PAIN MANAGEMENT

Pharmacy Practice Department

Qassim University

level (8) - lectrue (6)

February 16, 2025
PREVALENCE AND
EPIDEMIOLOGY
 Worldwide 47% of the population has suffered from
headache within the previous year.
 Tension type (stress headaches) and migraine

headaches are the most common headache types.

 Episodic tension-type headache (70%) is more

prevalent than chronic TTH (1%-3%) of adults.

 Tension-type headache is more common between

40-49 years, occurs in a female-to-male ratio of 5:4

 Prevalence and epidemiology :

Migraine is more sever , but less common, occurring in 10% of

people worldwide.
Headaches caused by sinus congestion and those resulting
from the overuse of analgesics are also common
 TYPE OF HEADACHES
(IHS CLASSIFICATION)

Primary headache secondary headache

Medication over use Sinus headache

headache

Cluster headache
Tension-type headache (TTH) Migraine headache

Chronic TTH Episodic TTH With aura Without

aura
3
Frequent episodic TTH Infrequent episodic TTH
TYPE/ CLASSIFICATION OF HEADACHES
 Chronic headache occur 15 or more days per month for at least
3 months, whereas episodic tension type headaches occur less
than 15 days per month.
 Medication-overuse headaches are considered primary
because they do not have a physiologic origin
 Secondary headache are symptoms of an underline condition
such as head trauma, stroke, substance abuse or withdrawal,
bacterial and viral diseases, and disorders of craniofacial
structures.
PATHOPHYSIOLOGY OF HEADACHE
 The episodic tension-type headache subtype is thought to
result in pain felt by the peripheral nervous system, whereas
the chronic tension-type headache is thought to result from
stimuli to the central nervous system
 A genetic component appears to influence the presence or

absence of tension-type headache.

 Furthermore, it is likely that tension-type and migraine

headaches share pathophysiologic features, making them

similar than distinct.
PATHOPHYSIOLOGY OF HEADACHE
 Migraine headache probably arise from a complex interaction of
neuronal and vascular factor
• Migraine is suggested to occurs through dysfunction of the
trigeminovascular system
• Neuronal depolarization that spreads slowly across the cerebral
cortex is observed during the aura phase.
• Magnesium deficiency may contribute to this state
• During the headache phase, stimulation (by an axon reflex) of
trigeminal sensory fibers in the large cerebral and dural vessels
causes neuropeptide release with concomitant neurogenic
inflammation, vasodilation, and activation of platelets and mast
cells
 Migraine
and TTH may
co-exist
?
?

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 TENSION-TYPE HEADACHE
 The pain is typically
• Bilateral
• pressing or tightening in quality
• mild to moderate in intensity.
• Not aggravated by routine physical activity

 Episodic tension-type headache (ETTH) occurs in episodes of

variable duration and frequency.

 Chronic tension-type headache (CTTH) occurs on more than 15

days per month for at least 6 months.
 MIGRAINE HEADACHE
(CLINICAL FEATURES)
A migraine headache is characteristically:
• Unilateral
• Pulsating
• Builds up over minutes to hours
• Moderate to severe in intensity
• Associated with nausea and/or vomiting
• Sensitivity to light and sound
• Disabling
• Aggravated by routine physical activity
MIGRAINE PHASES
 There are 4 symptom phases to a migraine :
a. Prodrome: can occur hours and possibly days; food
craving ,tiredness, or burst of energy , nervous, yawning ,change
in behavior ,poor consistent, highly individual but relative
consistent to each patient
b. Aura-phase
c. The attack: Headache phase: Within an hour of resolution
of the aura symptoms
d. Post-prodromal phase: patient feel lethargic, tired,
(resolution phase )
 MIGRAINE WITH AURA
(CLASSICAL MIGRAINE)
 Aura comprises of neurologic symptoms :

 Flashing area or blind spot

 visual and auditory hallucination
 Tingling
 Numbness lips, face, hand.
 Difficulty speaking
 One side muscle weakness
14
feature Tension-type Migraine Sinus headache
headache headache

Location Bilateral Usually unilateral Face, forehead, or

periodical area

Over the top of the

head, extending to
neck
Nature Varies from diffuse Throbbing; may be Pressure behind eyes
ache to tight, pressing, preceded by an aura or face; dull, bilateral
constricting pain pain
onset gradual Sudden Simultaneous with
sinus symptoms,
including purulent
nasal discharge
Duration Hours to days Hours to 2-3 days Days (resolves with
sinus symptoms)

Non-headache Scalp tenderness, neck Nausea, vomiting Nasal congestion

symptoms pain and muscle
tension
18
 ETIOLOGY OF
HEADACHE
 TTH manifest in response to stress, anxiety,
depression, emotional conflict, fatigue, anger,
aggression
 Migraine headaches :

Food , drinks , exercises , medication, stress,

irregular sleep, bright lights, hunger, smells, and
hormones changem medication ( OCC , nitrate )

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ETIOLOGY OF HEADACHE….CONT
Medication-overuse headaches
• Usually associated with frequent medication use
(> weekly) for 3 months or longer and occur
within hour of stopping the agent and
readministration of the agent provides relief.
• Associated with acetaminophen , aspirin ,some
NSAIDs, and caffeine , triptans, opioids,
ergotamine
• Tapered and subsequently eliminated
ETIOLOGY OF HEADACHE….CONT
Sinus headache is usually localized to facial areas over the
sinuses.
 The pain of a sinus headache is described as dull and

pressure- like.
 Stooping or blowing the nose often intensifies the pain, but

the headache is not accompanied by nausea, vomiting, or

visual disturbances
 Persistent sinus pain and/or discharge suggests possible

infection and requires referral for medical evaluation

ETIOLOGY OF HEADACHE….CONT
Sinus headache occurs when infection or blockage of the
paranasal sinuses causes inflammation or distention of the
sensitive sinus walls. Sinus congestion may be caused by
viral or bacterial infection, or by allergic rhinitis
 Secondary headaches are symptoms of an underline

condition such as head trauma, stroke, substance abuse or

withdrawal, bacterial and viral diseases, and disorders of
craniofacial structures
 GENERAL TREATMENT
APPROACH
 Goal of treatment
 Alleviate acute pain
 Restore normal function
 Prevent relapse
 Minimize side effects
 Reduce the frequency of chronic headaches
 Most pt with episodic TTH respond well non-pharmacological intervention and/or
OTC drugs
 Chronic TTH usually benefit from physical therapy and relaxation exercise and OTC
(<3 days per week)
 Menstrual migraine, should take an analgesic (NSAIDs) before and throughout the
event
 (Sinus headache = decongestant effective &OTC analgesics )
 Medication-overuse headache treated under medical supervisual
 NONPHARMACOLOGICAL
THERAPY

1) Regulation of lifestyle
 Regular schedule for eating and sleeping
 Dietary restriction of food contain triggers
 A void of hunger (hypoglycemia)
 Mg supplementation
 Avoidance of food with vasoactive substances (e.g.
Caffeine, tyramine, phenylalanine)
 Get regular aerobic exercise
PHARMACOLOGICAL THERAPY

Minimization of emotional stressors )2


Method to cope with stress/ avoid stressful situations
 Consider individual or family psychotherapy
Physical therapy techniques )3
 Use of ice bag
 Massage or cervical traction
 Stretching and strengthening exercises for cervical
musculature
CERVICAL TRACTION
PHARMACOLOGICAL THERAPY

 Available OTC analgesic drugs

 Acetaminophen Acetylated
 Aspirin salicylate
 Magnesium salicylate Non-
acetylated
salicylate
 Ibuprofen NSAIDs
 Naproxen
 ACETAMINOPHEN
 Analgesic and antipyretic
 Effective for mild to moderate pain of non visceral origin
 A very low incidence of cross-reactivity in aspirin-intolerant patient
 Acetaminophen produces analgesia through central inhibition of
prostaglandin synthesis.
 onset of relief: 30 minutes after oral administration
 Duration of activity is approx. 4 hours and 6-8 hours with an
extended-release formulation.
 Maximum number of days of treatment: 3 days.
 Product storage requirements…
ACETAMINOPHEN …CONT

 Safety consideration:
o Has no effect on Urinary excretion of uric acid.
o Dose exceed 2275 mg/week have been associated with
increase in INR
o Hepatotoxicity –risk factor
1-Pre-existing liver disease.
2-Concurrent use of potentially hepatotoxic drugs.
3-Poor nutritional intake.
4-Ingestion of 3 or more alcoholic intake pre day.
o Less GIT irritation, erosion
o Allergic reaction : skin reddening, blisters, rash
 SALICYLATE (ASA)
 Indication: analgesic, antipyretic and anti-inflammatory.

 Mechanism of action: Inhibition of COX-1 and COX-2 lead to

inhibition of prostaglandin which reduces the sensitivity of pain receptors
to the initiation of pain impulses at site of inflammation and trauma
 Dosage forms: E/C tablet, buffering , SR, conventional tablet,
effervescent solutions.
 Expected time to onset of relief = 30 minute .
 Maximum number of days of treatment : 3 days .
 Store in a closed container at room temperature a way from moisture and
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children .
 SALICYLATE (ASA) ….CONT
 Safety consideration
1. GIT mucosal damage – blood loss is dose dependent.
2. Chronic GIT bleeding can deplete total body Fe
3. Aspirin intolerance : two type: bronchospastic type and
urticaria-Angioedema type (occur within 3 hr of
ingestion)
4. Cross reaction with ibuprofen (98%) and naproxen
(100%)
5. Salicylism: ringing in the ears, nausea, and vomiting.
SALICYLATE (ASA) ….CONT

5. Risk factor for development of salicylism-related ulcer:

1. Age more than 60yrs.
2. History of PUD.
3. higher dose of ASA.
4. NSAID-related dyspepsia.
5. Concomitant use of other NSAID, anticoagulant,
bisphosphonate, clopidogrel.
6. Rheumatoid arthritis.
7. Alcohol use.
8. H. pilory infection.
SALICYLATE (ASA) ….CONT
 Patient with a history of aspirin intolerance should be
advised to avoid all aspirin and NSAID.
 Drug interaction
• Reference
 C/I: before and after surgery , allergy
 Aspirin should not be used in children and teenager
for viral infections(Ryes syndrome)
URTICARIA-ANGIOEDEMA

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 NSAIDS
 Analgesic (mild to moderate pain of non-visceral origin),
antipyretic and anti-inflammatory
 Relieve minor pain associated with
 Headache
 Common cold
 Toothache
 Muscle ache
 Backache
 Arthritis
 Menstrual cramps
NSAIDS
 Expected time to onset of relief : 30 to 60 minutes .
 Duration of activity is up to 12 hours for naproxen sodium

And 6 -8 hours for ibuprofen .

 Maximum number of days the therapy should be employed:

not more than 3 days per week .

 Store in a closed container at room temperature a way from

moisture and children .

 NSAIDS
 Ibuprofen approximately 3.5 time more potent as analgesic than
aspirin

 Naproxen: used for patient > 12 yr

 Ketoprofen recommended for > 15 yr
 Safety consideration: common ADR
 GIT: dyspepsia, heart burn, anorexia,
Ketoprofen > aspirin > ibuprofen
naproxen
- Dizziness, fatigue, nervousness, rashes,
photosensitivity, fluid retention
 NSAIDS…CONT

 Safety consideration:
 May increase risk for CV & cerebrovascular events
 NSAIDs are contraindicated in History of intolerance to aspirin
or other NSAIDs
 Non-acetylated salicylate is suitable alternative in intolerance
 Patient should be cautioned that
 Ibuprofen increases bleeding time

(it displace plasma protein –bound warfarin and increase its

antiplatelet activity)
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 Alcohol: Increase GI adverse effect.
 NSAIDS…
CONT.
 Safety consideration….cont:
• Drug-drug interaction (book)
• Digoxin, ACEIs, diuretics, methotroxate
Patient with preexisting CHF
Patient with preexisting renal impairment

(NSIAD decrease renal blood flow and GFR)

Factors increasing risk of renal toxicity


atherosclerotic CVD
Use of diuretics

Diabetic mellitus

Advanced age

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 COMBINATION
PRODUCT
 OTC combination analgesic product
are available
 Aspirin - caffeine
 Acetaminophen - aspirin
 Acetaminophen - aspirin - caffeine
 Acetaminophen - caffeine
 Acetaminophen - Mg salicylate
 Acetaminophen - pseudoephedrine
 Naproxen - pseudoephedrine Sinus
 Ibuprofen headache
- pseudoephedrine
 SPECIAL POPULATION GUIDELINE

 Aspirin during the last 3 months of pregnancy causes

Pregnancy and lactation

intrauterine growth retardation, salicylate intoxication

 Nursing mother should avoid aspirin
 NSAIDs C/I in 3rd trimester: cause Patent Ductus
Arteriosus (PDA) in the fetus
 Ibuprofen, naproxen considered compatible with breast
feeding, but ketoprofen labeling recommend that nursing
mother not use it
 SPECIAL POPULATION GUIDELINE
 Age is important consideration when selecting an appropriate OTC
Pediatric and geriatric

drugs
 < 2 yr ask pediatrician
 > 2 yr may use paracetamol, ibuprofen.
 < 12 yr naproxen not recommended

 older patient at risk of salicylate and NSAIDs related ADRs

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44
COMPLEMENTARY THERAPIES :
 Butterbur, feverfew, riboflavin, and coenzyme Q10
commonly are used for the prevention of migraine
headaches
 Peppermint used for treatment of tension headache

and magnesium for treatment and prevention of

migraine headache
 Acupuncture has been used to prevent migraine and

tension- type headache. Several studies found

acupuncture effective in reducing frequency and
severity of headache.
 Stress relief and relaxation techniques such as

massage, yoga, and biofeedback therapy may be

useful for the prevention and treatment of headache
F/U EVALUATION OF PATIENT OUTCOMES
HEADACHE
 Appropriate
follow-up evaluation will depend on
headache frequency and severity:
 For patients with episodic headaches, a trial of 6-12
weeks may be needed to assess efficacy of treatment.
For chronic headache, follow-up evaluation after 4-6
weeks should be adequate to assess treatment
efficacy.
In all cases, patients should seek medical attention if
headache persist longer than 3 days or worsen
despite self-treatment,
Patients with migraine headaches who are not
adequately self-treament should be referred for a
PATIENT EDUCATION FOR
HEADACHE
handbook
Nonprescription drugs

39
THANKS