• ear

• ensure proper technique for best measurement

Temporal

• forehead “No touch”

• convenient

Exclusions To Self Care

• Patients >3 months old with rectal temp>- 104 F

• Patients < 3 months old with rectal temp >- 100.1F

• children with a history of febrile seizures or seizures

• serve symptoms of infection

• risk of hyperthermia

• Impaired oxygen utilization(cardiovascular or pulmonary disease)

• impaired immune function (cancer, HIV)

• CNS damage (head trauma, stroke)

• Patients > 2 years old with fevers that last 3 days without treatment

• patients < 2 years old with fevers that last > 24 hours

Nonpharmacologic therapies for fever

• Fluid replacement

  • children - increase by 20-60 ml (1-2 oz) per hour

  • Adults- increase by 60-120 ml (2-4 oz) per hour

• Wearing lightweight clothing, removing blankets

• Maintain a comfortable room temperature

• Body sponging/bathing- limited effectiveness

  • Do not recommend ice baths or alcohol solutions

Approach to Treatment Fever

• Ensure accurate measurement of the body temperature

  • Product specific

  • Use the same thermometer at the same site for duration of illness

• If non-excluded, treatment may include OTC antipyretics (APAP or Ibuprofen) and non-pharm measures

• Counseling

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

  • Pediatrics &liquid preparations- measure the dose to avoid medications errors

  • Do not alternate between APA and ibuprofen- this may increase the risk of med errors and side effects

• Follow-up see a healthcare provider if:

  • Fever persists > 72 hours

  • Additional symptoms develop (stiff neck, serve headache, sore throat, serve ear pain, unexplained rash, repeated vomiting/diarrhea)

Pathophysiology Musculoskeletal Pain

Exclusions to self care

• Serve pain (pain score>6)

• 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 (excluding menstrual pain)

• Accompanying signs of infection, nausea , or vomiting

• Visually deformed joint, abnormal movement, weakness/ numbness in limbs suspected fracture

• pregnancy

• < 2 years of age

• back pain pain associated with loss of bowel and bladder control

Non-pharmacologic therapies RICE for muscle

Rest

• Rest injured area until pain is reduced, generally 1-2 days

• Use slings, splints, crutches as necessary

Ice

• Apply ice as soon as possible after injury

• 15-20 min increments

• At least 3-4 times daily

• Continue until swelling subsides (usually 1-3 days)

Compression

• Apply compression to the injured area with elastic support bandage

Elevation

• Elevation the injured area at or above level of heart 2-3 hours a day (if possible)

Non-pharmacologic therapies- Heat

• For non-inflammatory case only - do not administer to injured or inflamed areas

  • Do not use with topical agents ( analgesic or other)

  • Do not use on broken skin

  • Do not use on areas of skin with decrease

• Recommended as adjunct non-pahrm therapy of osteoarthritis

  • Increase blood flow, reduce muscle spasm alleviate stiffness

• Apply in 15-20 min increments 3-4 times daily

Non-Pharmacologic Therapies OTHER

• Stretching, massaging and adequate hydration

• TENS ( transcutaneous electrical nerve stimulation)

• Chiropractor

• Physical therapy

• Acupuncture

• Magnesium sulfate baths ( Epsom salt)

Treatment Goals

• Decrease intensity of pain

• Decrease duration of pain

• Restore function of the affected area

• Prevent re-injury and disability

• Prevent acute pain from becoming chronic persistent pain

Approach To Treatment Musculoskeletal Pain

• Non-drug therapy: RICE or heat

• OTC oral analgesics-Limit to 10 days of self-care use

  • APAP- can be used for inflammatory pain, including osteoarthritis

  • NSAIDs-better for inflammatory pain

• Topical analgesics

  • Do not concurrently with heat

  • Monitor for changes in skin condition

  • Do not apply to wounded, broken, or irrated skin

  • Avoid eyes, inside of nose, mouth or genitals.

• Follow-up

  • Pain persists >10 days (excluding osetoarthritis

  • Symptoms do not improve for >- 7 days

Acetaminophen (APAP)

MAO

• central inhibition of prostaglandin synthesis

• BLACK BOX WARNING

  • hepatotoxicity

• Counsel patients

• Adhere to MDD recommendations

• CHeck other RXs and OTCs that may contain APAP

Acetaminophen Dosing

Adults (>12 years)

• IR products: 325mg-1000mg every 4-6 hours as needed

• ER PRODUCTS: 600-1300MG EVERY 8 hours as needed

Children (<12 years)

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

• maximum of 480mg per dose *5 doses (2,400 mg) OR 75mg/kg/day

Acetaminophen Considerations

• Maximum daily dose of APAP from all non prescription and prescription products (single ingredient or combination)

• < 4,000mg daily → Appropriate for acute (short term) use or those under HCP supervision

• < 3,000 mg daily→ Appropriate for those using chronically, or without HCP supervision

• < 2000 mg daily→Consider for in those with liver disease, use of other hepatotoxic drugs, poor nutritional intake, warfarin or > 3 alcoholic beverages daily

• Children→Do not exceed 75mg/kg/day or 2,400 daily

• Stop taking APAP and seek medical attention if you develop nausea, vomiting drowsiness, confusion, or abdominal pain

NSAIDs -MOA

• Reversibility inhibit COX-1 and COX-2 enzymes

• Decreased prostaglandin formation (both centrally and peripherally)

• Decreased pain, fever, inflammation

• OTC NSAIDS are non-selective

• risks

  • Cox-1 inhibition→increased risk of bleeding

  • COx-2 inhibition → increased of clotting

  • Cox1 and 2 inhibition→ increased risk of GI events (ulcers, bleed)

NSAIDs warning

• BLACK BOX WARNINGS (CLASS WIDE)

• Stomach bleeding and other GI events

• Serious CV events, including myocardial infarction (MI), stroke

• Adverse effects:

  • Edema, heartburn, dyspepsia, GI bleeds, CV events

• Do not use IBU with ASA- will prevent anti-platelet effects of

  • Via competitive inhibition of COX-1 binding site

  • Not true with naproxen

NSAID + Salicylate considerations

• Contraindications

• Chronic/recurrent GI ulcers

• coagulation/bleeding disorders

• concurrent anticoagulants/ antiplatelets

• Heart failure

• Kidney disease

• Aspirin allergy, aspirin sensitive asthma, nasal polyps, rhinitis

• High risk for heart disease or stroke (unless supervised by healthcare provider)

• Last trimester of pregnancy (unless surprised by healthcare provider)

• Avoid salicylates in history of gout or hyperuricemia

Ibuprofen Dosing

Adults

• 200-400 mg every 4-6 hours as needed

• maximum of 1,200 mg daily

Children (>6 months and <12 years )

• 5-10 mg/ kg 6-8 hours as needed

• Maximum of 300 mg per dose *4 doses (1,200 mg daily) or 40mg/kg/day

Naproxen Dosing

Adults (>12 years )

• 220mg every 8-12 hours as needed

• may take 440mg (2 tablets) within the first hour for initial dose

• Maximum of 660 mg daily

Children DO NOT USE

Salicylates MOA

• MOA - inhibition of COX-1 and COX-2

  • Antiplatelet effects with inhibition of TXA2 (thromboxane) (eg baby aspirin)

  • Compared to NSAIDs, platelet inhibition is irreversible (NSAIDs are reversible)

• Dosage forms -ASA

  • Regular IR: absorbed in stomach and small intestine, may irritate stomach

  • Enetric- coated: delay absorption until small intestine, avoid stomach irritation, ulcer risk

  • PPIs other antacids may negate this effect

  • Buffered: co-formulated with an antacid to reduce stomach upset symptoms

• ASA intolerance

  • Cutaneous or respiratory

  • Not an immunologically mediated allergy

  • Increased risk in those with chronic urticaria, nasal polyps

Aspirin Dosing

Adults(>18 years)

• 325-1000 mg every 4-6 hours as needed

• Maximum of 4000mg daily

Children (< 18 years) DO NOT USE

Magnesium Salicylate Dosing

Adults ( >18 years)

• 1160mg every 6 hours as needed

• Maximum of 4640 mg daily

Children (<18 years) DO NOT USE

Salicylate Considerations

REYE’s Syndrome

• Do not give aspirin or products containing aspirin to children and teenagers who have or are recovering from chicken pox or influenza-like symptoms.

• Recommend avoiding use in children and teenagers (<18 years old)

• Signs/symptoms: lethargy, nausea, vomiting, changes in behavior

• can lead to neurologic damage, fatty liver, hypoglycemia

• AVOID ASA CONTAINING PRODUCTS IN CHILDREN!!

NSAID + APA

• product containing both IBU +APAP

• considerations + contraindications apply from BOTH products

• Side effects and possible toxicity from BOTH products

Caffeine

• Indicated only for treatment of headaches

• Found in several combination product such as Excedrin

• MOA (in headache)- vasoconstriction through adenosine receptor antagonism

• May cause withdrawal headaches when chronic consumption is stopped

• Caffeine itself may be a trigger for migraines

When will my medication work

Acetaminophen

• onset: 30-60 minutes

• duration: 4-6 hours

Ibuprofen

• onset:15-30 minutes

• duration: 6-8 hours

Naproxen

• onset: 30 -60 minutes

• duration: up to 12 hours

Aspirin

• onset: <60 minutes

• duration: 4-6 hours

Special populations

Pediatric

• 6 months- 2 years (you dose!)

• > 2 years can use APAP or IBU per label

• <12 avoid naproxen

• <18 avoid ASA

Pregnancy

• APAP is recommended

• NSAIDs- do not use in 3rd trimester ( okay in 1st 2nd is the safest)

• Avoid ASA

Lactation

• IBU demonstrated best safety

• APAP and NSAIDs are compatible

• Avoid ASA

Elderly

• NSAIDs not recommended

Kidney dysfunction

• Avoid NSAIDs and salicylates

Liver dysfunction

• Avoid APAP

Diclofenac (Voltaren )

• February 2020-FDA reclassified diclofenac 1% topical gel as a nonprescription drug

  • approved for the treatment of osteoarthritis in the hand, wrist, elbow, foot, ankle, and knee in patients> 18 years of age

• Topical NSAID- similar riks as oral?

  • Amount absorbed systemically is 6% or 17* less than oral diclofenac (an Rx NSAID)

• Indicated for osteoarthritis

• If no pain relief within 7 days- conatct HCp

• DO not use use longer than 21 days ( unless directed by HCP)

Diclofenac- Dosing

use the dosing card included in every box

total MDD (including all joints)= 32 g daily

upper body

• apply 2 grams up to 4x daily

• MDD=8g per joint

lower body

• apply 4 grams to 4 x daily

• MDD= 16g per joint

Lidocaine

MOA

• Inhibition of nerve impulse conduction via sodium channel blockade

Dosing

• Vary by formulation

• Patches: up to 3 applications at once up to 12 hours in 24 h

Caution

• Avoid in patients sensitive/ allergic to other amide anesthetics (‘caine’s-benzocaine prilocaine, procaine/novocaine, etc)

• Do not exceed MDD, do not apply to open wounds

Capsaicin

MOA

• Triggers the release and eventual depletion of substance P from sensory neurons at site of application

  • Elicts a transient feeling of warmth or burning stimulation of TRPV1 receptor

    • Repeated applications decrease burning sensation

• Dosing

  • Initiate at once every 4-6 hours, once pain relief is noticed, may decrease to 3-4x daily

• Counseling

  • Use gloves during AND wash hands thoroughly after applying

  • AVOID touching mucous membranes

  • Pain relief may take anywhere from 14 days to up to 6 weeks in cases of chronic pain

Methyl Salicylate

• MoA

• Counterirritant – production of a less severe pain to counter a more intense one via nerve stimulation (i.e., a distraction)

• Rubefacient – vasodilation of cutaneous blood vessels, leading to a sensation of heat that may exert a counterirritant effect (the “hot” in IcyHot)

• Inhibition of central and peripheral prostaglandin synthesis

• Adverse reactions

• Local – irritation, rash, blistering

• Systemic – salicylate toxicity (increased risk with heat exposure and exercise after applying)

  • Some systemic salicylate absorption – use with caution in populations sensitive to salicylate effects (e.g. patients at a higher risk for bleeds)

• Avoid in:

• Children

• Those sensitive to aspirin, severe asthma, nasal polyps

Trolamine salicylate

MOA-salicyate

• not a counterirritant

• Absorbed through skin and produces synovial salicylate concentrations similar to ASA

Adverse effects

• Same as salicylates

Utilization

• Efficacy date is lacking

• Use if other counterirritants are bothersome (irritation, scent)

Camphor

MOA

• counterirritant at concentration> 3 %

• Rubefacient when applied vigorously

ingestion may lead to serious adverse reaction: seizures, delirum, coma, dealth

Avoid use in children

Menthol

MOA

• Counterirritant at concentrations > 1.25%

• Activates TRPM8 receptor to trigger a cold sensation, followed by warmth

• Acts as a permeability enhancer when administered with other topical agents

• Caution – menthol hypersensitivity

• Discontinue if irritation, rash, burning, stinging, swelling, or infection occurs

Topical products general counseling

• Immediately discontinue and seek medical attention if pain, swelling, blistering of the skin occurs after application

• Do not bandage the area tightly where the product has been applied

• Do not use heat where the product has been applied

• Do not apply to wounded, damaged, broken, or irritated skin

• Do not allow these medications to come in contact with eyes, inside the nose or mouth, or with genitals