Community Pharmacy Symptoms, Diagnosis, and Treatment PDF

COMMUNITY PHARMACY 2e SYMPTOMS, DIAGNOSIS AND TREATMENT Australian and New Zealand edition Paul Rutter & David Newby COMMUNITY PHARMACY 2e SYMPTOMS, DIAGNOSIS AND TREATMENT Australian and New Zealand edition 2012 2012 Els Elsevi evier er Aus Austra tralia lia © 201 2012 2 Els Elsevi evier er Aus Austra tralia lia COMMUNITY PHARMACY 2e SYMPTOMS, DIAGNOSIS AND TREATMENT Australian and New Zealand edition Paul Rutter BPharm, MRPharmS, PhD Principal Lecturer, School of Pharmacy, University of Wolverhampton, UK David Newby BPharm, PhD Associate Professor, Faculty of Health, University of Newcastle, Australia Original UK edition by Paul Rutter Sydney Edinburgh London New York Philadelphia St Louis Toronto © 201 2012 2 Els Elsevi evier er Aus Austra tralia lia Contents Preface vii Preface to the UK edition viii Introduction ix How to use this book xiii Acknowledgements xvi UK acknowledgements xvii Useful websites xviii 1 Respiratory system 1 2 Ophthalmology 43 3 Otic conditions 65 4 Central nervous system 77 5 Women’s health 99 6 Gastroenterology 123 7 Dermatology 181 8 Musculoskeletal conditions 245 9 Paediatrics 267 10 Speciﬁc product requests 293 Answers to case study questions 307 Abbreviations 313 Glossary of terms 315 Index 317 © 201 2012 2 Els Elsevi evier er Aus Austra tralia lia © 201 2012 2 Els Elsevi evier er Aus Austra tralia lia Preface Community pharmacy has evolved signiﬁcantly over the of retail outlets. Drugs that fall into the Pharmacist Only last few decades. Although the role of pharmacists in category are those that, it has been decided, would beneﬁt delivering primary healthcare has been longstanding, the from the input of the pharmacist. This should be seen as demand for self-care in the community has increased a privilege, and not be taken for granted. It is important dramatically. In Australia it is estimated that over $4 that pharmacists use this opportunity to demonstrate that billion is spent annually on self-care items, most of the public gains by these additional restrictions. which are medicines. This contrasts with just over $8 Some may argue that community pharmacy has clear billion spent annually on medicines subsidised on pre- conﬂicts of interest. On the one hand, as a healthcare scription by the government through the Pharmaceutical professional, the health and safety of the patient are Beneﬁts Scheme. paramount. However, as a retailer, proﬁtability and A number of factors have inﬂuenced the trend towards making sales are important. Community pharmacists greater self-care, including increased patient autonomy, make a signiﬁcant amount of their income by selling better access to information about treatments and the things, in contrast to other healthcare professionals who availability of more effective non-prescription medicines. are largely remunerated for their cognitive services. The latter has come about partly through the reschedul- Therefore, it is important that, when assisting the public ing of prescription medicines to non-prescription. Phar- in making choices about purchasing medicines, pharma- macists in Australia and New Zealand are in a unique cists ensure their advice and guidance is based on the position in that the scheduling of medicines in these best available evidence to maximise the outcomes for the countries includes a special classiﬁcation, Pharmacist patient. It is hoped that this book will help pharmacists, Only (or Restricted in NZ), which falls between the Pre- both practising and in training, to diagnose and differ- scription Only and Pharmacy Only schedules, and requires entiate problems that are amenable to self-care, and then involvement of the pharmacist in their sales. This con- make choices of appropriate management that have evi- trasts with the UK, which only has Prescription Only and dence to support their efﬁcacy. Pharmacy classiﬁcations, and the USA, where medicines are either Prescription Only or they can be sold in a range David Newby © 201 2012 2 Els Elsevi evier er Aus Austra tralia lia Introduction Community pharmacists are the most accessible health- all Pharmacist Only medicines in Australia are required care professionals. No appointment is needed to consult to have a Consumer Medicines Information leaﬂet, as do a pharmacist and patients can receive free, unbiased some Pharmacy Only medicines. If appropriate, these advice almost anywhere. On a typical day a pharmacist should also be considered. Another good source of written practising in an ‘average’ community pharmacy can real- materials is the Pharmacy Self Care fact sheets, available istically expect to help between 5 and 15 patients who through the Pharmaceutical Societies in Australia and present with various symptoms for which they are seeking New Zealand (see www.psa.org.au and www.psnz.org.nz). advice, reassurance, treatment or a combination of all three. Unlike most other healthcare professionals, com- Approaches to differential diagnosis munity pharmacists do not normally have access to the patient’s medical record and thus have no idea about Try to avoid using acronyms what the person’s problem is until a conversation is initi- ated. This presents the community pharmacist with a great Traditionally, the use of acronyms has been advocated to challenge to correctly differentially diagnose the patient. help pharmacists remember what questions to ask a patient. However, it is important that pharmacists do not Communication skills rely solely on acronyms in trying to differentially diag- nose a person’s presenting complaint; acronyms are rigid, For the most part pharmacists will be totally dependent inﬂexible and often inappropriate. Every patient is dif- on their ability to question patients in order to arrive at ferent and therefore it is unlikely that an acronym can a differential diagnosis. This is in stark contrast to the be fully applied and, more importantly, using acronyms GP and, to a lesser extent, the nurse, who can draw on can mean that you miss vital information that could physical examination and diagnostic tests to help them shape your course of action. Some of the more commonly arrive at a diagnosis. Opportunities for pharmacists to used acronyms are discussed brieﬂy below. perform a physical examination are limited by the lack WWHAM of privacy within a pharmacy and also a lack of training in correct examination technique; diagnostic testing is This is the simplest acronym to remember but it is also never employed because of the costs (which would have the worst one to use. It gives the pharmacist very limited to be passed on to the patient) and the invasive nature information from which to work and it is unlikely that a of most tests (e.g. blood taking for analysis). correct differential diagnosis will be made. If used at all, Having said this, a number of studies have shown that, it should be with caution and it is probably only useful in more than three-quarters of all cases, taking a patient for counter assistants to use when a patient ﬁrst presents, history alone will result in the correct diagnosis. This so that a general picture of the person’s presenting com- ﬁgure rises slightly if a history is supplemented with a plaint can be established. physical examination and yet further if laboratory inves- tigations are also conducted. Meaning of the letter Attributes of the acronym It is vital, therefore, that pharmacists possess excellent W Who is the patient? Positive points communication skills to ensure the correct information is W What are the symptoms? Establishes presenting obtained from the patient. This will be drawn from a H How long have the combination of good questioning technique, listening complaint symptoms actively to the patient and picking up on non-verbal cues. been present? In addition to having skills in listening, the pharmacist A Action taken? Negative points must also be able to communicate information to the M Medication being taken? Fails to consider general patient. While this is often done verbally, it is important appearance of patient. No that, where appropriate, written information is provided social/lifestyle factors taken to back up any verbal instructions. Many of the websites into account; no family provided at the end of each disease state and in the history sought; not speciﬁc or in-depth enough; no ‘Useful websites’ section of this book provide links to history of previous symptoms additional information to supplement counselling. Also, © 201 2012 2 Els Elsevi evier er Aus Austra tralia lia x Introduction Other acronyms that have been suggested as being factors or the relevance of a family history. They are very helpful for pharmacists in differential diagnosis are much designed to establish the nature and severity of the ENCORE, ASMETHOD and SIT DOWN SIR. Although presenting complaint. This, in many instances, will be these three acronyms are more comprehensive than adequate but for intermittent conditions (e.g. irritable WWHAM, they are still limited. No one acronym takes bowel syndrome, asthma, hayfever) they might well miss into consideration all of the factors that might impinge important information. Likewise, positive family history on the differential diagnosis. All fail to establish a full with certain conditions (e.g. psoriasis, eczema) provides history from the patient in respect to lifestyle and social useful clues in establishing a diagnosis. The Pharmaceutical Society of Australia has devel- oped a protocol for non-pharmacist staff for both symp- Meaning of the letter Attributes of the acronym tom-based requests and product-speciﬁc requests. The protocol is based around the words WHAT, STOP and GO: E Explore Positive points N No medication ‘Observe’ section suggests WHAT – what is the problem C Care taking into account the STOP – assess the situation O Observe appearance of the patient GO – proceed if appropriate R Refer – does he or she look very E Explain unwell? The acronyms WHAT and STOP stand for: Negative points Sections on ‘No medication’ and ‘Refer’ add little to the Meaning of the letter differential diagnosis W Who is the patient? process. No social/lifestyle H How long have they had the symptoms? factors taken into account; A Actual symptoms – what are they? no family history sought T Treatment for this or any other conditions? S Symptoms that should be referred T Totally sure? Meaning of the letter Attributes of the acronym O Overuse or abuse? A Age/appearance? Positive points P Pharmacist only or pharmacist preferred* S Self or someone else? Establishes the nature of the *Where the patient expresses a desire to speak to the pharmacist M Medication? problem and if the patient E Extra medicines? has suffered from previous If non-pharmacist staff encounter any of the STOP condi- T Time persisting? similar episodes tions they should refer to the pharmacist. This protocol H History? is aimed at screening patients, and pharmacists are O Other symptoms? Negative points encouraged to use the guide to develop protocols in D Danger symptoms? Exact symptoms and severity speciﬁc areas of the pharmacy. not fully established. No social/lifestyle factors taken into account; no family history sought Clinical decision making Whether we are conscious of it or not, most people will Meaning of the letter Attributes of the acronym – at some level – use clinical decision making to arrive S Site or location? Positive points at a differential diagnosis. Diagnostic reasoning is a com- I Intensity or severity? Establishes the severity and ponent of clinical decision making and involves recogni- T Type or nature? nature of problem and if tion of cues and analysis of data. Very early in a clinical D Duration? the patient has suffered encounter, and based on limited information, a pharma- O Onset? from previous similar cist will arrive at a small number of hypotheses. The episodes pharmacist then sets about testing these hypotheses by W With (other symptoms)? asking the patient a series of questions. The answer to N Annoyed or aggravated? Negative points each question allows the pharmacist to narrow down the S Spread or radiation? Fails to consider general number of possible diagnoses either by eliminating par- I Incidence or frequency appearance of patient. No ticular conditions or conﬁrming his or her suspicions of pattern? social/lifestyle factors a particular condition. Once the questioning is over, the R Relieved by? taken into account; no pharmacist should be in a position to differentially diag- family history sought nose the patient’s condition. © 201 2012 2 Els Elsevi evier er Aus Austra tralia lia Introduction xi epidemiology states that tension headache is most Key steps in the process likely but females are more prone to migraine than males. 1. Formulating a diagnosis based on the patient and the initial presenting What line of questioning do you take? (2. Asking ques- complaint tions.) Your main aim is to differentiate between tension and migraine headache: Before any questions are asked of the patient you should think about the line of questioning you are going to take: Nature of the pain What is the general appearance of the patient? Does Tension headache usually produces a dull ache, as the person look well or unwell? Is the person you opposed to the throbbing nature of migraine pain: are about to talk to the patient or someone acting patient’s response: dull ache on the patient’s behalf? This will shape your pharmacist’s thoughts: suggestive of tension thinking as to the severity of the problem. headache. How old is the patient? This is very useful information. Epidemiological studies for a wide Location of the pain range of conditions and disease states have shown Tension headache is generally bilateral; migraine is often that certain age groups will suffer from certain unilateral: problems. For example, it is very unlikely that a child who presents with cough will have chronic patient’s response: all over bronchitis but the probability of an elderly person pharmacist’s thoughts: suggestive of tension having chronic bronchitis is much higher. headache. What sex is the patient? As with age, sex can dramatically alter the chances of suffering from Severity of pain certain conditions. Migraines are ﬁve times more Tension headache is not usually severe and disabling; common in women than men, yet cluster headache migraine can be disabling: is nine times more common in men than women. patient’s response: bothersome more than stopping What is the presenting complaint? Some conditions her doing things are much more common than others. Therefore you pharmacist’s thoughts: suggestive of tension could form an idea of what condition the patient is headache. likely to be suffering from based on the laws of probability. For example, if a person presents with a The answers so far are indicative of tension headache. headache then you should already know that the However, further speciﬁc questions relating to lifestyle most common cause of headache is tension and previous and family history should be asked. It would headache, followed by migraine and then cluster be expected that there was no family history of migraine headache. Other causes of headache are rare but and there is probably some trigger factor causing the obviously need to be eliminated. Your line of headache, for example increased stress due to work or questioning should try to conﬁrm or refute the most personal pressures. The patient might therefore have had likely causes of headache. similar headaches in the past. Finally, even though at this stage you are con- ﬁdent of your differential diagnosis you should still 2. Asking questions ask a couple of questions to rule out any sinister pathology. Obviously you are expecting the answers The questions you ask the patient will be speciﬁc to that from these questions to be negative to support your patient. After establishing who the person is, how sick differential diagnosis. Any questions that invoke he or she is and what the presenting complaint is, a the opposite response to that expected will require number of targeted questions speciﬁc to that patient further investigation. should be asked. The following scenario will illustrate this point: A 31-year-old female asks for advice about a head- 3. Conﬁrming facts ache she has. What are your initial thoughts? (1. Formulating a Before making a recommendation to the patient it is diagnosis based on the patient and the initial presenting always helpful to try and recap the information elicited. complaint): This is especially important when you have had to ask a lot of questions. It is well known that short-term working the patient is present memory is relatively small and that remembering all the the patient is female and in her early thirties pertinent facts is difﬁcult. Summarising the information the patient looks and sounds OK at this stage will not only help you formulate your ﬁnal © 201 2012 2 Els Elsevi evier er Aus Austra tralia lia xii Introduction diagnosis but will also allow the patient to add further intermittently when regular use for short periods of time information or to correct you on facts that you have is more appropriate to break the pain cycle). After estab- failed to remember correctly. lishing who the medicine is for, and whether they have The way in which one goes about establishing what used it before, it is important that questions about the is wrong with the patient will vary from practitioner to complaint being treated are asked including the severity practitioner. However, it is important that whatever and duration, anything they have tried so far, and what method is adopted it must be sufﬁciently robust to be of other medical conditions and medicines they may take. beneﬁt to the patient. Using a clinical decision-making Only after establishing that use is appropriate should the approach to differential diagnosis allows you to build a sale proceed. fuller picture of the patient’s presenting complaint. It is both ﬂexible and speciﬁc to each individual, unlike acronyms. Documentation It is important that pharmacists document their activi- Product-based requests ties. Apart from the legal requirements for documenta- tion, such as the recording of the sales of certain Many people will come into a pharmacy to purchase Pharmacist Only medicines, professional standards and a speciﬁc product. Pharmacists should never assume the Competency Standards for Pharmacists all state the that just because the patient has heard of, or used, the need to maintain adequate records. This includes docu- product before that they are adequately informed about menting overuse or inappropriate use of medicines, the medicine. It is important that product-speciﬁc requests treatment plans, required follow-up of patients and are treated with the same rigour as symptom-based referrals or discussions with healthcare professionals. requests. Pharmacists should establish whether use of the This may be done electronically using the patient product is appropriate. Inappropriate use in this context records of the dispensing computing system or in paper is not related only to overuse or abuse, but also includes form, such as pre-printed referral forms. The latter are using the wrong product for the symptoms, or not using available from some of the suppliers of pharmacy the product in the optimal way (e.g. using analgesics stationery. © 201 2012 2 Els Elsevi evier er Aus Austra tralia lia How to use this book This book is divided into ten chapters. The ﬁrst nine doesn’t know where the kidneys are. However, this book are systems based and structured in the format shown in is not intended to replace an anatomy text and the reader Figure 1. The ﬁnal chapter is product based and has a is referred to the list of further reading for anatomy texts. slightly different format. A list of abbreviations and a glossary are included at the end of the book. Self-assessment questions Key features of each chapter Twenty multiple choice and at least two case study ques- tions are presented at the end of each chapter. These are At the beginning of each chapter a short section address- designed to test factual recall and applied knowledge. ing basic anatomy and history taking speciﬁc to that They start with simple traditional multiple choice ques- body system is presented. A basic understanding of tions in which the right answer has to be picked from a the anatomical location of major structures is useful series of ﬁve possible answers, and work up to more when attempting to diagnose/exclude conditions from a complex, interrelated questions. patient’s presenting complaint. It would be almost impos- The case studies challenge you with ‘real-life’ situa- sible to know whether to treat or refer a patient who tions. All are drawn from practice and have been encoun- presented with symptoms suggestive of renal colic if one tered by practising pharmacists, but have been modiﬁed 1. Respiratory system 2. Ophthalmology 3. Otic conditions 4. Central nervous system 5. Women's health 6. Gastroenterology 7. Dermatology 8. Musculoskeletal conditions 9. Paediatrics 10. Specific product requests Background General overview of eye anatomy History taking Red eye Eyelid disorders Dry eye Self-assessment Red eye Background Prevalence and epidemiology Aetiology Arriving at a differential diagnosis Clinical features of conjunctivitis Conditions to eliminate Primer for differential diagnosis Trigger points indicative of referral Evidence base for OTC medication Practical prescribing and product selection Hints and tips Further reading and websites Fig. 1 Structure of this book. © 201 2012 2 Els Elsevi evier er Aus Austra tralia lia xiv How to use this book for inclusion in the book. For all questions, a set of encourage pharmacists to examine these conditions if answers is provided at the end of the book to allow possible—to assist in this, photographs demonstrating self-reﬂection. standard presentations of these complaints have been included in those chapters relating to these types of conditions. However, it is important to note that patients Elements included under may not present with ‘classical’ signs, and careful ques- tioning is usually required to help reach a differential each condition diagnosis. The same structure has been adopted for every condition. This is intended to help the reader approach differential Primer for differential diagnosis diagnosis from the position of clinical decision-making. A ‘primer for differential diagnosis’ is available for a To help summarise the information, tables and algorithms number of the conditions covered. This algorithmic are included for many of the conditions. approach to differential diagnosis is geared towards nearly or recently qualiﬁed pharmacists. This feature is Arriving at a differential diagnosis not intended to be solely relied upon in making a differ- ential diagnosis but to act as an aide memoire. It is antici- A table summarising the key questions that should be pated that the primers will be used in conjunction with asked for each condition is included. The relevance (i.e. the text, thus allowing a broader understanding of the the rationale for asking the question) is given for each differential diagnosis of the condition being considered. question. This will allow pharmacists to determine what questions to ask of every patient to enable a differential Trigger points indicative of referral diagnosis. For some conditions, such as those that affect the eye A summary box of trigger factors when it would be and some skin conditions, it will be possible for the prudent to refer the patient to a medical practitioner is pharmacist to have a look at the affected area. We would presented for each condition. Table 1. ADEC pregnancy categories ADEC category Deﬁnition A Drugs which have been taken by a large number of pregnant women and women of childbearing age without any proven increase in the frequency of malformations or other direct or indirect harmful effects on the fetus having been observed B1 Drugs that have been taken by only a limited number of pregnant women and women of childbearing age, without an increase in the frequency of malformation or other direct or indirect harmful effects on the human fetus having been observed. Studies in animals have not shown evidence of an increased occurrence of fetal damage B2 Drugs that have been taken by only a limited number of pregnant women and women of childbearing age, without an increase in the frequency of malformation or other direct or indirect harmful effects on the human fetus having been observed. Studies in animals are inadequate or may be lacking, but available data show no evidence of an increased occurrence of fetal damage B3 Drugs that have been taken by only a limited number of pregnant women and women of childbearing age, without an increase in the frequency of malformation or other direct or indirect harmful effects on the human fetus having been observed. Studies in animals have shown evidence of an increased occurrence of fetal damage, the signiﬁcance of which is considered uncertain in humans C Drugs that, owing to their pharmacological effects, have caused or may be suspected of causing harmful effects on the human fetus or neonate without causing malformations. These effects may be reversible D Drugs that have caused, are suspected to have caused or may be expected to cause an increased incidence of human fetal malformations or irreversible damage. These drugs may also have adverse pharmacological effects X Drugs that have such a high risk of causing permanent damage to the fetus that they should not be used in pregnancy or when there is a possibility of pregnancy © 201 2012 2 Els Elsevi evier er Aus Austra tralia lia How to use this book xv Evidence-based non-prescription Hints and tips boxes medicines and practical prescribing and product selection A summary box of useful information is provided near the end of each condition. This contains information that These two sections present the reader, ﬁrst, with an eval- does not fall readily into any of the other sections but is uation of the current literature on whether a non- none the less useful. For example, some of the hints and prescription medicine works and, second, with a quick tips boxes give advice on how to administer eye drops, reference to the dose of the medicine and when it cannot suppositories and other forms of medicines that are not be prescribed. This does not replace textbooks such as taken via the oral route. Stockley’s drug interactions or Briggs’ Drugs in pregnancy and lactation, but it does allow the user to ﬁnd basic data References, further reading and web sites in one text without having to reach for three or four other texts to answer simple questions. To supplement the text, at the end of each condition a The pregnancy recommendations in this book are list of selected references and reading is provided for based largely on those of the Australian Drug Evalua- those who wish to seek further information on the subject. tion Committee’s (ADEC) Pregnancy Categories (Table 1). Web sites are also provided, as many people now have In some instances respected evidence-based texts, such internet access. All the sites have been checked and were as the Australian Medicines Handbook, have taken a active and relevant at the time of writing (January 2011). more pragmatic approach and have suggested limited Finally, all information presented in the book is accu- use in pregnancy may be appropriate despite not having rate and factual as far as the authors are aware. It is an ADEC category of A. In these instances this is noted acknowledged that guidelines change, products become in the summary tables. However, given that pharmacists discontinued and new information becomes available should only be managing minor, self-limiting condi- over the lifetime of a book. Therefore, if any information tions, it is prudent that no medicines are recommended in the book is not current or valid, the authors would be in the ﬁrst trimester, unless they carry an ADEC cate- grateful of any feedback, positive or negative, to ensure gory of A. that the next edition is as up-to-date as possible. © 201 2012 2 Els Elsevi evier er Aus Austra tralia lia Chapter 4 Central nervous system In this chapter Background 77 Headache 77 General overview of CNS anatomy 77 Insomnia 86 History taking 77 Self-assessment questions 92 Background Headache The number of patient requests for advice and/or prod- Background ucts to treat headache and insomnia makes up a smaller Headache is not a disease state or a condition but rather proportion of a pharmacist’s workload than other condi- a symptom, of which there are many causes. Headache tions such as coughs and colds – yet sales for analgesics can be the major presenting complaint, for example in and hypnotics are extremely high. The vast majority of migraine, tension and cluster headache, or one of many patients will present with benign and non-serious condi- symptoms, for example in an upper respiratory tract tions and in only very few cases will sinister pathology infection. be responsible. Headache classiﬁcation General overview of CNS anatomy If the pharmacist is to advise on appropriate treatment and referral then it is essential to make an accurate diag- The central nervous system (CNS) comprises the brain nosis. However, with so many disorders having headache and spinal cord. Its major function is to process and as a symptom, pharmacists should endeavour to follow integrate information arriving from sensory pathways an agreed classiﬁcation system. The 2nd edition of the and communicate an appropriate response back via affer- International Headache Society (IHS) classiﬁcation is now ent pathways. CNS anatomy is complex and beyond the almost universally accepted (Table 4.1). The system ﬁrst scope of this book. The reader is referred to any good distinguishes between primary and secondary headache anatomical text for a comprehensive description of CNS disorders. This is useful to the community pharmacist, as anatomy. any secondary headache disorder is symptomatic of an underlying cause and would normally require referral. In the IHS system, primary headaches are classiﬁed on History taking symptom proﬁles, relying on careful questioning coupled with epidemiological data on what the distribution of a A differential diagnosis for all CNS conditions will particular headache disorder has within the population. be made solely from questions asked of the patient. It is especially important that a social and work- Prevalence and epidemiology related history is sought alongside questions asking about the patient’s presenting symptoms because pres- The exact prevalence of headache is not precisely known. sure and stress are implicated in the cause of CNS However, virtually everyone will have suffered from a conditions. headache at some time; it is probably the most common © 201 2012 2 Els Elsevi evier er Aus Austra tralia lia 78 Central nervous system Table 4.1 IHS Classiﬁcation of headache Primary 1. Migraine, including: 3. Cluster headache and other trigemina headache 1.1 Migraine without aura autonomic cephalalgias, including: disorders 1.2 Migraine with aura 3.1 Cluster headache 2. Tension-type headache, including: 4. Other primary headaches 2.1 Infrequent episodic tension-type headache 2.2 Frequent episodic tension-type headache 2.3 Chronic tension-type headache Secondary 5. Headache attributed to head and/or neck 8.2 Medication-overuse headache headache trauma, including: 8.2.1 Ergotamine-overuse headache disorders 5.2 Chronic post-traumatic headache 8.2.2 Triptan-overuse headache 6. Headache attributed to cranial or cervical 8.2.3 Analgesic-overuse headache vascular disorder, including: 9. Headache attributed to infection, including: 6.2.2 Headache attributed to subarachnoid 9.1 Headache attributed to intracranial 6.4.1 Headache attributed to giant cell infection haemorrhage arteritis 10. Headache attributed to disorder of 7. Headache attributed to non-vascular homeostasis intracranial disorder, including: 11. Headache or facial pain, attributed to 7.1.1 Headache attributed to idiopathic disorder of cranium, neck, eyes, ears, nose, intracranial hypertension sinuses, teeth, mouth or other facial or 7.4 Headache attributed to intracranial cranial structures including: neoplasm 11.2.1 Cervicogenic headache 8. Headache attributed to a substance or its 11.3.1 Headache attributed to acute withdrawal, including: glaucoma 8.1.3 Carbon monoxide-induced headache 12. Headache attributed to psychiatric disorder 8.1.4 Alcohol-induced headache Neuralgias and 13. Cranial neuralgias, central and primary 14. Other headache, cranial neuralgia, central other headaches pain and other headaches including: or facial primary facial pain 13.1 Trigeminal neuralgia Source: adapted by the British Association of Headache (BASH) from the International Headache Society Classiﬁcation Subcommittee, The International Classiﬁcation of Headache Disorders, 2nd ed. Cephalalgia 2004, Blackwell Publishing, with permission pain syndrome experienced by humans. A study by understood. Pain control systems modulate headaches of Heywood and others (1998) involving 1717 individuals all types, independent of the cause. However, the exact in Melbourne, Australia, found 87% reported at least one aetiology of tension headache and migraine are still to headache in the previous year. They also found that more be fully elucidated. Tension headache is commonly than 1 in 10 had sought advice from a pharmacist about referred to as muscle contraction headache, as electro- their headache. myography has shown pericranial muscle contraction, Tension headache has been reported to affect between which is often exacerbated by stress. However, similar 40 and 90% of people in Western countries at some time muscle contraction is noted in migraine sufferers and this in their life. Migraine affects approximately 15% of theory has now fallen out of favour. Consequently, no women, in whom it is three times more common than current theory for tension headache is unanimously in men. Prevalence peaks between 30 to 40 years of endorsed but recent studies suggest a neurobiological age. Conversely, cluster headache which is also more basis. prevalent in the 30 to 40 year-old age group, is ﬁve to Traditionally, migraine was thought to be a result of six times more prevalent in men. abnormal dilation of cerebral blood vessels but this vas- cular theory cannot explain all migraine symptoms. The Aetiology use of 5 HT1 agonists to reduce and stop migraine attacks suggests some neurochemical pathophysiology. Migraine Considering headache affects almost everyone, the mech- is therefore probably a combination of vascular and neu- anisms that bring about headache are still poorly rochemical changes – the neurovascular hypothesis. © 201 2012 2 Els Elsevi evier er Aus Austra tralia lia Headache 79 Migraine also appears to have a genetic component with present with headaches can be defensive, especially if about 70% of patients having a ﬁrst-degree relative with they feel they are undergoing an ‘inquisition’. Therefore, a history of migraine. pharmacists must establish a report with the patient, while carefully explaining why the information will help Arriving at a differential diagnosis with them assisting the patient. Given that headache is extremely common, and most Clinical features of headache patients will self-medicate, any patient requesting advice should ideally be seen by the pharmacist, as it is likely In a community pharmacy the overwhelming majority of that the headache has either not responded to non- patients (80–90%) will present with tension headache. A prescription medicine or is troublesome enough for the further 10% will have migraine. Very few will have other patient to seek advice. Arrival at an accurate diagnosis primary headache disorders and fewer still will have a will rely on careful questioning; therefore, a number of secondary headache disorder. This part of the text there- headache-speciﬁc questions should be asked (Table 4.2). fore concentrates on migraine, tension and cluster In addition to these symptom-speciﬁc questions, the headaches. pharmacist should also enquire about the person’s social history because social factors – mainly stress – play a Tension-type headache signiﬁcant role in headache. Ask about the person’s work and family status to determine if the person is suffering Tension-type headaches can be classed as either episodic from greater levels of stress than normal. Although careful questioning is important, many patients who or chronic. Episodic tension-type headache can be further subdivided into infrequent and frequent forms. Most 4 Table 4.2 Speciﬁc questions to ask the patient: Headache Question Relevance Onset of In early childhood or a young adult, primary headache is most likely. After 50 years of age the headache likelihood of a secondary cause is much greater Headache and fever at the same time imply an infectious cause Headache that follows head trauma might indicate post-concussive headache or intracranial pathology Frequency and Headache associated with the menstrual cycle or certain times, e.g. weekend or holidays, timing suggests migraine Headaches that occur in clusters at the same time of day/night suggest cluster headache Headaches that occur on most days with the same pattern suggest tension headache Location of pain Cluster headache is nearly always unilateral in frontal, ocular or temporal areas (see Fig 4.1) Migraine headache is unilateral in 70% of patients but can change from side to side from attack to attack Tension headache is often bilateral, either in frontal or occipital areas, and described as a tight band Very localised pain suggests an organic cause Severity of pain Pain is a subjective personal experience and there are therefore no objective measures. Using a numeric pain intensity scale should allow you to assess the level of pain the person is experiencing: 0 represents no pain and 10 the worst pain possible Dull and band-like suggests tension headache Severe to intense ache or throbbing suggests haemorrhage or aneurysm Piercing, boring, searing eye pain suggests cluster headache Moderate to severe throbbing pain that often starts as dull ache suggests migraine Triggers Pain that worsens on exertion, coughing and bending suggests a tumour Food (in 10% of sufferers), menstruation and relaxation after stress are indicative of migraine Lying down makes cluster headache worse Attack duration Typically migraine attacks last between a few hours and 3 days Tension headaches last between a few hours and several days, e.g. a week or more Cluster headache will only normally last 2 to 3 h © 201 2012 2 Els Elsevi evier er Aus Austra tralia lia 80 Central nervous system severely affect the patient’s quality of life and should not be managed by the community pharmacist. Tension or migraine Migraine Frontal There are an estimated 2 million migraine sufferers in Australia, and the cost of migraine has been put at over $1 billion per annum (Parry 1992). The peak onset for a person to have their ﬁrst attack is often in adoles- cence or as a young adult. Migraines are rare over the Cluster, glaucoma, sinusitis age of 50 and anyone in this age group presenting for the ﬁrst time with migraine-like symptoms should be referred to the GP to eliminate secondary causes of head- Orbital ache. If this is not their ﬁrst attack they will normally have a history of recurrent and episodic attacks of head- ache. Attacks last anything between a few hours and up to 3 days. The average length of an attack is 24 hours. The IHS classiﬁcation recognises several subtypes of Subarachnoid tension, haemorrhage migraine. However, the major subtypes are migraine with aura (classical migraine) and migraine without aura Occipital (common migraine). A migraine attack can be divided into three phases: Phase one: premonitory phase (prodrome phase), which can occur hours or possibly days before the headache. The patient may complain of a change in Migraine, temporal arteritis mood or notice a change in behaviour. Feelings of well-being, yawning, poor concentration and food cravings have been reported. These prodromal Temporal features are highly individual but are relatively Fig. 4.1 Location of pain in headache. consistent to each patient. Identiﬁcation of ‘triggers’ is sometimes possible if a patient keeps a diary (Table 4.3). Phase two: headache with or without aura. patients will present to the pharmacist with the infre- Phase three: as the headache subsides the patient quent episodic form. Headaches last from 30 minutes to may feel lethargic, tired and drained before recovery, up to 7 days in duration and often the patient will have which may take several hours and is termed the a history of recent headaches. They might have tried resolution phase. non-prescription medicine without complete symptom resolution or say that the headaches are becoming Headache with aura (classic migraine) more frequent. Pain is bifrontal or bioccipital, generalised and non-throbbing (Figure 4.1). The patient might This accounts for less than 25% of migraine cases. describe the pain as tightness or a weight pressing The aura, which are fully reversible, develops over 5 to down on their head. The pain is gradual in onset and 20 minutes and can last for up to 1 hour. It can either tends to worsen progressively through the day. Pain is be visual or neurological. Visual auras can take many normally mild to moderate and not aggravated by move- guises, such as scotomas (blind spots), fortiﬁcation ment, although it is often worse under pressure or stress. spectra (zig-zag lines) or ﬂashing and ﬂickering lights. Nausea and vomiting are not associated with tension- Neurological auras (pins and needles) typically start in type headache and it rarely causes photo- or phonopho- the hand, migrating up the arm before jumping to the bia. Overall, the headache has only a limited impact on face and lips. Within 60 minutes of the aura ending the the individual. headache usually occurs. Pain is unilateral, throbbing and Patients who have frequent episodic tension-type moderate to severe. Sometimes the pain becomes more headaches suffer more frequent headaches that last generalised and diffuse. Physical activity and movement longer and over time these can develop into chronic tends to intensify the pain. Nausea affects almost all tension-type headache. These headaches occur for more patients but less than a third will vomit. Photophobia than 15 days per month, and might occur daily and last and phonophobia often make patients seek a dark quiet for at least 3 months. These types of headaches can room to relieve their symptoms. The patient might also © 201 2012 2 Els Elsevi evier er Aus Austra tralia lia Headache 81 Table 4.3 Triggers and strategies to reduce migraine attacks Trigger Strategy Stress Maintain regular sleep pattern Take regular exercise Modify work environment Relaxation techniques (e.g. yoga) Diet – any food Maintain a food diary. If an attack occurs within 6 hours of food ingestion and is could be a potential reproducible it is likely that it is a trigger for migraine trigger but foods Eat regularly and do not skip meals implicated include: Note: detecting triggers is complicated because they appear to be cumulative jointly Cheese contributing to a ‘threshold’ above which attacks are initiated Citrus fruit Chocolate suffer from fatigue, ﬁnd concentrating difﬁcult and be irritable. Headache without aura (common migraine) headache require referral, as OTC management is very unlikely to be effective. 4 Rhinosinusitis The remaining 75% of sufferers do not experience an The pain tends to be relatively localised, usually orbital, aura but do suffer from all other symptoms as described unilateral and dull. A course of decongestants could be above. tried but if treatment failure occurs referral to the GP for possible antibiotic therapy would be needed. For further Cluster headache information on rhinosinusitis, see Chapter 1 page 13. Cluster headache is predominantly a condition that affects men over the age of 30 years. Typically the head- Eye strain ache occurs at the same time each day with abrupt onset Patients who perform prolonged periods of close work, and lasts between 10 minutes and 3 hours, with 50% of for example people who look at computer screens for patients experiencing night-time symptoms. Patients are extended periods, can suffer from frontal aching head- woken 2 to 3 hours after falling asleep with steady ache. In the ﬁrst instance, patients should be referred to intense unilateral orbital boring pain, often described as an optometrist for a routine eye check. being poked in the eye with a red-hot poker. Additionally, conjunctivitis and nasal congestion (which laterally becomes watery) are experienced on the same side of the Medication overuse headache head as the headache. Patients with long-standing symptoms of headache who The condition is characterised by periods of acute medicate regularly, can develop medication overuse attacks, typically lasting a number of weeks to a few headache (MOH). The exact mechanism of MOH is poorly months with sufferers experiencing between one and understood but may include genetic factors and/or three attacks per day. This is then followed by periods of changes in serotonin receptors that promote pain. Patients remission, which can last months or years. During acute with migraine and tension headaches seem to be at great- phases, alcohol can trigger an attack. Nausea is usually est risk. The result is a cycle where patients take more absent and a family history uncommon. and more painkillers that are stronger and stronger in The key differences between the three conditions are order to control the pain. Patients will experience daily shown in Table 4.4. or near daily headaches that are described as dull and nagging. Obviously in these cases a medication history Conditions to eliminate is essential and should prompt the pharmacist to refer the patient to the GP. Treatment is to stop all analgesia All suspected secondary causes of headache except for a number of weeks and requires careful planning. sinusitis and alcohol-induced (‘hangover’) need to be However, like many things prevention is better than cure, referred. In addition, patients suffering from cluster and therefore pharmacists should intervene as soon as 2012 2012 Els Elsevi evier er Aus Austra tralia lia 82 Central nervous system Table 4.4 Difference in symptom presentation for primary headaches Severity (pain score Precipitating Who is Duration Timing and nature Location from 0–10)* factors affected Tension- Can last Symptoms worsen as Bilateral and 2–5 Stress due to All age groups type days day progresses. most often at changes in work or and both sexes Non-throbbing pain back of head home environment equally affected Migraine Average Associated with Usually 4–7 Food (in 10% of Three times attack lasts menstrual cycle and unilateral sufferers) and more common 24 hours weekends Throbbing family history in women. Rare pain and nausea. in children Dislike of bright lights and loud noise Cluster 1–3 hours Attacks occur at Unilateral, often >7 Alcohol Three to ﬁve same time of day behind the eye times more Intense boring pain or temples common in men *These are rough guides set by the authors and are not evidence-based possible if they think someone is over using medicines unlikely that a patient would present in the pharmacy with for headaches. such symptoms but if one did then immediate referral is needed. Glaucoma Patients experience a frontal/orbital headache with pain Temporal arteritis in the eye. Sometimes, but not often, the eye appears red The temporal arteries that run vertically up the side of and is painful. Vision is blurred and the cornea can look the head, just in front of the ear, can become inﬂamed. cloudy. In addition, the patient might notice haloes When this happens, they are tender to touch and might around the vision. For further information on glaucoma be visibly thickened. Unilateral pain is experienced and see Chapter 2 page 47. the person generally feels unwell with fever, myalgia and general malaise. Scalp tenderness is also possible, espe- Meningitis cially when combing the hair. It is most commonly seen in the elderly, especially women. Prompt treatment with Severe generalised headache associated with fever, an oral corticosteroids is required because the retinal artery obviously ill patient, neck stiffness, a positive Kernig’s can become compromised, leading to blindness. Urgent sign (pain behind both knees when extended) and latterly referral is needed. a purpuric rash are classically associated with meningitis. However, meningitis is notoriously difﬁcult to diagnose early and any child who has difﬁculty in placing the chin Conditions causing raised on the chest, looks and feels unwell, has a headache and intracranial pressure a temperature above 38.9°C should be referred urgently to accident and emergency as the patient can decline Space-occupying lesions (brain tumour, haematoma and rapidly and has a case fatality rate of 5–10%, higher if abscess) can give rise to varied headache symptoms, they develop sepsis. ranging from severe chronic pain to intermittent moder- ate pain. Pain can be localised or diffuse and tends to be more severe in the morning, with a gradual improvement Subarachnoid haemorrhage over the next few hours. Coughing, sneezing, bending The patient will experience very intense and severe pain, and lying down can worsen the pain. Nausea and vomit- located in the occipital region. Nausea and vomiting ing are common. After a prolonged period of time neu- are often present and a decreased level of consciousness rological symptoms start to become evident, such as is prominent. Patients often describe the headache as drowsiness, confusion, lack of concentration, difﬁculty the worst headache they have ever had. It is extremely with speech and paraesthesia. © 201 2012 2 Els Elsevi evier er Aus Austra tralia lia Headache 83 Any patient with a recent history (last 2 to 3 months) always unilateral. It is three times more common in of head trauma, headache of longstanding duration or women than men. insidious worsening of symptoms, especially decreased consciousness and vomiting, must be referred for fuller Depression evaluation. Depression often presents with tension-like headaches. Check for loss of appetite, weight loss, decreased libido, sleep disturbances and constipation. If the patient exhib- Trigeminal neuralgia its these characteristics then referral to the GP would Pain follows the course of either the second (maxillary be necessary to determine if the patient is suffering – supplying the cheeks) or third (mandibular – supplying from depression. Recent changes to the patient’s social the chin, lower lip and lower cheek) division of the nerve circumstances, for example loss of job, might also support leading to pain experienced in the cheek, jaws, lips or your differential diagnosis. gums. Pain is short-lived, usually lasting only a couple Figure 4.2 will help in the differentiation of serious of minutes, but is severe and lancing and is almost and non-serious causes of headache. Patient presents with headache No Refer 4 > 50 years New, severe < 12 yearsSigns of headache Age ❶ infection No Yes > 12 years but < 50 years Treat Yes Refer ❷ Unilateral No Pain dull and Sinister pathology? pain band-like No Yes Yes Yes Orbital pain No Throbbing Nausea and /or No Worse when Cluster and tearing pain vomiting stressed Yes Yes No No Nausea and/or Yes Tension Refer Temples tender vomiting headache Yes Yes Temporal Family history Refer ❸ arteritis of migraine Sinister pathology? No Yes Pain worse in Migraine morning Yes No Yes Refer No Pain lasts Sinister pathology? < 3 days Fig. 4.2 Primer for differential diagnosis of headache. ❶ Age has not experienced similar headache symptoms before. Mass lesions (tumours and haematoma) and temporal arteritis should be Caution should be exercised in children who present with considered. headache. Although the majority of headaches will not have an organic cause, children under 12 are probably best referred if they show no signs of a systemic infection (e.g. fever, malaise). ❸ Referral for suspected sinister pathology Nausea and vomiting in the absence of migraine-like symptoms ❷ Referral for suspected sinister pathology should be treated seriously. Mass lesions and subarachnoid haemorrhage need to be eliminated. With increasing age it is more likely that a sinister cause of headache is responsible for the symptoms, especially if the patient © 201 2012 2 Els Elsevi evier er Aus Austra tralia lia 84 Central nervous system the additional beneﬁt appears modest at best (for more TRIGGER POINTS indicative of referral: Headache information see lower back pain in Chapter 8, page 246. It should also be noted that long-term trials are lacking Headache unresponsive to adequate doses of and therefore the potential for the caffeine to cause a analgesics withdrawal headache, resulting in a cycle of increased Headache in children under 12 years with stiff analgesic use as seen with older pain relievers such as neck or skin rash APC powders, has not been fully investigated. Headache occurs after recent (1 to 3 months) trauma injury Metoclopramide and paracetamol Headache that has lasted for more than 2 weeks Nausea and/or vomiting in the absence of The non-prescription preparations contain paracetamol migraine symptoms 50 mg and metoclopramide 5 mg per tablet. Although Neurological symptoms, if migraine excluded, there is limited data on the efﬁcacy of the combination especially change in consciousness product, several evidence-based guidelines, including the New or severe headache in patients over 50 years Therapeutic Guidelines and the NPS, advocate the com- Progressive worsening of headache symptoms bination of paracetamol and metoclopramide in the treat- over time ment of mild/moderate migraine where nausea/vomiting Symptoms indicative of cluster headache are present. Very sudden and/or severe onset of headache Prochlorperazine Prochlorperazine given parenterally has been shown in Evidence base for trials to be effective in reducing pain in migraine head- non-prescription medicines aches when used without any analgesics (Coppola et al 1995). However, there is limited evidence of the efﬁcacy Simple analgesia (paracetamol, aspirin and ibuprofen) of oral prochlorperazine in migraine headaches. Despite has shown clinical beneﬁt in relieving some migraine this, the Therapeutic Guidelines recommend the addition attacks and should be taken as early as possible. Approxi- of prochlorperazine to simple analgesics if nausea is a mately 60% of patients can expect a reduction in the problem in patients with a migraine. severity of pain from moderate/severe to mild/none 2 hours after treatment but only a quarter of patients will Summary be pain-free within 2 hours. Because migraine is associ- ated with gastric stasis standard OTC doses might be Simple analgesics are suitable for tension headaches and inadequate to relieve migraine symptoms. Only one for some patients with migraines. There is insufﬁcient product, paracetamol plus metoclopramide, is speciﬁcally evidence to support the claim that non-prescription com- marketed OTC to aid relief from pain and nausea associ- bination analgesics containing low doses of codeine are ated with migraine. Prochlorperazine in packs of 10 or stronger than simple analgesics alone, and they are likely less tablets is approved for OTC use in the treatment of to cause more side-effects. From the limited trial data nausea associated with migraine. reviewed it appears that paracetamol plus metoclopra- A systematic review investigating comparative efﬁ- mide, or the addition of prochlorperazine to simple anal- cacy of simple analgesics for episodic tension-type head- gesics such as paracetamol or ibuprofen, may be useful ache concluded that all simple analgesics had similar in patients with mild to moderate migraine who suffer efﬁcacy (measured as >50% pain relief) (Verhagen et al nausea/vomiting as part of their migraine attack. 2006). However, the authors did suggest that ibuprofen However, if nausea or vomiting were a prominent feature might be more effective than paracetamol. Combinations of a migraine attack, referral to a doctor would be of simple analgesics with codeine have been promoted required as rectal or parenteral routes for administering for ‘strong pain’. However, there is doubt whether the metoclopramide or prochlorperazine are required. amount of codeine in these preparations is sufﬁcient to provide any additional pain relief. Further, there is Practical prescribing and product selection growing evidence of problems with the over-use of these products resulting from dependence on the codeine com- Prescribing information relating to speciﬁc products used ponents (Frei et al 2010). In response to the ongoing to treat migraine in the section ‘Evidence base for non- concerns about the over-use of codeine-containing prod- prescription medicines’ is discussed and summarised in ucts, all non-prescription analgesic products containing Table 4.5, and useful tips relating to medication overuse codeine were rescheduled in Australia and New Zealand headaches are given in Hints and Tips Box 4.1. Prescrib- in 2010 to require their sale only with the involvement ing information relating to simple analgesics used for of the pharmacist. Combinations of paracetamol and caf- episodic tension headaches can be found in Chapter 8 feine are also promoted for strong pain relief. However, under acute low back pain (page 246) and in Table 8.2. © 201 2012 2 Els Elsevi evier er Aus Austra tralia lia Headache 85 Table 4.5 Practical prescribing: Summary of medicines for migraine Patients in whom Drug interactions care should be Medicine Use in children Likely side-effects of note exercised Pregnancy Paracetamol and >12 years Sedation; occasional Increased sedation Young adults, Category A, but metoclopramide dystonic reactions with alcohol, particularly young manufacturer opioid analgesics, women warns against anxiolytics, use hypnotics and antidepressants Prochlorperazine >2 years; >12 Sedation, dry mouth, Drugs that Very young and Category C; years for buccal possible Parkinson- prolong QT elderly avoid preparation like symptoms interval, levodopa HINTS AND TIPS BOX 4.1: MIGRAINE Simple analgesia Recommend a soluble formulation to maximise the absorption of analgesic before it is inhibited by gastric stasis, and instruct to patient to take the dose as soon as possible when the symptoms start 4 Codeine-containing Doses of codeine of greater than 30 mg are generally needed to provide any additional preparations analgesic effect over and above that from simple analgesics alone. Further, in migraine codeine can worsen nausea and vomiting. Therefore, codeine-containing analgesics are best avoided. Prevention of migraine Patients should be encouraged to identify and avoid triggers such as certain foods, stress, and overworking. Relaxation therapy and yoga may help some patients Metoclopramide plus paracetamol recommended adult dose is one or two tablets (5–10mg), two or three times a day. In an acute attack four tablets The non-prescription products are approved for use in (20mg) can be taken. The dose for children over 2 years adults, and children over 12 years of age. The recom- is 250 micrograms/kg two or three times a day. However, mended dose for adults is one or two tablets/capsules to given the increased risk of extra-pyramidal side-effects start, then one or two tablets/capsules every 4 hours as in children it is probably best avoided. The buccal dose required, with a maximum of six tablets in 24 hours. The for adults and children over 12 years is one to two tablets dose for adolescents aged 12 to 17 years is one tablet to (3–6mg) placed in the buccal cavity twice a day. Like start and then one tablet every 4 hours as required, with metoclopramide it can cause dystonic reactions, and a maximum of three tablets per day. At therapeutic doses occasionally can prolong QT interval. Prochlorperazine is metoclopramide and paracetamol are generally well tol- best avoided in patients who are pregnant or breast erated. However, up to 10% of people may suffer drowsi- feeding. ness and fatigue due to the metoclopramide. A rare side-effect of metoclopramide is dystonic reactions. These Complementary therapies are more common in younger people ( 3 weeks Signs of anxiety or Yes Refer factors depression No No Treat ❷ Yes Altered sleep Drug induced Yes pattern Contact GP to No No review the management Treat ❸ Yes Stress related Underlying of the patient condition Yes No No Treat ❸ Yes Poor sleep Refer hygiene Refer No No Drug induced Yes 4 Fig. 4.4 Primer for differential diagnosis of insomnia. ❶ No cases of insomnia lasting longer than 3 weeks should be ❷ Patients should not take antihistamines for more than 7 to 10 treated with non-prescription medicine. If a previously undiagnosed continuous days as tolerance to their effect can develop. medical condition is suspected, most often

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