OTC Pain Relievers

General Medications for Pain and Fever

• Common medications to treat pain and fever include acetaminophen, ibuprofen, naproxen, and aspirin.

OTC Topical Products for Pain

• OTC options for topical pain relief include menthol, capsaicin, lidocaine, and diclofenac gel, sometimes in combination.

Combination Products for Pain

• Combination products like Tylenol with ibuprofen or naproxen with acetaminophen exist, but being mindful of the individual ingredients is crucial.

General Clinical Pearls for Topical Products

• Counsel patients on proper use and read labels carefully to note active ingredients, especially in combination products.
• Avoid excessive or insufficient use of topical products.
• Do not apply on open wounds, damaged, broken, or irritated skin to prevent burns, cellular damage, or infection.
• Remove the product immediately and seek medical attention if skin irritation occurs.
• Avoid bandaging areas where topical products have been applied, as it can produce heat, cause wounds, increase medication effect, and lead to side effects.
• Do not heat any products that have been applied.

Lidocaine Patches

• Lidocaine patches should be kept on for 12 hours, followed by a 12-hour break and using a heating pad while using a lidocaine patch is not advised.
• Prescription lidocaine patches are 5% strength, while OTC patches are 4% strength and patients should be counseled about the lower dose if using the OTC option.

Additional Clinical Pearls for Pediatric Patients

• Always verify the patient's age and weight due to weight-based dosing and age-related contraindications for pediatric pain and fever products.
• Use approved measuring techniques like syringes or measuring cups, avoiding kitchen tablespoons or direct bottle consumption.
• Note how the temperature was taken (ear, mouth, armpit) as different methods have different cutoffs, which is important for discussing fever and exclusion criteria.

Headaches: Prevalence and Types

• Headaches are common, with 50% of the world population experiencing one in the past year and headaches can be categorized as primary (migraines, chronic tension, cluster) or secondary (trauma, strokes, substance abuse, disorders of the face, medication overuse).

Main Types of Headaches

• Tension Type Headache: Bilateral location, diffuse ache, mild to moderate intensity, gradual onset, 30 minutes to a week duration, aggravated by stress and anxiety, with scalp tenderness, neck pain, and muscle tension as non-headache symptoms.
• Migraine Headache: Typically localized to one side, throbbing/pulsating nature, moderate to severe intensity, sudden onset, 4 to 72 hours duration, aggravated by physical activity, bright lights, and sound, with possible aura as a non-headache symptom.
• Sinus Headache: All around the face and forehead, tense pain/pressure, mild to severe intensity, onset similar to congestion, duration corresponds with nasal congestion, aggravated by nasal congestion, with nasal congestion/blockage/stuffiness as non-headache symptoms.

Other Types of Headaches

• Cluster Headache: Located behind the eyes.
• Post-traumatic Headache: Located in the temples, forehead, and back of the neck.
• Medication Overuse Headache: Variable location.

Aura

• Aura includes visual disturbances (seeing colors, blurry vision) right before a migraine.

Patient Presenting with a Headache: Treatment Algorithm

• SCHOLAR-MAC is used to assess symptoms and history and determine exclusions to self-care.
• Assess analgesic use: Referral is needed if analgesics are used for headaches greater than three days per week.
• Determine if the patient has a diagnosis (migraine, sinus, episodic tension type).
• Treatment varies based on the type of headache.
• Recommend non-pharmaceutical and pharmaceutical therapies if no exclusions and understanding the headache type: NSAIDs, acetaminophen, salicylates.

Exclusions to Self-Care for Headaches

• Severe head pain.
• Headache with rapid onset of maximum pain.
• Concerning change in headache pattern.
• Headache that persists for 10 days.
• Age < 8 years.
• High fever or signs of serious infection.
• Neck stiffness.
• Neurologic changes.
• Last trimester of pregnancy or new headache during pregnancy.
• Secondary causes of headache (except minor sinus headaches).
• No formal diagnosis of migraine (with migraine symptoms).
• History of liver disease or consumption of ≥ 3 alcoholic drinks per day.

Non-Pharmacological Approaches for Headaches

• Keep a headache diary to monitor trends and triggers.
• Acupuncture and stress management.
• Breathing exercises.
• Physical therapy
• Regular sleep pattern.
• Eating full meals.
• Resting in a dark room.
• Ensuring restful sleep.
• Ice packs or cold packs.
• Massaging temples.
• Magnesium supplements (OTC).
• Avoiding foods with vasoactive substances.
• Monitoring caffeine intake.

Pharmacological Approaches for Headaches (OTC)

• Options include acetaminophen (Tylenol), ibuprofen (Motrin, Advil), naproxen, magnesium salicylate (Dewitt's, Doan's, Percogesic), and aspirin.

Important Considerations for Pharmacological Therapy in Children (< 12 years old)

• Two main OTC recommendations: Ibuprofen or Acetaminophen, using weight-based dosing.
• Ibuprofen Dosing: 5 to 10 milligrams per kilogram, every six to eight hours as needed, maximum daily dose of 300 milligrams per dose, up to four doses, daily maximum of 1200 milligrams.
• Acetaminophen (Tylenol) Dosing: 10 to 15 milligrams per kilogram, every four to six hours, maximum daily dose of 480 milligrams per dose, up to five doses, not exceeding 2,400 milligrams per day.
• Become familiar with adult dosing for community rotations.

When to Avoid Pharmacological Therapy (Salicylates - Aspirin)

• Avoid in patients with asthma, GI ulcers, gout, coronary artery bypass graft (CABG), high blood pressure, chronic heart failure, kidney disease, allergy to aspirin, or those under 18 years of age.

When to Avoid Pharmacological Therapy (NSAIDs - Motrin, Ibuprofen, Naproxen)

• Same contraindications as aspirin.
• Avoid naproxen specifically in patients younger than 12 years of age.

Reye's Syndrome

• Reye's syndrome is associated with salicylate use in children/teenagers recovering from chickenpox or a flu/viral infection.
• It can cause increased pressure inside the brain, leading to coma, brain damage, and death and early signs include changes in behavior, nausea, or vomiting.
• Refer immediately for emergency care if a young child with headache, especially with nausea and vomiting, has received aspirin.

Fever

• Fever is a leading cause of emergency visits in patients younger than 15 years old, and it is often self-limiting.
• Hyperthermia is a dysregulation of body's ability to regulate heat production or heat exposure, while hyperpyrexia is a very high fever (greater than 106 degrees Fahrenheit with an oral thermometer).
• Pyrogens are fever-producing substances that activate the body's defenses, leading to the production of prostaglandins.

Types of Thermometers

• Oral: In the mouth, most people's go-to, digital reading.
• Rectal: In the rectum, for babies less than three months old, most accurate for core temperature.
• Digital Pacifier: Pacifier with a thermometer, for little babies (easier to tolerate).
• Tympanic (Ear): In the ear, easy to use, digital, fast, close to rectal/oral.
• Temporal (Forehead): Swept across the forehead, easy to use, digital, fast, can be used for young ones if rectal not working.
• Axillary (Armpit): Under the armpit, non-invasive, easy to use, digital.

Fever Definitions Based on Thermometer Type

• Rectal: Greater than 100.4°F
• Oral: Greater than 99.5°F
• Axillary: Greater than 99°F
• Tympanic: Greater than 100.4°F
• Temporal: Age-based: 0-2 months: > 100.7°F (38.1°C), 3 months-4 years:100.3°F (37.9°C), > 4 years: 100.1°F (37.8°C)

Non-Pharmacological Approaches for Fever

• Adequate fluid intake: Varies by age (1-2 ounces/hour for kids, 3-4 ounces/hour for adults), avoiding sports drinks or fruit juice due to high sugar content.
• Body sponging with tepid (cool to warm) water after giving antipyretic medication.
• Wearing light clothing
• Removing blankets.
• Maintaining a comfortable room temperature.
• Avoid heavy clothes to prevent excessive sweating.

Mechanisms of Action (Brief)

• NSAIDs are Cox inhibitors which inhibit prostaglandin production, which causes fever.

Fever Treatment Algorithm

• SCHOLAR-MAC patient (or caregiver).
• Ask how the temperature was measured and if done correctly and offer to take the temperature if needed.
• If fever is present, address exclusions to self-care.
• If oral temperature is above 100.1°F and there is equivalent discomfort/agitation, an agent can be provided if requested.
• Recommend non-pharmacological options.
• For patients less than two years old, inform caregivers about expected response time (some response in 24 hours).
• For older children and adults, expect some response in about three days (fevers are self-limiting).

Exclusions to Self-Care for Fever

• Infants:
  • Greater than three months old with rectal temperature ≥ 100.4°F.
  • Less than three months old with rectal temperature ≥ 100.4°F.
• Severe symptoms of an infection.
• Anything that "just doesn't feel right" (clinical judgment).
• Signs of infection.
• Impaired immune function (immunosuppression, HIV, cancer).
• History of seizures with fever in children.
• Fever that persists for more than three days with or without treatment.
• Child is really sleepy, irritable, or hard to wake up (lethargic).
• Diarrhea, vomiting, inability to keep down fluids.
• Stiff neck (potential sign of meningitis).

Fever and Pain Medication Calculations (Pediatrics)

• Memorizing pediatric dosing is really important, and maximum doses for adults are important to know.
• Pediatric dosing is weight-based.
• Acetaminophen Dosing (Pediatric):10 to 15 milligrams per kilogram, with a maximum dose of 480 milligrams per dose.
• A hint for remembering dosing: Both acetaminophen and ibuprofen have 10 milligrams per kilogram in their dosing range.
• Dosing frequency for both: Approximately every six hours.
• Ibuprofen Dosing (Pediatric):
  • 5 to 10 milligrams per kilogram.
  • Maximum dose for adults: 300 milligrams per dose, up to four doses (not exceeding 1200 mg daily).
  • Scheduled every six to eight hours.
• NSAID Use Age Limitations for Self-Treatment:
  • Ibuprofen: Approved for kids six months and older.
  • Naproxen: Generally used for kids 12 and older (hard on the belly for younger children).
• Acetaminophen is generally a safer bet for young kids.

Musculoskeletal Pain (MSK)

• 20% of all adults in the US reported MSK medical conditions and classifications of MSK pain include myalgia, tendonitis, bursitis, sprain, strain, and osteoarthritis.

Detailed Explanation of MSK Conditions

• Myalgia: Pain in the muscles of the body, with dull, constant pain, aches, weakness, and fatigue, varying with trauma (acute) or drug-induced (e.g., statins).
• Tendonitis: Inflammation of the tendons around joint areas, with warmth, swelling, redness, mild to moderate pain after use, and loss of range of motion, typically gradual.
• Bursitis: Inflammation of the bursae (fluid-filled sacs in joints that reduce friction), with warmth, swelling, redness, possible crepitus, and constant pain worsening with movement/pressure, acute with injury or overuse (common in knee, shoulder, big toe).
• Sprain: Stretching or tearing of the ligament in a joint, with swelling, bruising, initial severe pain followed by pain with joint use, tenderness, and reduced joint stability/function, acute with injury (trauma), affecting ligaments.
• Strain: Hyperextension of a joint resulting in overstretching or tearing of muscle or tendon, with severe pain with continued pain and movement (and at rest), muscle weakness, and loss of some function, acute with injury (trauma), affecting muscles or tendons.
• Osteoarthritis: Protective cartilage in joints wears down, with joint deformities, swelling, dull pain, and joint stiffness (less than 20-30 minutes), over years (typically in older population), with nodules on fingers being common.

Assessing Pain

• Numeric Rating Scale (NRS): Pain rated on a scale of 0 (no pain) to 10 (worst pain imaginable).
• Wong-Baker Faces Pain Rating Scale: Uses faces to help patients (especially children) express their pain when they are not comfortable with numbers.
• Mild pain is 1-3, moderate is 4-6, and severe is 7-10.

Assessing a Patient with Pain: Algorithm

• Interview the patient (SCHOLAR-MAC) to get pertinent information.
• Identify exclusions
• Rule out exclusions and contraindications.
• Determine the cause of pain: Overexertion, muscle/joint injury, diagnosis/suspected osteoarthritis.
• Recommend appropriate therapies:
  • Overexertion/muscle/joint injury: RICE (Rest, Ice, Compression, Elevation).
  • Osteoarthritis: Non-pharm and pharm therapies.
• Pharmacological: NSAIDs, Tylenol, aspirin, topical analgesics.
• Follow up to ensure no underlying conditions or issues.

Exclusions for Self-Care (Musculoskeletal Pain)

• Severe pain (7-10).
• Long-lasting pain (duration of more than 7-10 days), even with self-treatment.
• Increased intensity or change of character of pain.
• Pelvic or abdominal pain (unless typical cramps).
• Long-lasting pain accompanied by nausea, vomiting, fever, other systemic signs.
• Visually deformed joint, abnormal movement, weakness in any limb, numbness, or suspected fracture.
• Pregnancy.
• Patient less than two years of age (for back pain specifically mentioned here).
• Back pain with loss of bowel movement or bladder control.

Non-Pharmacological Approaches for Musculoskeletal Pain

• Warming up and stretching to prevent injury
• Hydration.
• Wearing appropriate footwear
• Massaging muscles.
• Physical therapy
• TENS (Transcutaneous Electrical Nerve Stimulation) therapy: Electrical pulses for muscle stimulation (massage-like effect).
• Acupuncture.
• RICE Method:
  • Rest: Generally one to two days.
  • Ice: As soon as possible, three to four times a day for one to three days.
  • Compression: Injured area with elastic support or bandage.
  • Elevation: Limb/body part above heart level to decrease swelling and pain.

Topical Analgesics

• FDA approved for minor to moderate aches and pains of muscles and joints.
• Trolamine salicylate: For arthritis-type pain
• Diclofenac gel (1%): Recommended for arthritis pains.
• Lidocaine: Topical anesthetic, numbs the pain.
• Counterirritants include capsaicin, derived from chili peppers, which creates a hot sensation on the skin, relieving pain by causing a paradoxical effect.
• Counterirritants are good for muscle soreness and stiff necks, where pain relief comes from nerve stimulation rather than suppression.