CNS, OTC, and Pain Medications

• The OSPAP Programme discusses CNS (Central Nervous System) and OTC (Over-the-Counter) medications
• The learning outcomes are to recognize types of headache, musculoskeletal pain and insomnia, recommend appropriate OTC treatment and counsel the patient, and recognize when to refer.

Pain - OTC Analgesics

• OTC analgesics are used to treat mild to moderate pain, somatic pain, headaches, and dysmenorrhea
• Need to know the uses, licensing, doses, cautions, contraindications, side effects, counseling and warnings for paracetamol, aspirin, ibuprofen, codeine/dihydrocodeine combination products, naproxen, and topical formulations
• Topical formulations include rubefacients, NSAIDs, freezing agents, and local anesthetics

Headache Types

• Headaches can be classified as migraine, tension headache, cluster headaches, temporal arteritis, trigeminal neuralgia, chronic daily headache, and sinusitis

Migraine

• Migraine is a primary episodic headache disorder characterized by episodic severe headaches that are commonly but not always unilateral
• Throbbing or pulsating headaches are associated with symptoms such as photophobia, phonophobia, nausea, and vomiting

Migraine Types

• Migraine with aura presents with neurological symptoms, alterations in vision/scotomas (pro-dromal phase), tingling/numbness (paraesthesia), and nausea or vomiting are 3x more common in women than men
• Migraine without aura has an absence of neurological symptoms and GI symptoms may occur; both sides of the head may be affected; there is no pro-dromal phase

Migraine Causes

• Migraine has a significant genetic component, with about half of people with migraine having a first-degree relative with the condition
• Migraine trigger factors include dietary, hormonal, physical, environmental, and psychological factors like stress, tension, and anxiety

Phases of Migraine

• Migraine phases include Prodromal Phase/Aura, Attack, and Resolution Phase/Postdromal phase

Migraine Symptoms - Initial/Prodromal

• Includes mood variation, yawning, food cravings, and fluid retention

Migraine Symptoms - Aura

• Symptoms include flashing lights/arc of light, blind spot, numbness and tingling sensation, weakness, and clumsiness
• Aura symptoms last less than an hour

Migraine Symptoms - Attack

• Symptoms include severe headache, throbbing/pulsing pain, usually unilateral, nausea and vomiting, photophobia, and phonophobia

Migraine Symptoms - Resolution

• Symptoms fade slowly; headache becomes less severe

Migraine Symptoms - Postdromal

• Symptoms include hangover effect, fatigue, depressed mood
• Migraine is also associated with an increased risk of depression, bipolar affective disorder, anxiety disorder, and panic disorder

Migraine Treatment

• Analgesics like paracetamol, aspirin, ibuprofen, codeine, and dihydrocodeine can be used as OTC treatments
• Caffeine may be a trigger
• Anti-emetics such as buclizine (pink Migraleve) and prochloperazine (Bucastem M) which blocks the chemoreceptor trigger zone, quelling N&V can be used
• Triptans or selective 5-HT agonists constrict blood vessels that are dilated during an attack and acts fast
• Sumatriptan is available OTC; only 50% of migraine sufferers consult their doctor

Sumatriptan - OTC Sale

• The questionnaire used to help deal with OTC sales is replaced with standard questioning
• Supply criteria include migraine diagnosed by a doctor or pharmacist, simple analgesics tried and ineffective, must be between 18-65 years of age
• Also includes an established and stable pattern of migraine, with or without aura, migraine for at least one year and having at least 5 or more attacks

Sumatriptan - Precautions For Use

• Concomitant use of SSRI/SNRI, St John's wort (Hypericum perforatum) and combined oral contraceptives or who have heart disease risk factors (contraindicated in patients who have three or more risk factors i.e. diabetes, high cholesterol levels, smoking/use of NRT)

Sumatriptan - Contraindications

• Should not be used in those under 18 or over 65, who are pregnant or breastfeeding, have CV disease or hypertension and those with 3 or more CV risk factors, history of stroke, renal or hepatic impairment
• Also with epilepsy or history of seizures, MAOIs in last 2 weeks, or a known triptan allergy

Sumatriptan - Interactions

• Ergotamine (and its derivatives e.g. methysergide), MAOIs, 5-HT receptor agonists (triptans), tricyclic antidepressants and SSRIs/SNRIs

Other Contraindications for Sumatriptan Use

• Hepatic or renal impairment, prophylactic use of sumatriptan, ischaemic heart disease, coronary vasospasm (Prinzmetal's angina), cardiac arrhythmia, peripheral vascular disease and hypertension

Patient Characteristics to Refer for Migraine

• Risk of heart disease/three or more cardiovascular risk factors, under 18 or over 65 years of age, and pregnancy/breastfeeding

Symptom History Necessitating Referral

• Headaches lasting for over 24 hours, symptoms have changed, first migraine occurs after age 50, and four or more attacks per month

Atypical Symptoms That May Indicate Rare Variant Migraines

• Unilateral motor weakness, double vision, clumsy and uncoordinated movements, tinnitus, reduced level of consciousness, seizure-like movements and rash with headaches

History that Necessitates a Referral

• Seizures, myocardial infarction, cerebrovascular accident (CVA/stroke), transient ischaemic attack (TIA/mini-stroke)
• Referral is warranted if CoC use: if migraine started recently or symptoms have got worse and concomitant use of St John's wort

Hypersensitivity Referrals

• Sulfonamides, Sumatriptan and any excipients in the preparation

Conditions That Warrant Referral For Migraine

• For prevention of migraine, hemiplegic migraine, basilar migraine and ophthalmoplegic migraine

How To Use Sumatriptan

• One tablet should be taken ASAP at the first signs of a migraine headache; if symptoms return after initial relief, a 2nd tablet may be taken after at least 2 hours
• No more than 2 tablets should be taken in 24 hours and if the 1st tablet does not give any relief then the 2nd should not be taken which is not a a migraine
• Do not take as a prophylactic treatment

Counseling For Migraine Sufferers

• Avoid trigger factors, immediate analgesic use, prioritize sleep, dark & quiet environment, hot/cold compress, prescribed treatment & prophylaxis

Tension Headache

• Causes are posture, emotional stress, anxiety, prolonged concentration, fatigue
• Symptoms include dull persistent pain, pressure or a tight band around the head, dizziness, fatigue, sweating and mild nausea

Tension Headache - Treatment

• Syndol tablets contain paracetamol 450.00mg, codeine phosphate 10.00mg, doxylamine succinate 5.00mg and caffeine 30.00mg
• Simple analgesics or paracetamol

Tension Headache - Counsel

• Avoid over and prolonged treatment
• Identify causes like use of computer screens, stress management, exercise/yoga and massage can be helpful

Cluster Headaches

• Characterized by severe boring pain around the eye
• More common in men and tend to start their 30s or 40s
• Features unilateral pain, blocked nostril, hot, reddened cheek, lasts 15mins-3 hours and a similar time of day; refer to GP

Temporal Arteritis

• Severe pain around temples
• Continuous/intermittent throbbing/steady pain
• Red, prominent temporal artery and jaw pain
• Partial or complete loss of vision and requires immediate referral

Trigeminal Neuralgia

• Characterized by nerve pain that is unilateral
• Sudden & severe shooting pain that lasts for up to 2 mins, several attacks per day and pain when touched; refer for treatment with carbamazepine/pregabalin

Chronic Daily Headache

• Defined as headache that lasts for > 4 hours on > 15 days per month
• Analgesic/opioid/caffeine dependence
• Rebound withdrawal symptoms can happen
• Restrict opioid analgesic use to up to 3 days to prevent these headaches, break the cycle of analgesic use and a slow steady reduction in opioid dose

Sinusitis

• Defined as symptomatic inflammation of the paranasal sinuses that leads to swelling of the mucosal lining
• This is usually triggered by a viral infection and secondary bacterial infection could potentially develop (2% of cases)
• Other symptoms include pressure buildup which causes pain, is usually unilateral or central, behind and between the eyes and bending forwards or lying down worsens the pain
• Treat OTC with pain killers/decongestants/saline nasal wash or drops and follow guidelines for respiratory OTC

Red Flags - Headache

• Migraine with combined contraceptive, frequent migraine/treatment failure, severe headache of > 4 hours duration *clinical exceptions that require referral
• Other red flags are suspected ADR, associated neck stiffness, visual disturbance, associated with injury/trauma, children under 12 years

Musculoskeletal Pain

• The musculoskeletal system = bony skeleton + associated soft tissues....eg. ligaments, skeletal muscles, tendons
• Causes of pain are inflammation, injury/trauma and mechanical

Rheumatoid Arthritis

• Inflammation of synovial lining of peripheral joints
• Symptoms include starts at any age, extreme joint pain, polyarthritis, affects other systems eg. eyes, swelling, prolonged morning stiffness and reduced mobility

Rheumatoid Arthritis Counsel

• Simple analgesics, NSAIDs, topical formulations, fish oils and oil of evening primrose are types of treatment
• Must counsel how to adapt to disability, avoid analgesic over use, caution with NSAIDs, advise about DMARDs, cytotoxic drugs, corticosteroids and provide information about corticosteroid injections

Osteoarthritis

• Slow progressive disorder of articular cartilage and bone affecting joints of peripheral and spinal skeleton
• Symptoms over age 55 years, monoarticular, joint pain, stiffness after prolonged rest and functional impairment

Osteoarthritis Treatment and Counsel

• Simple analgesics, NSAIDs, topical formulations, glucosamine 1500mg/day, chondroitin 1200mg/day are treatments
• Must counsel patient on joint protection, weight loss, keep active (exercise little and often), physiotherapy

Gout

• Disorder of purine metabolism characterised by a raised uric acid level in the blood (hyperuricaemia) and the deposition of urate crystals in joints and other tissues such as soft connective tissues or the urinary tract

Gout Symptoms

• Includes inflammatory arthritis of single joint, is extremely painful & red, skin may peel; tends to attack joints in the extremities

Gout Phases

• A long period of asymptomatic hyperuricaemia before gout manifests; 'interval gout', or 'intercritical gout' followed by acute attacks of gouty arthritis; the final period of chronic tophaceous gout, where people have nodules affecting joints
• Gout may present without hyperuricaemia, and hyperuricaemia may occur without gout

Gout - Risk Factors

• Uric acid is the end-product of the breakdown of purines (adenine and guanine); it exists as sodium urate in extracellular fluid
• Impaired renal excretion can lead to hyperuricemia which is the single most important risk factor for developing gout
• Duration and magnitude of hyperuricemia correlates with the likelihood of development of gouty arthritis, uric acid kidney stones and age of onset
• Hyperuricemia - risk factors include CVD, renal disease, diabetes, obesity, metabolic syndrome, dyslipidaemia, severe psoriasis, alcoholism, and use of certain drugs (eg. diuretics)

Gout - Prevalence

• More common in men (30–60 years of age) and in older people; rare in young 3 weeks).

Insomnia - Causes

• Stress & tension, bereavement, and abnormal concern about sleep

Psychiatric Causes of Insomnia

• Anxiety & depression and psychosis & dementia

Insomnia - Pharmacological Causes

• Caffeine, decongestants, theophylline, beta blockers, bronchodilators, thyroxine, corticosteroids, alcohol and benzodiazepine/antidepressant/opiate withdrawal

Insomnia Symptoms

• Difficulty falling asleep (sleep latency insomnia) and difficulty in staying asleep; also poor quality sleep and day time drowsiness that leads to inability to concentrate

Insomnia - Treatment

• Non-pharmacological (relaxation techniques and sleep hygiene measures); OTC remedies; sedative antihistamines and complementary therapies and prescribed hypnotics

Insomnia - Other symptoms

• Pain, Nnasal congestion, cough, CHF,respiratory disease, Parkinson’s disease, pregnancy, cramps and nocturia

Non-Pharmacological

• deal with physical tension and other symptoms that occur

Treatment Techniques

• Wind down during evening, avoid caffeine, meals, alcohol, go to bed only when tired, relax and adjust temp for bedroom,get up at the same time every morning and CBT

OTC - Types of Treatment

• Types of herbal treatments and nasal plasters

Treatment options-OTC

• Antihistamines, diphenhydramine and promethazine, 20-30 mins before bedtime, not longer than 14 consecutive nights side effects

Hypnotics - Symptoms

• Lowest dose, short course, withdraw gradually, zopiclone, zolpidem, zaleplon
• Benzodiazepines: Eg: nitrazepam, temazepam

Melatonin

• Produced by the body’s pineal gland during darkness and is thought to regulate sleep
• Levels are lower in the elderly; Supplementation -to aid restoration of sleep pattern
• For jet lag and insomnia; and also available prescription

Insomnia - Referral

• With suspected depression; chronic problem and under 16 years