Background Information

Headache is not a disease state or a condition but rather a symptom, of which there are many causes. Virtually everyone will have suffered from a headache at sometime and it is probably the most common type of pain experienced by humans.

The commonest types of headaches are hangover, tension headaches, migraine and sinusitis.

Hangover: A nagging, constant pain, similar to a tension headache. It is caused by dehydration.

Tension Headache: This is the most common type of headache. It can be caused by various emotional stresses, anxiety or fatigue. It is thought to result from muscle spasm in the neck and scalp. They are described as a weight on top of the head, a band of tension across the forehead, back of the head and neck. It produces a constant or nagging pain. Pain is bi-frontal or bi-occipital, generalised and non-throbbing. Pain is normally gradual in onset and tends to worsen progressively through the day. Pain is normally mild to moderate and not aggravated by movement.

Migraine: Classical migraine is often associated with alterations in vision before the attack starts – blurred vision, flashing lights etc. Patients may also experience tingling or numbness on one side of the body, in the lips, face, fingers or hands. It is associated with a severe pain, generally located over one eye – often described as a throbbing pain.

The pain may be excruciating. Nausea and vomiting often accompany the migraine. Some people are prone to migraines. In others, the attacks are often precipitated by certain foods (chocolate and cheese), emotional, psychological and hormonal factors (especially associated with the menstrual cycle). Women are three times more likely to suffer from migraines than men.

Sinusitis: This type of headache is often associated with a cold or with hayfever. It is caused by inflammation and swelling of the mucosal membranes that line the inside of the sinuses. The inflamed mucosa produce mucus – however, this cannot drain away because of the swelling. This leads to a build up of pressure causing pain behind the eye and in the forehead. It may be worse when leaning forwards or lying down.

If the patient has already completed a suitable course of treatment for the sinusitis with no improvement then they should be advised to go to their doctor because the sinus cavity may have become infected and they may require antibiotic treatment.

Other Causes:

Dental pain – the excitation of pain nerves in the teeth can produce a referred headache.

Period Pain - is associated with menstruation. It can start around the age of 12 years and ceases around the age of 50. Acramping pain (period pain) affects most women at some stage in their menstruating lives and up to 50% of women will also experience symptoms of nausea/vomiting, headache, fatigue and back pain.

Headache

PREVIOUS HISTORY:

A previous history of a similar type of headache is useful because it will help to distinguish this headache from that caused by something more serious.Migraine sufferers tend to have recurrent episodes of migraine.

MEDICATION:

The patient should be asked about their prescribed medication – some medications (e.g. Nitrates or contraceptive pill) cause headaches.

Speak with the Pharmacist

Headache

 

• The patient is under 12 years of age (unusual in kids-check for meningitis)
• The patient is taking any medication or has any medical conditions
• There is a recent head injury → doctor
• The headache has lasted more than 4 hours and is severe
• An effective treatment hasn’t worked
• The pain is sudden, severe and across the back of the head
• The headache is described as deep sited, severe and worse when lying down
• There is neck stiffness
• There is a ‘non-blanching’ rash
• The patient describes the headache as being unusual for them
• The temples are inflamed, red or painful
• The patient is vomiting persistently.
• Recent head trauma
• Cluster headache - night-time symptoms, steady intense unilateral orbital boring pain. Additionally, conjunctivitis and nasal congestion

 

Period Pain

 

• If period pain is occurring at times other than the beginning/end of cycle
• If pain is severely disabling
• Signs of infection (e.g. fever)
• Women over the age of 30
• Unexplained bleeding

 

Dental Pain

 

• If there is excessive bleeding
• If the patient has had recent dental treatment and is still in pain
• If the patient is asthmatic or suffers from stomach problems
• Any associated fever

 

Active Ingredients

Paracetamol is the mainstay of all analgesia. It is the third oldest known painkiller (after morphine and aspirin) but we still don’t fully know how it works!We do know that it reduces the responsiveness of nerve endings to painful stimuli and it reduces the transmission of painful signals in the nervous system and is an effective painkiller.It helps to restore body temperature to normal.It has no ant-inflammatory action. It won’t interact with other medication (some reports suggest that it interacts with warfarin, so call the pharmacist if the patient says they are on warfarin). It is safe to use by asthmatics and is the only painkiller suitable for infants from 2months old.

The danger with paracetamol is when it is taken in overdose – doses of over 8 tablets per day – it produces acute liver failure and the patient dies slowly over several days.Anybody suspected of having taken a paracetamol overdose should go immediately to the emergency department of their hospital. It takes 24 hours before the first symptom of the liver failure, abdominal pain becomes apparent.It is often too late at this stage to reverse the damage.

Paracetamol is rapidly and completely absorbed within about 30 minutes.(i.e. solid and dispersion doses differ very slightly in their rate of absorption)

Paracetamol Regulations

Intended to reduce the number of deaths resulting from paracetamol OD whether by design or by accident.

Limits the pack sizes available in general shops and limits them to sell only one packet. It is therefore necessary to check with the pharmacist every time a customer wishes to purchase two packets of paracetamol containing product.

Ibuprofen is the most commonly sold anti-inflammatory in pharmacies. Relative to other anti-inflammatory drugs (on prescription) its action is mild.

It is anti-inflammatory, painkilling and reduces temperature.

 

• Suitable from 3months +
• Anecdotal evidence suggests that it reduces temperature more quickly than paracetamol.
• Not suitable for asthmatics who are sensitive to Aspirin/Ibuprofen The sensitivity manifests itself as wheezing, bronchoconstriction and skin rash. (It is not actually confined to asthmatics but occurs mostly in people with allergies –asthma, hay fever, urticaria and nasal polyps)
• Not suitable for people with stomach ulcers
• Can interact with some medications (blood pressure, ulcer, blood thinning etc.) – so call the pharmacist if the patient is on any medication.
• Drug of choice in dental and muscular pain.

 

Aspirin is a very effective anti-inflammatory, analgesic and antipyretic (lowers temperature).

However:

 

• it cannot be given to children under 16 (may precipitate Reye’s Syndrome)
• it will interact with medication, esp. Warfarin and can produce a very dangerous bleed.
• it can give rise to or exacerbate stomach ulcers.
• it can cause a severe allergic reaction in certain (circa 5%) asthmatics.
• it should not be recommended to patients following dental extractions or other cases involving excessive bleeding as it could prevent the blood from clotting.

 

Caffeine is frequently added to paracetamol preparations. It is used as a stimulant to enhance the analgesia.

Codeine is a narcotic analgesic, related to morphine. It is actually quite a weak painkiller –doses in excess of 15mg are needed to show any painkilling activity

However:

 

• It is addictive – beware of people buying multiple packets of codeine containing products or buying them with indecent regularity!
• It causes constipation
• It causes drowsiness – and can impair people’s ability to drive.

 

See McCartan’s Pharmacy SOP for codeine containing products. Consult the Pharmacist before any sale

Buclizine is an active ingredient found in Migraleve® Pink. It reduces nausea and vomiting.

Doxylamine is an ingredient found in Syndol® tablets. It is an antihistamine and has a relaxing and sedating effect and therefore is useful for tension headaches.

Hyoscine is an active ingredient found in Feminax® tablets. It acts as an antispasmodic and therefore reduces cramping period pains. It is only present in very small doses.

Children

Paracetamol is the primary analgesic/antipyretic in Children.

It is not associated with the side effects of other anti-inflammatory drugs

 

• Reye’s syndrome with Aspirin
• Stomach upset – can occur with ibuprofen
• Do not get sensitivity to anti-inflammatory drugs -(certain asthmatics are sensitive to aspirin and other anti-inflammatory drugs and can develop a life-threatening allergic after taking them).

 

Usually formulated as suspensions – Calpol®, Paralink® etc. which are now licensed from 2 months (following the child’s vaccinations)

Also comes in suppository form – Paralink® Suppositories– these are useful in babies who won’t swallow a liquid.

Dozol® and Teedex® both contain paracetamol and diphenhydramine (a sedating antihistamine). They are licensed for the relief of teething pains and the sleeplessness associated with it.

Look out for people buying these repeatedly – some people use these to sedate their children. While this is ok over 5-7 days it can lead to the child becoming dependent on this to go to sleep and rebound sleeplessness when discontinued.

Ibuprofen is suitable for use in children from 3months (Nurofen Liquid® and Provin®)

It is licensed for fast effective and long lasting reduction in temperature and relief of pain associated with teething, toothache, earache, sore throat, headache, sprains and strains and cold and flu symptoms.

 

Treatments

Tension Headache:

 

• Treatment with paracetamol containing products as listed above, refer to pharmacist for combination products
• If over 16 can treat with aspirin containing products as listed above

 

Migraine:

 

• Migraleve® can give the best relief from pain and nausea. Both migraleve pink and yellow contain codeine and paracetamol but the pink tablets contain the additional ingredient buclizine. The dose for adults and children over 14 is two Migraleve® Pink tablets when the migraine begins and if further treatment is required 1-2 of the yellow tablets every 4-6hrs. Dose is reduced to 1 tablet for 10-14 yr olds.

 

Sinus Headache:

 

• Decongestants constrict enlarged and inflamed blood vessels within the nasal passages. This eases congestion, pain and helps breathing. Decongestant tablets are available as Sudafed®, Sinutab® and in multi-ingredient products for cold and flu such as Benylin 4 Flu® and Uni-flu®.The standard daily dose is one tablet up to four times a day. Decongestants are best avoided in pregnancy, diabetes, those on blood pressure medication and with hyperthyroidism. As they are stimulants it is best not to take them before bedtime as they can cause sleep disturbances
• Decongestant nasal sprays/drops are a safer treatment option for children over 6 yrs, diabetics and those with high blood pressure. No decongestant nasal drop or spray should be used for longer than 7 days because rebound congestion can occur. Products include Otrivine® Nasal sprays/drops, Sudafed nasal spray ® and child Otrivine® nasal drops.
• Olbas® oil over 5yrs. Olbas® pastilles over 7yrs. Now Olbas® Oil for Children from 3months.

 

Period Pain

 

• Ibuprofen should be used as the first treatment option. Nurofen® has a standard adult dose of 1-2 tablets three times a day, after food. It is best avoided in asthmatics and patients with stomach problems. Nurofen® Plus has additional codeine and the sale should be referred to the pharmacist.
• If patients got inadequate results from or didn’t fit the criteria for the use then Feminax® should be tried. Feminax® is a combination product of paracetamol/codeine and hyoscine that helps reduce the tightness and cramping experienced in the abdomen. The adult dose is 2 tablets every 4hrs (max of 8in 24hrs). Refer to pharmacist! Side effects include drowsiness.

 

Dental Pain

 

• Nurofen® Plus is the best OTC treatment for dental pain. (Refer to pharmacist)
• Solpadeine® would also relieve pain (refer to pharmacist)
• Corsodyl® mouthwash is antibacterial and should be rinsed around the mouth for 1 min then spat out to treat infected sore gums that are bleeding. This can be repeated twice daily
• Clove oil can be applied to the area and will give local pain relief.

 

Helpful Additions

Headaches: associated with cold and flu or sinus pressure: Vitamin C, Echinacea, Zinc, Garlic, Olbas® Oils

Period Pain: Motilium® for nausea, hot water bottles can confer some pain relief when applied to abdomen, vitamin B6 and Evening Primrose Rose Oil taken a few days before and during a period can help with irritability and mood swings.

Useful Advice

 

• Patients who perform prolonged periods of computer work, for example VDU operators, can suffer from frontal aching headache. This could be down to eyestrain and patients should be referred to an optician for a routine eye check
• Migraine sufferers may benefit from resting in a dark quiet room for a period of time to help relieve their symptoms
• Application of a warm hot water bottle can confer relief in period pain.
• Nurofen® Express targets pain twice as fast as standard ibuprofen.

ADULTS AND CHILDREN OVER 12

Table 1 showing many different OTC products used against pain and the common cold

 

Name	Paracetamol	Ibiprofen	Aspirin	Caffeine	Codeine	Other
Panadol	☺
Solpadeine	☺			☺	☺
Maxilief	☺			☺	☺
Syndol	☺			☺	☺	Doxylamine
Feminax	☺			☺	☺	Hyoscine
Panadeine	☺				☺
Migraleve Pink	☺				☺	Buclizine
Migraleve Yellow	☺				☺
Lemsip Cold & Flu Capsules	☺			☺
Panadol Extra	☺			☺
Panadol Night	☺					Diphenhydramine
Lemsip	☺
Calpol	☺
Paralink	☺
Teedex	☺					Diphenhydramine
Dozol	☺					Diphenhydramine
Tramil	☺			☺
Veganin	☺			☺	☺
Disprol	☺
Hedex	☺
Sinutab	☺					Pseudoephedrine
Solpa-Sinus	☺					Pseudoephedrine
Uniflu	☺					Diphenhydramine, Phenylephrine, Vitamin C
Uniflu Plus	☺				☺	Diphenhydramine, Phenylephrine, Vitamin C
Benylin 4 flu	☺					Pseudoephedrine, Diphenhydramine
Benylin Day & Night	☺					Pseudoephedrine, (Diphenhydramine)
Day Nurse	☺					Pholcodine Pseudoephedrine
Night Nurse	☺					Promethazine, Dextromethorphan
Lemsip Flu Strength	☺					Pseudoephedrine, Vitamin C
Nurofen		☺
Nurofen Plus		☺		☺	☺
Advil		☺
Advil Cold & Flu		☺				Pseudoephedrine
Nurofen Cold & Flu		☺				Pseudoephedrine
Disprin			☺
Aspro Clear			☺
Codis			☺
Anadin			☺			Quinine
Anadia Extra	☺		☺	☺
Anadin Max. Strength			☺	☺
Alka-Seltzer			☺			Sod. Carbonate

 

Key

 

Yellow contains decongestant → Not be used in diabetes, heart disease, high blood pressure, glaucoma, prostrate enlargement and hyperthyroidism and best not given at night

Green contains antihistamine → Not to be used in glaucoma, prostrate enlargement

Pink contains both decongestant and antihistamine → Not to be used in all conditions in yellow and green

Light Blue contains aspirin → not to be used in those under 16

Pregnancy and Lactation

Paracetamol - Epidemiological studies in human pregnancy have shown no ill effects due to paracetamol used in the recommended dosage, but patients should follow the advice of their doctor regarding its use. Paracetamol is excreted in breast milk but not in a clinically significant amount. Available published data do not contraindicate breast feeding.

Ibuprofen - not to be used unless physician says so as there is risk of especially in the first and third trimesters of pregnancy. Ibuprofen can be seen in breast milk and some say is compatible in breastfeeding but other sources say not so would error on the side of caution and not recommend it.

Aspirin - Pregnancy: Although clinical and epidemiological evidence suggests the safety of aspirin for use in pregnancy, caution should be exercised when considering use in pregnant patients. Aspirin has the ability to alter platelet function and there may be a risk of haemorrhage in infants whose mothers have consumed aspirin during pregnancy. Prolonged pregnancy and labour, with increased bleeding before and after delivery, decreased birth weight and increased rate of stillbirth have been reported with high blood salicylate levels. With high doses there may be premature closure of the ductus arteriosus and possible persistent pulmonary hypertension in the newborn. Analgesic doses of aspirin should be avoided during the last trimester of pregnancy. Therefore recommend paracetamol instead.

Lactation: As aspirin is secreted into breast milk, Nu-Seals should not be taken by patients who are breast-feeding, as there is a risk of Reye's syndrome in the infant.

High maternal doses may impair platelet function in the infant.

 

• Caffeine - is compatible in both pregnancy and breast feeding just be careful in combination products. However one source states that caffeine taken during pregnancy, it appears that the half-life of caffeine is prolonged. This is a possible contributing factor in hyperemesis gravidarum (severe morning sickness).
• Codeine - is not recommended in pregnancy or breastfeeding
• Buclizine - there is limited data but there is a suggested risk in pregnancy and so would not recommend. One source for migraleve pink says... Whilst there are no specific reasons for contra-indicating Migraleve during pregnancy, as with all drugs it is recommended that Migraleve be used in pregnancy only when the physician has considered the need in respect of the patients' welfare. Therefore in pharmacy we cannot sell.
• Doxylamine - is compatible in pregnancy and although there is limited data in breastfeeding it is probably compatible although again be careful what it is in combination with.
• Hyoscine - Limited data and would not recommend in pregnancy and breastfeeding.
• Pseudoephedrine - human data suggests risk and there is limited data in breast feeding so would not recommended
• Diphenhydramine - is compatible in pregnancy and although limited data in breastfeeding is probably compatible
• Dextramorphin - is not recommended in pregnancy or breastfeeding

PARACETAMOL ON ITS OWN IS THE SAFEST OPTION!