PAIN, HEADACHE AND

FEVER
D MSOWOYA
LEARNING OUTCOMES
• Discuss the approach to evaluating minor illnesses and symptoms
• Define pain and discuss how it is assessed
• Discuss the use of the WHO analgesic ladder
• Appraise the use of adjuvants in managing different types of neuropathic pain
• Explain how to assess a patient presenting with a headache
• Describe the different types of headaches commonly presented in retail pharmacies
and their management
• Discuss when to refer patients presenting with a headache
• Differentiate fever from hyperthermia and hyperpyrexia
• Describe how temperature is measured
• Distinguish the management of hyperpyrexia and hyperthermia
Responding to Minor Illnesses and
Symptoms
•W
•W
•H
•A
•M
• W – Who is the patient?
• W – What are the symptoms
• H – How long have the symptoms been present
• A – Action taken
• M – Medication being taken
•S
•I
•T
•D
•O
•W
•N
•S
•I
•R
• S – Site or location of a sign/symptom
• I – Intensity or severity
• T – Type or nature
• D – Duration
• O – Onset
• W – With (other symptoms)
• N – ANnoyed or aggravated by
• S – Spread or radiation
• I – Incidence or Frequency
• R – Relieved by
PAI
N
Definition of Pain
• ‘An unpleasant sensory and emotional experience
associated with, or resembling that associated with,
actual or potential tissue damage’
-International Association for the Study of Pain, 2020
Classification of Pain
 Acute Pain Chronic Pain
Associated with some specific conditions, but
Usually tied to a specific injury or accident,
underlying cause is not always be known

May be self limiting of short duration Persistent, recurring or episodic pain

Pain that persists for months or years after

Pain decreases with time as injury heals
healing of an injury

Duration may range from a few minutes to Also defined as pain that lasts for more than
less than six months 6 months

Examples: Rheumatological disorders, cancer

Examples: Tissue injury, surgery, broken bone
pain, nerve damage
 Somatic Visceral Neuropathic
pain pain Pain
Peripheral nociceptors in Originates in internal Caused by nerve damage in
skin, musculoskeletal organs, esp abdominal and central or peripheral nerve
system thorax organs damage

Described as burning,
Described as sharp, Described as deep, poorly
shooting, scalding,
localised, aching pain localised, diffuse pain
paroxysmal

post-herpetic neuralgia,
E.g. Intramuscular E.g. Appendicitis,
Peripheral neuropathies
injections, superficial burns Myocardial infarction,
(diabetes, HIV), phantom
and lacerations Gallstones
limb pain
 Pain is
PAIN ASSESSMENT SUBJECTIVE

Characteristics of the pain:

• Location, intensity, radiation, duration, onset
• Use of pain scales to determine pain severity: mild, moderate, severe

Medical history:
• Underlying conditions, pain conditions

Medication history:
• Analgesics used and their outcomes

Factors that increase or reduce the pain

Impact on psychological well-being and social activities

ASSESSING PAIN INTENSITY
• Subjective Assessment of Pain
• Numerical rating scale
• Visual analogue scale
• Verbal rating scale
• FACES pain scale
• Objective Assessment ???
• Tools developed which incorporate
factors such as:
• Physiological – heart rate, BP, Respiratory
rate
• Behavioural Pain Scale –
• Facial expression
• Vocalisation
Pain Management

Pharmacotherapy Non-Pharmacotherapy
Opioid and non-opioid
Physical therapy
analgesics

Adjuvant medications,
Psychological therapy
Corticosteroids

Neural Blockade Acupuncture and massage

WHO ANALGESIC LADDER

STEP 3
MODERATE TO SEVERE PAIN
Strong Opioid + Non-Opioid ±
STEP 2 Adjuvant
MILD TO MODERATE PAIN
Weak Opioid + Non-Opioid ±
STEP 1 Adjuvant
MILD PAIN
Non-Opioid ± Adjuvant
Choice of Non-Opioid Analgesic
• Paracetamol
Cautions
• First choice in most cases • Max 4g(adult) per day to avoid risk of
• Preferred agent for the elderly hepatotoxicity
• Risk elevated by talking multiple drug
• Good alternative for those who formulations which contain paracetamol
• Heavy alcohol use
can’t tolerate NSAIDs
• Patients with liver disease
• May be used in young children
starting from 2 months Contraindications:
• Allergy to paracetamol
• Patients with severe active liver disease
NSAID
NSAIDS Cautions and
Contraindications
Cautions Contraindications
• Cardiovascular disease • History of hypersensitivity reaction
• History of GI bleeding and Peptic Ulcer NSAIDs
Disease • Active bleeding
• Liver impairment • Active GI bleeding and active PUD
• Aspirin sensitive asthma • Moderate to severe Renal impairment
• Aspirin-sensitive asthmatics
• Uncontrolled Heart Failure
• 3rd trimester of pregnancy and during
labour
Weak Opioids
• Tramadol • Codeine
• Has fewer opioid side effects and • Also has low potential for
reduced potential for addiction addiction
• Common Adverse Effects • Adverse Effects
• Nausea, lowers seizure threshold • Constipation, nausea and
(risk of convulsions) vomiting
• May cause adverse psychiatric
effects i.e. hallucinations,
confusions
• Not to be used in pregnancy
ADJUVANT MEDICATION
• Adjuvant medication are products with a primary indication other
than for pain that are used in combination with analgesics
• For example tricyclic antidepressants such as amitriptyline which is
used in neuropathic pain.
Adjuvant drugs used in the treatment of pain

Drug class Type of Pain Example

Anticonvulsants Neuropathic pain Gabapentin
Pregabalin
Carbamazepine
Antidepressants Neuropathic pain Amitriptyline
Burning pain Venlafaxine
Duloxetine
Muscle relaxants Muscle spasm Baclofen

Steroids Nerve compression Dexamethasone

Prednisone
Bisphosphonates Bone pain Pamidronate
Alendronate
Zoledronic acid

Antispasmodics Smooth muscle spasm Hyoscine

Benzodiazepines Anxiety related Diazepam

Midazolam
Case
• A 55-year-old woman comes to your pharmacy with following
prescription and a knee injury, and a refill for her co-comorbidities.
• Diclofenac gel 1.16% bd to affected area
• Diclofenac sodium enteric coated tablets 75mg bd
• Fluoxetine 20mg capsules od mane
• Assess the appropriateness of the analgesia
HEADACHE
Headache
• Most common complaint
presented to community
pharmacies
• May be a symptom of a
major illness so it should be
properly assessed
Types of Headache
Primary Headaches Secondary Headaches
• The Headache is the disorder, • Headache is a symptom
not caused by an underlying secondary to underlying cause
cause. • Cerebrovascular e.g. High BP
• Migraine headaches • Neoplastic
• Cluster headaches • Infections
• Tension-type headaches • Drug induced, overuse
• Treat the underlying cause
Assessing a Headache
HEADACHE LOCATION
HEADACHE LOCATION
SPECIFIC QUESTIONS TO ASK
PATIENTS
• Age of Patient
• Time of day when attacks occur
• Duration of attack
• Intensity of pain
• Location of pain
• Precipitating factors (e.g. food, activities)
• Factors that relieve or improve headache
• Concomitant phenomena
• Significance to patient – impact onlifestyle.
Primary Headaches
Migraine Headache

• Causes: combination of vascular and neurochemical factors

• Onset: acute
• Main Types of Migraine:
• Migraine without aura (Common migraine)
• Migraine with aura (Classic migraine)
• Aura – sensory changes ie visual disturbances
MIGRAINE PRECIPITATING FACTORS
• Stress, emotion, noise, light/glare, • Dietary factors:
disturbed sleep patterns • Alcohol
• Physiological factors: epilepsy, allergy, • Tyramine (e.g., red wine, ripened
cheeses)
hypoglycaemia, hormonal fluctuations
• Nitrites (e.g., cured meat products)
during menstrual cycle
• Phenylethylamine (e.g., chocolate,
• Drugs: cheese)
• Oestrogens i.e. ethinylestradiol, • Aspartame (e.g., artificial sweeteners,
diet sodas)
• Nitrates e.g. nitroglycerin
• Caffeine withdrawal or excessive caffeine
• overuse or withdrawal – ergots, intake
triptans, analgesics
Principles of Treating Migraine
Headaches
• Treat migraine early to maximise efficacy foe abortive therapy
• Maximise initial dose, instead of repeating small doses
• Use non-oral route for patients with significant nausea and vomiting
• Consider need for preventative therapy in patients with frequent
headaches, or those not responding to acute therapies
Migraine management
• Non-opioid analgesics
• NSAIDS and paracetamol, usually used in combination
• Analgesic should be taken at first sign of attack
• GI motility is slowed during attack and absorption slowed
• Dopamine Receptor Antagonists
• IV Metoclopramide, IV prochlorperazine
• May be used to enhance gastric absorption and decrease nausea
and vomiting
• Also effective at reducing migraine headache pain
Migraine management
• Serotonin 5-HT Receptor Agonists • Triptan Contraindications:
• Only recommended for those officially • Concurrent use of medications with
diagnosed with migraine ergot derivatives, MAOIs
• Triptans—sumatriptan,
• Use of Triptans to be limited to not • Hepatic or renal impairment,
more than 10 days a month to • Cardiovascular, cerebrovascular and
avoid medication overuse peripheral vascular conditions
headache • such as hypertension, a previous
• Ergots
myocardial infarction, ischaemic
• Ergotamine and dihydroergotamine heart disease, coronary
• Contraindicated in pregnancy as vasospasm, cardiac arrhythmias, a
they induce hypertonic uterine
contractions
history of cerebrovascular
accident
Migraine Prophylaxis
• When is migraine prophylaxis • Drugs used in Migraine Prophylaxis
therapy recommended? • Antihypertensives
• Frequent migraines > 4 per month • Beta Blockers - Propranolol,
• Long-lasting migraine headaches Metoprolol, Atenolol
• Causing significant disability or • Calcium Channel Blocker -
diminishing quality of life Verapamil
• Failure of acute therapies • Antidepressants
• Serious adverse effects of acute • Amitriptyline, Venlafaxine
therapies
• Anticonvulsants
• Risk of medication overuse
headache • Valproate, Topiramate
• Menstrual migraine • Coenzyme Q10
TENSION HEADACHE
• Frontal, occipital and bilateral
• Described as a tightness or
weight pressing down on their
head
• May be episodic or chronic
• Duration – 30 minutes to 7 days
TENSION HEADACHE
• Cause: Exact cause unknown. Might be due to peri-cranial muscle
contraction
• Caused or worsened by fatigue, stress, anxiety
• Management:
• Acute – Analgesics
• Chronic – Analgesics, antidepressants
CLUSTER HEADACHE
• Symptoms – unilateral, conjunctival
redness, lacrimation,(painful
watering eye) and nasal congestion.
• Pain is intense
• Onset – sudden, occurs at the same
time each day, usually at night
• Daily episodes over weeks or
months followed by a remission
• Duration: 10 minutes – 3 hours
CLUSTER HEADACHE
• Usually affects men 40 to 60 years of age
• Triggers: alcohol
• Has to be referred for treatment
• Prophylaxis – verapamil
• Treatment – sumatriptan
SINUSITIS
• Presentation: localised to periorbital
area or forehead
• Onset: gradual, may last several
days
• Cause: Complication secondary to
viral respiratory infection
• Sinus cannot drain the increased
mucus produced
• Tender when pressure is applied
• Worse when bending forward or
lying down
CHRONIC DAILY HEADACHE
• Headache present on most days of the month > 15 days
• Duration: may be over 6 months, longer or shorter
• Intensity or patterns of pain may vary
• Possible causes: medication overuse,
• Referral necessary to determine underlying cause and rule out more
serious conditions
Medication overuse headache

Headache Medicine Rebound More pain

Headache reliever

Relief Short term

relief
Medication overuse headache
• Rebound headache from repeated use of headache medications used
• Common cause of frequent headache
• Detailed patient drug use history of use is required
• Usually occurs with combinations of caffeine and triptan containing
analgesics
• Treating Medication overuse headache
• Weaning the overused medication
• Strategy depends on the medication,
• systematic withdrawal of drug may be needed to avoid withdrawal symptoms
• Provide acute or bridging therapy
• Initiate preventive therapy
TRACTION HEADACHE
• Caused by inflammation and compression of the brain and associated
structures
• Common causes of traction headaches:
• meningitis, encephalitis
• haematoma
• tumours and cerebral abscesses,
• sinusitis
When to refer patients presenting
with headache
• Recent head trauma within past • Headache lasts for more than 2
3 months weeks
• Nausea and vomiting in absence • Headache unresponsive to
of migraine analgesics
• New or severe headache in • Progressive worsening of
patients>50 years symptoms over time
• New or severe headache in • <12 years, with stiff neck and
pregnant women fever
• New, severe or abrupt • Temples are tender with jaw pain
‘thunderclap’ headache • Cluster headache symptoms
Management of Headaches
• Use of analgesics following WHO ladder
• Different formulations of a drug may utilised for various conditions
• Trauma to neck and shoulder muscles may cause tension or
stiffness which may lead to headache – topical analgesics
• Causative factors or aggravating factors should be avoided
• i.e. eye strain,
• food or alcohol
• or relieved in some way i.e. relaxation and massage for stress
induced headaches
FEVER (PYREXIA)
Fever
• Generally used to refer to body
temperature higher than normal
temperature of 37ºC
• Normal body temperature differs
depending on age, site of
measurement – oral, rectal,
axillary
• Body temperature is normally
controlled by the
thermoregulatory centre of the
hypothalamus
Causes of Fever
• Causes of fever:
• Exogenous Pyrogens ie microbes, toxins may stimulate productions
of pyrogenic cytokines
• Inflammation
• Complications of fever: febrile convulsions, Status epileptus
 Measuring temperature
• Can be done by using a:
• Digital thermometer: oral, armpit and rectal
• Glass thermometer:
• Infra-red thermometers: ear and forehead
• Forehead strip
Factors affecting Choice of
Thermometer
• Accuracy
• Digital thermometers are more accurate than other electronic devices, forehead
strips least accurate
• Infra-red thermometer accuracy can be affected by impacted wax
• Cost
• Glass thermometers cheapest, followed by forehead strips, digital thermometers
and infra-red thermometers are most expensive
• Safety
• Glass thermometer may break
• Convenience in use
• Infra-red thermometers and forehead strips are very convenient for use in children
Management of fever
• Use of antipyretic agent
• Paracetamol
• NSAIDS
• Light clothing
• Maintain good airflow
• Sufficient fluid intake
• Sponging with tepid water.
• If febrile convulsions occur, treat with IV or rectal fast acting
anticonvulsant ie diazepam
 FEVER / PYREXIA HYPERTHERMIA/HEAT STROKE HYPERPYREXIA

DESCRIPTION Set point in the hypothalamic Thermoregulatory centre remains Pathology similar to
regulatory centre shifts upwards unchanged. pyrexia, temperature
and normal body mechanisms try Heat production mechanisms or heat much higher at >
to raise the body temperature i.e. exposure is greater than body 41.5ºC
shivering or conserve body heat mechanisms for dispelling heat.

CAUSES Increased production of hot environments, over insulating severe infections, brain
prostaglandins and cytokines due clothes, hypohydration, metabolic haemorrhages
to pyrogens disease ie hyperthyroidism, some drugs
ie atropine, ecstasy, serotonin syndrome,
anaesthetics

TREATMENT Antipyretics Antipyretics are ineffective Combination of

Cooling sponge baths, intravenous antipyretics and
hydrations. cooling sponge baths
REFERENCES
• Harrison TR et al.(2018)Harrison’s Principle of Internal medicine (20th edition)
McGraw Hill Education
• Azzopardi, L. (2010) Lecture Notes in Pharmacy (1st edition). London, Pharmaceutical
Press.
• Nathan, A. Fasttrack: Managing symptoms in the pharmacy(1st edition). London,
Pharmaceutical Press.
• Blenkinsopp, A et al. Symptoms in the pharmacy (7th edition). Wiley Blackwell
Publishing.
• Rutter, P. (2017)Community Pharmacy: Symptoms, Diagnosis and Treatment(4th
edition). Elsevier
• Porat R et al. Pathophysiology and treatment of fever in adults. In: UpToDate,
Weller, PF ed UpToDate, Waltham, MA, 2019.
• C Edwards, P Stillman(2006). Minor illness or Major Disease, 4th
edition. Pharmaceutical Press
• S H Mahmoud (2019) Patient Assessment in Clinical Pharmacy, A
comprehensive Guide. 1 st edition, Springer
• Other forms of migraine: Hemiplegic migraine, Ophthalmoplegic
migraine
• https://www.uptodate.com/contents/acute-treatment-of-migraine-in-
adults?
search=migraine&source=search_result&selectedTitle=1~150&usage_
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