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
201
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© 201
2012
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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
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Contents
Preface
Preface to the UK edition
Introduction
How to use this book
Acknowledgements
UK acknowledgements
Useful websites
vii
viii
ix
xiii
xvi
xvii
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
Abbreviations
Glossary of terms
Index
307
313
315
317
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Preface
Community pharmacy has evolved significantly over the
last few decades. Although the role of pharmacists in
delivering primary healthcare has been longstanding, the
demand for self-care in the community has increased
dramatically. In Australia it is estimated that over $4
billion is spent annually on self-care items, most of
which are medicines. This contrasts with just over $8
billion spent annually on medicines subsidised on prescription by the government through the Pharmaceutical
Benefits Scheme.
A number of factors have influenced the trend towards
greater self-care, including increased patient autonomy,
better access to information about treatments and the
availability of more effective non-prescription medicines.
The latter has come about partly through the rescheduling of prescription medicines to non-prescription. Pharmacists in Australia and New Zealand are in a unique
position in that the scheduling of medicines in these
countries includes a special classification, Pharmacist
Only (or Restricted in NZ), which falls between the Prescription Only and Pharmacy Only schedules, and requires
involvement of the pharmacist in their sales. This contrasts with the UK, which only has Prescription Only and
Pharmacy classifications, and the USA, where medicines
are either Prescription Only or they can be sold in a range
of retail outlets. Drugs that fall into the Pharmacist Only
category are those that, it has been decided, would benefit
from the input of the pharmacist. This should be seen as
a privilege, and not be taken for granted. It is important
that pharmacists use this opportunity to demonstrate that
the public gains by these additional restrictions.
Some may argue that community pharmacy has clear
conflicts of interest. On the one hand, as a healthcare
professional, the health and safety of the patient are
paramount. However, as a retailer, profitability and
making sales are important. Community pharmacists
make a significant amount of their income by selling
things, in contrast to other healthcare professionals who
are largely remunerated for their cognitive services.
Therefore, it is important that, when assisting the public
in making choices about purchasing medicines, pharmacists ensure their advice and guidance is based on the
best available evidence to maximise the outcomes for the
patient. It is hoped that this book will help pharmacists,
both practising and in training, to diagnose and differentiate problems that are amenable to self-care, and then
make choices of appropriate management that have evidence to support their efficacy.
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David Newby
Introduction
Community pharmacists are the most accessible healthcare professionals. No appointment is needed to consult
a pharmacist and patients can receive free, unbiased
advice almost anywhere. On a typical day a pharmacist
practising in an ‘average’ community pharmacy can realistically expect to help between 5 and 15 patients who
present with various symptoms for which they are seeking
advice, reassurance, treatment or a combination of all
three. Unlike most other healthcare professionals, community pharmacists do not normally have access to the
patient’s medical record and thus have no idea about
what the person’s problem is until a conversation is initiated. This presents the community pharmacist with a great
challenge to correctly differentially diagnose the patient.
Communication skills
For the most part pharmacists will be totally dependent
on their ability to question patients in order to arrive at
a differential diagnosis. This is in stark contrast to the
GP and, to a lesser extent, the nurse, who can draw on
physical examination and diagnostic tests to help them
arrive at a diagnosis. Opportunities for pharmacists to
perform a physical examination are limited by the lack
of privacy within a pharmacy and also a lack of training
in correct examination technique; diagnostic testing is
never employed because of the costs (which would have
to be passed on to the patient) and the invasive nature
of most tests (e.g. blood taking for analysis).
Having said this, a number of studies have shown that,
in more than three-quarters of all cases, taking a patient
history alone will result in the correct diagnosis. This
figure rises slightly if a history is supplemented with a
physical examination and yet further if laboratory investigations are also conducted.
It is vital, therefore, that pharmacists possess excellent
communication skills to ensure the correct information is
obtained from the patient. This will be drawn from a
combination of good questioning technique, listening
actively to the patient and picking up on non-verbal cues.
In addition to having skills in listening, the pharmacist
must also be able to communicate information to the
patient. While this is often done verbally, it is important
that, where appropriate, written information is provided
to back up any verbal instructions. Many of the websites
provided at the end of each disease state and in the
‘Useful websites’ section of this book provide links to
additional information to supplement counselling. Also,
all Pharmacist Only medicines in Australia are required
to have a Consumer Medicines Information leaflet, as do
some Pharmacy Only medicines. If appropriate, these
should also be considered. Another good source of written
materials is the Pharmacy Self Care fact sheets, available
through the Pharmaceutical Societies in Australia and
New Zealand (see www.psa.org.au and www.psnz.org.nz).
Approaches to differential diagnosis
Try to avoid using acronyms
Traditionally, the use of acronyms has been advocated to
help pharmacists remember what questions to ask a
patient. However, it is important that pharmacists do not
rely solely on acronyms in trying to differentially diagnose a person’s presenting complaint; acronyms are rigid,
inflexible and often inappropriate. Every patient is different and therefore it is unlikely that an acronym can
be fully applied and, more importantly, using acronyms
can mean that you miss vital information that could
shape your course of action. Some of the more commonly
used acronyms are discussed briefly below.
WWHAM
This is the simplest acronym to remember but it is also
the worst one to use. It gives the pharmacist very limited
information from which to work and it is unlikely that a
correct differential diagnosis will be made. If used at all,
it should be with caution and it is probably only useful
for counter assistants to use when a patient first presents,
so that a general picture of the person’s presenting complaint can be established.
Meaning of the letter
W Who is the patient?
W What are the symptoms?
H How long have the
complaint symptoms
been present?
A Action taken?
M Medication being taken?
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Attributes of the acronym
Positive points
Establishes presenting
Negative points
Fails to consider general
appearance of patient. No
social/lifestyle factors taken
into account; no family
history sought; not specific
or in-depth enough; no
history of previous symptoms
x
Introduction
Other acronyms that have been suggested as being
helpful for pharmacists in differential diagnosis are
ENCORE, ASMETHOD and SIT DOWN SIR. Although
these three acronyms are more comprehensive than
WWHAM, they are still limited. No one acronym takes
into consideration all of the factors that might impinge
on the differential diagnosis. All fail to establish a full
history from the patient in respect to lifestyle and social
E
N
C
O
R
E
Meaning of the letter
Attributes of the acronym
Explore
No medication
Care
Observe
Refer
Explain
Positive points
‘Observe’ section suggests
taking into account the
appearance of the patient
– does he or she look very
unwell?
Negative points
Sections on ‘No medication’
and ‘Refer’ add little to the
differential diagnosis
process. No social/lifestyle
factors taken into account;
no family history sought
A
S
M
E
T
H
O
D
Meaning of the letter
Attributes of the acronym
Age/appearance?
Self or someone else?
Medication?
Extra medicines?
Time persisting?
History?
Other symptoms?
Danger symptoms?
Positive points
Establishes the nature of the
problem and if the patient
has suffered from previous
similar episodes
Negative points
Exact symptoms and severity
not fully established. No
social/lifestyle factors taken
into account; no family
history sought
Meaning of the letter
Attributes of the acronym
S
I
T
D
O
Site or location?
Intensity or severity?
Type or nature?
Duration?
Onset?
Positive points
Establishes the severity and
nature of problem and if
the patient has suffered
from previous similar
episodes
W
N
S
I
With (other symptoms)?
Annoyed or aggravated?
Spread or radiation?
Incidence or frequency
pattern?
Relieved by?
R
Negative points
Fails to consider general
appearance of patient. No
social/lifestyle factors
taken into account; no
family history sought
factors or the relevance of a family history. They are very
much designed to establish the nature and severity of the
presenting complaint. This, in many instances, will be
adequate but for intermittent conditions (e.g. irritable
bowel syndrome, asthma, hayfever) they might well miss
important information. Likewise, positive family history
with certain conditions (e.g. psoriasis, eczema) provides
useful clues in establishing a diagnosis.
The Pharmaceutical Society of Australia has developed a protocol for non-pharmacist staff for both symptom-based requests and product-specific requests. The
protocol is based around the words WHAT, STOP and GO:
WHAT – what is the problem
STOP – assess the situation
GO
– proceed if appropriate
The acronyms WHAT and STOP stand for:
Meaning of the letter
W
H
A
T
Who is the patient?
How long have they had the symptoms?
Actual symptoms – what are they?
Treatment for this or any other conditions?
S
T
O
P
Symptoms that should be referred
Totally sure?
Overuse or abuse?
Pharmacist only or pharmacist preferred*
*Where the patient expresses a desire to speak to the pharmacist
If non-pharmacist staff encounter any of the STOP conditions they should refer to the pharmacist. This protocol
is aimed at screening patients, and pharmacists are
encouraged to use the guide to develop protocols in
specific areas of the pharmacy.
Clinical decision making
Whether we are conscious of it or not, most people will
– at some level – use clinical decision making to arrive
at a differential diagnosis. Diagnostic reasoning is a component of clinical decision making and involves recognition of cues and analysis of data. Very early in a clinical
encounter, and based on limited information, a pharmacist will arrive at a small number of hypotheses. The
pharmacist then sets about testing these hypotheses by
asking the patient a series of questions. The answer to
each question allows the pharmacist to narrow down the
number of possible diagnoses either by eliminating particular conditions or confirming his or her suspicions of
a particular condition. Once the questioning is over, the
pharmacist should be in a position to differentially diagnose the patient’s condition.
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Introduction
xi
● epidemiology states that tension headache is most
Key steps in the process
1. Formulating a diagnosis based
on the patient and the initial presenting
complaint
Before any questions are asked of the patient you should
think about the line of questioning you are going to take:
● What is the general appearance of the patient? Does
the person look well or unwell? Is the person you
are about to talk to the patient or someone acting
on the patient’s behalf? This will shape your
thinking as to the severity of the problem.
● How old is the patient? This is very useful
information. Epidemiological studies for a wide
range of conditions and disease states have shown
that certain age groups will suffer from certain
problems. For example, it is very unlikely that a
child who presents with cough will have chronic
bronchitis but the probability of an elderly person
having chronic bronchitis is much higher.
● What sex is the patient? As with age, sex can
dramatically alter the chances of suffering from
certain conditions. Migraines are five times more
common in women than men, yet cluster headache
is nine times more common in men than women.
● What is the presenting complaint? Some conditions
are much more common than others. Therefore you
could form an idea of what condition the patient is
likely to be suffering from based on the laws of
probability. For example, if a person presents with a
headache then you should already know that the
most common cause of headache is tension
headache, followed by migraine and then cluster
headache. Other causes of headache are rare but
obviously need to be eliminated. Your line of
questioning should try to confirm or refute the most
likely causes of headache.
2. Asking questions
The questions you ask the patient will be specific to that
patient. After establishing who the person is, how sick
he or she is and what the presenting complaint is, a
number of targeted questions specific to that patient
should be asked. The following scenario will illustrate this
point:
A 31-year-old female asks for advice about a headache she has.
What are your initial thoughts? (1. Formulating a
diagnosis based on the patient and the initial presenting
complaint):
● the patient is present
● the patient is female and in her early thirties
● the patient looks and sounds OK
likely but females are more prone to migraine than
males.
What line of questioning do you take? (2. Asking questions.) Your main aim is to differentiate between tension
and migraine headache:
Nature of the pain
Tension headache usually produces a dull ache, as
opposed to the throbbing nature of migraine pain:
● patient’s response: dull ache
● pharmacist’s thoughts: suggestive of tension
headache.
Location of the pain
Tension headache is generally bilateral; migraine is often
unilateral:
● patient’s response: all over
● pharmacist’s thoughts: suggestive of tension
headache.
Severity of pain
Tension headache is not usually severe and disabling;
migraine can be disabling:
● patient’s response: bothersome more than stopping
her doing things
● pharmacist’s thoughts: suggestive of tension
headache.
The answers so far are indicative of tension headache.
However, further specific questions relating to lifestyle
and previous and family history should be asked. It would
be expected that there was no family history of migraine
and there is probably some trigger factor causing the
headache, for example increased stress due to work or
personal pressures. The patient might therefore have had
similar headaches in the past.
Finally, even though at this stage you are confident of your differential diagnosis you should still
ask a couple of questions to rule out any sinister
pathology. Obviously you are expecting the answers
from these questions to be negative to support your
differential diagnosis. Any questions that invoke
the opposite response to that expected will require
further investigation.
3. Confirming facts
Before making a recommendation to the patient it is
always helpful to try and recap the information elicited.
This is especially important when you have had to ask a
lot of questions. It is well known that short-term working
memory is relatively small and that remembering all the
pertinent facts is difficult. Summarising the information
at this stage will not only help you formulate your final
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xii
Introduction
diagnosis but will also allow the patient to add further
information or to correct you on facts that you have
failed to remember correctly.
The way in which one goes about establishing what
is wrong with the patient will vary from practitioner to
practitioner. However, it is important that whatever
method is adopted it must be sufficiently robust to be of
benefit to the patient. Using a clinical decision-making
approach to differential diagnosis allows you to build a
fuller picture of the patient’s presenting complaint. It is
both flexible and specific to each individual, unlike
acronyms.
Product-based requests
Many people will come into a pharmacy to purchase
a specific product. Pharmacists should never assume
that just because the patient has heard of, or used, the
product before that they are adequately informed about
the medicine. It is important that product-specific requests
are treated with the same rigour as symptom-based
requests. Pharmacists should establish whether use of the
product is appropriate. Inappropriate use in this context
is not related only to overuse or abuse, but also includes
using the wrong product for the symptoms, or not using
the product in the optimal way (e.g. using analgesics
intermittently when regular use for short periods of time
is more appropriate to break the pain cycle). After establishing who the medicine is for, and whether they have
used it before, it is important that questions about the
complaint being treated are asked including the severity
and duration, anything they have tried so far, and what
other medical conditions and medicines they may take.
Only after establishing that use is appropriate should the
sale proceed.
Documentation
It is important that pharmacists document their activities. Apart from the legal requirements for documentation, such as the recording of the sales of certain
Pharmacist Only medicines, professional standards and
the Competency Standards for Pharmacists all state the
need to maintain adequate records. This includes documenting overuse or inappropriate use of medicines,
treatment plans, required follow-up of patients and
referrals or discussions with healthcare professionals.
This may be done electronically using the patient
records of the dispensing computing system or in paper
form, such as pre-printed referral forms. The latter are
available from some of the suppliers of pharmacy
stationery.
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How to use this book
This book is divided into ten chapters. The first nine
are systems based and structured in the format shown in
Figure 1. The final chapter is product based and has a
slightly different format. A list of abbreviations and a
glossary are included at the end of the book.
doesn’t know where the kidneys are. However, this book
is not intended to replace an anatomy text and the reader
is referred to the list of further reading for anatomy texts.
Self-assessment questions
Key features of each chapter
At the beginning of each chapter a short section addressing basic anatomy and history taking specific to that
body system is presented. A basic understanding of
the anatomical location of major structures is useful
when attempting to diagnose/exclude conditions from a
patient’s presenting complaint. It would be almost impossible to know whether to treat or refer a patient who
presented with symptoms suggestive of renal colic if one
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
Twenty multiple choice and at least two case study questions are presented at the end of each chapter. These are
designed to test factual recall and applied knowledge.
They start with simple traditional multiple choice questions in which the right answer has to be picked from a
series of five possible answers, and work up to more
complex, interrelated questions.
The case studies challenge you with ‘real-life’ situations. All are drawn from practice and have been encountered by practising pharmacists, but have been modified
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.
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xiv
How to use this book
for inclusion in the book. For all questions, a set of
answers is provided at the end of the book to allow
self-reflection.
Elements included under
each condition
The same structure has been adopted for every condition.
This is intended to help the reader approach differential
diagnosis from the position of clinical decision-making.
To help summarise the information, tables and algorithms
are included for many of the conditions.
Arriving at a differential diagnosis
A table summarising the key questions that should be
asked for each condition is included. The relevance (i.e.
the rationale for asking the question) is given for each
question. This will allow pharmacists to determine what
questions to ask of every patient to enable a differential
diagnosis.
For some conditions, such as those that affect the eye
and some skin conditions, it will be possible for the
pharmacist to have a look at the affected area. We would
encourage pharmacists to examine these conditions if
possible—to assist in this, photographs demonstrating
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
may not present with ‘classical’ signs, and careful questioning is usually required to help reach a differential
diagnosis.
Primer for differential diagnosis
A ‘primer for differential diagnosis’ is available for a
number of the conditions covered. This algorithmic
approach to differential diagnosis is geared towards
nearly or recently qualified pharmacists. This feature is
not intended to be solely relied upon in making a differential diagnosis but to act as an aide memoire. It is anticipated that the primers will be used in conjunction with
the text, thus allowing a broader understanding of the
differential diagnosis of the condition being considered.
Trigger points indicative of referral
A summary box of trigger factors when it would be
prudent to refer the patient to a medical practitioner is
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
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How to use this book
Evidence-based non-prescription
medicines and practical prescribing
and product selection
xv
Hints and tips boxes
These two sections present the reader, first, with an evaluation of the current literature on whether a nonprescription medicine works and, second, with a quick
reference to the dose of the medicine and when it cannot
be prescribed. This does not replace textbooks such as
Stockley’s drug interactions or Briggs’ Drugs in pregnancy
and lactation, but it does allow the user to find basic data
in one text without having to reach for three or four
other texts to answer simple questions.
The pregnancy recommendations in this book are
based largely on those of the Australian Drug Evaluation Committee’s (ADEC) Pregnancy Categories (Table 1).
In some instances respected evidence-based texts, such
as the Australian Medicines Handbook, have taken a
more pragmatic approach and have suggested limited
use in pregnancy may be appropriate despite not having
an ADEC category of A. In these instances this is noted
in the summary tables. However, given that pharmacists
should only be managing minor, self-limiting conditions, it is prudent that no medicines are recommended
in the first trimester, unless they carry an ADEC category of A.
A summary box of useful information is provided near
the end of each condition. This contains information that
does not fall readily into any of the other sections but is
none the less useful. For example, some of the hints and
tips boxes give advice on how to administer eye drops,
suppositories and other forms of medicines that are not
taken via the oral route.
References, further reading and web sites
To supplement the text, at the end of each condition a
list of selected references and reading is provided for
those who wish to seek further information on the subject.
Web sites are also provided, as many people now have
internet access. All the sites have been checked and were
active and relevant at the time of writing (January 2011).
Finally, all information presented in the book is accurate and factual as far as the authors are aware. It is
acknowledged that guidelines change, products become
discontinued and new information becomes available
over the lifetime of a book. Therefore, if any information
in the book is not current or valid, the authors would be
grateful of any feedback, positive or negative, to ensure
that the next edition is as up-to-date as possible.
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Chapter
4
Central nervous system
In this chapter
Background 77
General overview of CNS anatomy 77
History taking 77
Headache 77
Insomnia 86
Self-assessment questions
Background
92
Headache
The number of patient requests for advice and/or products to treat headache and insomnia makes up a smaller
proportion of a pharmacist’s workload than other conditions such as coughs and colds – yet sales for analgesics
and hypnotics are extremely high. The vast majority of
patients will present with benign and non-serious conditions and in only very few cases will sinister pathology
be responsible.
Background
Headache is not a disease state or a condition but rather
a symptom, of which there are many causes. Headache
can be the major presenting complaint, for example in
migraine, tension and cluster headache, or one of many
symptoms, for example in an upper respiratory tract
infection.
Headache classification
General overview of CNS anatomy
The central nervous system (CNS) comprises the brain
and spinal cord. Its major function is to process and
integrate information arriving from sensory pathways
and communicate an appropriate response back via afferent pathways. CNS anatomy is complex and beyond the
scope of this book. The reader is referred to any good
anatomical text for a comprehensive description of CNS
anatomy.
History taking
A differential diagnosis for all CNS conditions will
be made solely from questions asked of the patient.
It is especially important that a social and workrelated history is sought alongside questions asking
about the patient’s presenting symptoms because pressure and stress are implicated in the cause of CNS
conditions.
If the pharmacist is to advise on appropriate treatment
and referral then it is essential to make an accurate diagnosis. However, with so many disorders having headache
as a symptom, pharmacists should endeavour to follow
an agreed classification system. The 2nd edition of the
International Headache Society (IHS) classification is now
almost universally accepted (Table 4.1). The system first
distinguishes between primary and secondary headache
disorders. This is useful to the community pharmacist, as
any secondary headache disorder is symptomatic of an
underlying cause and would normally require referral. In
the IHS system, primary headaches are classified on
symptom profiles, relying on careful questioning coupled
with epidemiological data on what the distribution of a
particular headache disorder has within the population.
Prevalence and epidemiology
The exact prevalence of headache is not precisely known.
However, virtually everyone will have suffered from a
headache at some time; it is probably the most common
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78
Central nervous system
Table 4.1
IHS Classification of headache
Primary
headache
disorders
1. Migraine, including:
1.1 Migraine without aura
1.2 Migraine with aura
2. Tension-type headache, including:
2.1 Infrequent episodic tension-type
headache
2.2 Frequent episodic tension-type
headache
2.3 Chronic tension-type headache
Secondary
headache
disorders
5. Headache attributed to head and/or neck
trauma, including:
5.2 Chronic post-traumatic headache
6. Headache attributed to cranial or cervical
vascular disorder, including:
6.2.2 Headache attributed to subarachnoid
6.4.1 Headache attributed to giant cell
arteritis
7. Headache attributed to non-vascular
intracranial disorder, including:
7.1.1 Headache attributed to idiopathic
intracranial hypertension
7.4 Headache attributed to intracranial
neoplasm
8. Headache attributed to a substance or its
withdrawal, including:
8.1.3 Carbon monoxide-induced headache
8.1.4 Alcohol-induced headache
Neuralgias and
other headaches
13. Cranial neuralgias, central and primary
pain and other headaches including:
13.1 Trigeminal neuralgia
3. Cluster headache and other trigemina
autonomic cephalalgias, including:
3.1 Cluster headache
4. Other primary headaches
8.2 Medication-overuse headache
8.2.1 Ergotamine-overuse headache
8.2.2 Triptan-overuse headache
8.2.3 Analgesic-overuse headache
9. Headache attributed to infection, including:
9.1 Headache attributed to intracranial
infection haemorrhage
10. Headache attributed to disorder of
homeostasis
11. Headache or facial pain, attributed to
disorder of cranium, neck, eyes, ears, nose,
sinuses, teeth, mouth or other facial or
cranial structures including:
11.2.1 Cervicogenic headache
11.3.1 Headache attributed to acute
glaucoma
12. Headache attributed to psychiatric disorder
14. Other headache, cranial neuralgia, central
or facial primary facial pain
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
Heywood and others (1998) involving 1717 individuals
in Melbourne, Australia, found 87% reported at least one
headache in the previous year. They also found that more
than 1 in 10 had sought advice from a pharmacist about
their headache.
Tension headache has been reported to affect between
40 and 90% of people in Western countries at some time
in their life. Migraine affects approximately 15% of
women, in whom it is three times more common than
in men. Prevalence peaks between 30 to 40 years of
age. Conversely, cluster headache which is also more
prevalent in the 30 to 40 year-old age group, is five to
six times more prevalent in men.
Aetiology
Considering headache affects almost everyone, the mechanisms that bring about headache are still poorly
understood. Pain control systems modulate headaches of
all types, independent of the cause. However, the exact
aetiology of tension headache and migraine are still to
be fully elucidated. Tension headache is commonly
referred to as muscle contraction headache, as electromyography has shown pericranial muscle contraction,
which is often exacerbated by stress. However, similar
muscle contraction is noted in migraine sufferers and this
theory has now fallen out of favour. Consequently, no
current theory for tension headache is unanimously
endorsed but recent studies suggest a neurobiological
basis.
Traditionally, migraine was thought to be a result of
abnormal dilation of cerebral blood vessels but this vascular theory cannot explain all migraine symptoms. The
use of 5 HT1 agonists to reduce and stop migraine attacks
suggests some neurochemical pathophysiology. Migraine
is therefore probably a combination of vascular and neurochemical changes – the neurovascular hypothesis.
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Migraine also appears to have a genetic component with
about 70% of patients having a first-degree relative with
a history of migraine.
Arriving at a differential diagnosis
Given that headache is extremely common, and most
patients will self-medicate, any patient requesting advice
should ideally be seen by the pharmacist, as it is likely
that the headache has either not responded to nonprescription medicine or is troublesome enough for the
patient to seek advice. Arrival at an accurate diagnosis
will rely on careful questioning; therefore, a number of
headache-specific questions should be asked (Table 4.2).
In addition to these symptom-specific questions, the
pharmacist should also enquire about the person’s social
history because social factors – mainly stress – play a
significant role in headache. Ask about the person’s work
and family status to determine if the person is suffering
from greater levels of stress than normal. Although
careful questioning is important, many patients who
79
present with headaches can be defensive, especially if
they feel they are undergoing an ‘inquisition’. Therefore,
pharmacists must establish a report with the patient,
while carefully explaining why the information will help
with them assisting the patient.
Clinical features of headache
In a community pharmacy the overwhelming majority of
patients (80–90%) will present with tension headache. A
further 10% will have migraine. Very few will have other
primary headache disorders and fewer still will have a
secondary headache disorder. This part of the text therefore concentrates on migraine, tension and cluster
headaches.
Tension-type headache
Tension-type headaches can be classed as either episodic
or chronic. Episodic tension-type headache can be further
subdivided into infrequent and frequent forms. Most
Table 4.2
Specific questions to ask the patient: Headache
Question
Relevance
Onset of
headache
● In early childhood or a young adult, primary headache is most likely. After 50 years of age the
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
timing
● Headache associated with the menstrual cycle or certain times, e.g. weekend or holidays,
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
(see Fig 4.1)
● Cluster headache is nearly always unilateral in frontal, ocular or temporal areas
● 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
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severely affect the patient’s quality of life and should not
be managed by the community pharmacist.
Tension or migraine
Migraine
Frontal
Cluster, glaucoma, sinusitis
Orbital
Subarachnoid tension,
haemorrhage
Occipital
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 adolescence or as a young adult. Migraines are rare over the
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 headache. If this is not their first attack they will normally
have a history of recurrent and episodic attacks of headache. 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
migraine. However, the major subtypes are migraine
with aura (classical migraine) and migraine without aura
(common migraine). A migraine attack can be divided
into three phases:
● Phase one: premonitory phase (prodrome phase),
Migraine, temporal arteritis
Temporal
Fig. 4.1 Location of pain in headache.
patients will present to the pharmacist with the infrequent episodic form. Headaches last from 30 minutes to
up to 7 days in duration and often the patient will have
a history of recent headaches. They might have tried
non-prescription medicine without complete symptom
resolution or say that the headaches are becoming
more frequent. Pain is bifrontal or bioccipital, generalised
and non-throbbing (Figure 4.1). The patient might
describe the pain as tightness or a weight pressing
down on their head. The pain is gradual in onset and
tends to worsen progressively through the day. Pain is
normally mild to moderate and not aggravated by movement, although it is often worse under pressure or stress.
Nausea and vomiting are not associated with tensiontype headache and it rarely causes photo- or phonophobia. Overall, the headache has only a limited impact on
the individual.
Patients who have frequent episodic tension-type
headaches suffer more frequent headaches that last
longer and over time these can develop into chronic
tension-type headache. These headaches occur for more
than 15 days per month, and might occur daily and last
for at least 3 months. These types of headaches can
which can occur hours or possibly days before the
headache. The patient may complain of a change in
mood or notice a change in behaviour. Feelings of
well-being, yawning, poor concentration and food
cravings have been reported. These prodromal
features are highly individual but are relatively
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.
● Phase three: as the headache subsides the patient
may feel lethargic, tired and drained before recovery,
which may take several hours and is termed the
resolution phase.
Headache with aura (classic migraine)
This accounts for less than 25% of migraine cases.
The aura, which are fully reversible, develops over 5 to
20 minutes and can last for up to 1 hour. It can either
be visual or neurological. Visual auras can take many
guises, such as scotomas (blind spots), fortification
spectra (zig-zag lines) or flashing and flickering lights.
Neurological auras (pins and needles) typically start in
the hand, migrating up the arm before jumping to the
face and lips. Within 60 minutes of the aura ending the
headache usually occurs. Pain is unilateral, throbbing and
moderate to severe. Sometimes the pain becomes more
generalised and diffuse. Physical activity and movement
tends to intensify the pain. Nausea affects almost all
patients but less than a third will vomit. Photophobia
and phonophobia often make patients seek a dark quiet
room to relieve their symptoms. The patient might also
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Table 4.3
Triggers and strategies to reduce migraine attacks
Trigger
Strategy
Stress
●
●
●
●
Diet – any food
could be a potential
trigger but foods
implicated include:
Cheese
Citrus fruit
Chocolate
● Maintain a food diary. If an attack occurs within 6 hours of food ingestion and is
Maintain regular sleep pattern
Take regular exercise
Modify work environment
Relaxation techniques (e.g. yoga)
reproducible it is likely that it is a trigger for migraine
● Eat regularly and do not skip meals
● Note: detecting triggers is complicated because they appear to be cumulative jointly
contributing to a ‘threshold’ above which attacks are initiated
suffer from fatigue, find concentrating difficult and be
irritable.
headache require referral, as OTC management is very
unlikely to be effective.
Headache without aura (common migraine)
Rhinosinusitis
The remaining 75% of sufferers do not experience an
aura but do suffer from all other symptoms as described
above.
The pain tends to be relatively localised, usually orbital,
unilateral and dull. A course of decongestants could be
tried but if treatment failure occurs referral to the GP for
possible antibiotic therapy would be needed. For further
information on rhinosinusitis, see Chapter 1 page 13.
Cluster headache
Cluster headache is predominantly a condition that
affects men over the age of 30 years. Typically the headache occurs at the same time each day with abrupt onset
and lasts between 10 minutes and 3 hours, with 50% of
patients experiencing night-time symptoms. Patients are
woken 2 to 3 hours after falling asleep with steady
intense unilateral orbital boring pain, often described as
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
head as the headache.
The condition is characterised by periods of acute
attacks, typically lasting a number of weeks to a few
months with sufferers experiencing between one and
three attacks per day. This is then followed by periods of
remission, which can last months or years. During acute
phases, alcohol can trigger an attack. Nausea is usually
absent and a family history uncommon.
The key differences between the three conditions are
shown in Table 4.4.
Conditions to eliminate
All suspected secondary causes of headache except
sinusitis and alcohol-induced (‘hangover’) need to be
referred. In addition, patients suffering from cluster
Eye strain
Patients who perform prolonged periods of close work,
for example people who look at computer screens for
extended periods, can suffer from frontal aching headache. In the first instance, patients should be referred to
an optometrist for a routine eye check.
Medication overuse headache
Patients with long-standing symptoms of headache who
medicate regularly, can develop medication overuse
headache (MOH). The exact mechanism of MOH is poorly
understood but may include genetic factors and/or
changes in serotonin receptors that promote pain. Patients
with migraine and tension headaches seem to be at greatest risk. The result is a cycle where patients take more
and more painkillers that are stronger and stronger in
order to control the pain. Patients will experience daily
or near daily headaches that are described as dull and
nagging. Obviously in these cases a medication history
is essential and should prompt the pharmacist to refer
the patient to the GP. Treatment is to stop all analgesia
for a number of weeks and requires careful planning.
However, like many things prevention is better than cure,
and therefore pharmacists should intervene as soon as
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Table 4.4
Difference in symptom presentation for primary headaches
Severity
(pain score
from 0–10)*
Precipitating
factors
Who is
affected
2–5
Stress due to
changes in work or
home environment
All age groups
and both sexes
equally affected
Usually
unilateral
4–7
Food (in 10% of
sufferers) and
family history
Three times
more common
in women. Rare
in children
Unilateral, often
behind the eye
or temples
>7
Alcohol
Three to five
times more
common in men
Duration
Timing and nature
Location
Tensiontype
Can last
days
Symptoms worsen as
day progresses.
Non-throbbing pain
Bilateral and
most often at
back of head
Migraine
Average
attack lasts
24 hours
Associated with
menstrual cycle and
weekends Throbbing
pain and nausea.
Dislike of bright
lights and loud noise
Cluster
1–3 hours
Attacks occur at
same time of day
Intense boring pain
*These are rough guides set by the authors and are not evidence-based
possible if they think someone is over using medicines
for headaches.
unlikely that a patient would present in the pharmacy with
such symptoms but if one did then immediate referral is
needed.
Glaucoma
Patients experience a frontal/orbital headache with pain
in the eye. Sometimes, but not often, the eye appears red
and is painful. Vision is blurred and the cornea can look
cloudy. In addition, the patient might notice haloes
around the vision. For further information on glaucoma
see Chapter 2 page 47.
Meningitis
Severe generalised headache associated with fever, an
obviously ill patient, neck stiffness, a positive Kernig’s
sign (pain behind both knees when extended) and latterly
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
on the chest, looks and feels unwell, has a headache and
a temperature above 38.9°C should be referred urgently
to accident and emergency as the patient can decline
rapidly and has a case fatality rate of 5–10%, higher if
they develop sepsis.
Subarachnoid haemorrhage
The patient will experience very intense and severe pain,
located in the occipital region. Nausea and vomiting
are often present and a decreased level of consciousness
is prominent. Patients often describe the headache as
the worst headache they have ever had. It is extremely
Temporal arteritis
The temporal arteries that run vertically up the side of
the head, just in front of the ear, can become inflamed.
When this happens, they are tender to touch and might
be visibly thickened. Unilateral pain is experienced and
the person generally feels unwell with fever, myalgia and
general malaise. Scalp tenderness is also possible, especially when combing the hair. It is most commonly seen
in the elderly, especially women. Prompt treatment with
oral corticosteroids is required because the retinal artery
can become compromised, leading to blindness. Urgent
referral is needed.
Conditions causing raised
intracranial pressure
Space-occupying lesions (brain tumour, haematoma and
abscess) can give rise to varied headache symptoms,
ranging from severe chronic pain to intermittent moderate pain. Pain can be localised or diffuse and tends to be
more severe in the morning, with a gradual improvement
over the next few hours. Coughing, sneezing, bending
and lying down can worsen the pain. Nausea and vomiting are common. After a prolonged period of time neurological symptoms start to become evident, such as
drowsiness, confusion, lack of concentration, difficulty
with speech and paraesthesia.
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Headache
Any patient with a recent history (last 2 to 3 months)
of head trauma, headache of longstanding duration or
insidious worsening of symptoms, especially decreased
consciousness and vomiting, must be referred for fuller
evaluation.
always unilateral. It is three times more common in
women than men.
Depression
Depression often presents with tension-like headaches.
Check for loss of appetite, weight loss, decreased libido,
sleep disturbances and constipation. If the patient exhibits these characteristics then referral to the GP would
be necessary to determine if the patient is suffering
from depression. Recent changes to the patient’s social
circumstances, for example loss of job, might also support
your differential diagnosis.
Figure 4.2 will help in the differentiation of serious
and non-serious causes of headache.
Trigeminal neuralgia
Pain follows the course of either the second (maxillary
– supplying the cheeks) or third (mandibular – supplying
the chin, lower lip and lower cheek) division of the nerve
leading to pain experienced in the cheek, jaws, lips or
gums. Pain is short-lived, usually lasting only a couple
of minutes, but is severe and lancing and is almost
4
Patient presents
with headache
No
> 50 years
New, severe
headache
Signs of
infection
> 12 years but < 50 years
No
Yes
Refer
❷
Sinister pathology?
Yes
No
Unilateral
pain
Yes
No
Cluster
❶
Age
No
Orbital pain
and tearing
Throbbing
pain
No
No
Temples tender
Nausea and /or
vomiting
Treat
No
Worse when
stressed
Yes
Nausea and/or
vomiting
Yes
Yes
Pain dull and
band-like
Yes
Yes
Refer
Refer
< 12 years
Yes
Tension
headache
Yes
Temporal
arteritis
Refer
❸
Sinister pathology?
Family history
of migraine
No
Yes
Pain worse in
morning
No
Yes
Refer
Sinister pathology?
Migraine
No
Yes
Pain lasts
< 3 days
Fig. 4.2 Primer for differential diagnosis of headache.
❶
Age
Caution should be exercised in children who present with
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).
❷ Referral for suspected sinister pathology
With increasing age it is more likely that a sinister cause of
headache is responsible for the symptoms, especially if the patient
has not experienced similar headache symptoms before. Mass
lesions (tumours and haematoma) and temporal arteritis should be
considered.
❸ Referral for suspected sinister pathology
Nausea and vomiting in the absence of migraine-like symptoms
should be treated seriously. Mass lesions and subarachnoid
haemorrhage need to be eliminated.
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TRIGGER POINTS indicative of referral: Headache
● Headache unresponsive to adequate doses of
analgesics
● Headache in children under 12 years with stiff
neck or skin rash
● Headache occurs after recent (1 to 3 months)
trauma injury
● Headache that has lasted for more than 2 weeks
● Nausea and/or vomiting in the absence of
●
●
●
●
●
migraine symptoms
Neurological symptoms, if migraine excluded,
especially change in consciousness
New or severe headache in patients over 50 years
Progressive worsening of headache symptoms
over time
Symptoms indicative of cluster headache
Very sudden and/or severe onset of headache
the additional benefit appears modest at best (for more
information see lower back pain in Chapter 8, page 246.
It should also be noted that long-term trials are lacking
and therefore the potential for the caffeine to cause a
withdrawal headache, resulting in a cycle of increased
analgesic use as seen with older pain relievers such as
APC powders, has not been fully investigated.
Metoclopramide and paracetamol
The non-prescription preparations contain paracetamol
50 mg and metoclopramide 5 mg per tablet. Although
there is limited data on the efficacy of the combination
product, several evidence-based guidelines, including the
Therapeutic Guidelines and the NPS, advocate the combination of paracetamol and metoclopramide in the treatment of mild/moderate migraine where nausea/vomiting
are present.
Prochlorperazine
Evidence base for
non-prescription medicines
Simple analgesia (paracetamol, aspirin and ibuprofen)
has shown clinical benefit in relieving some migraine
attacks and should be taken as early as possible. Approximately 60% of patients can expect a reduction in the
severity of pain from moderate/severe to mild/none 2
hours after treatment but only a quarter of patients will
be pain-free within 2 hours. Because migraine is associated with gastric stasis standard OTC doses might be
inadequate to relieve migraine symptoms. Only one
product, paracetamol plus metoclopramide, is specifically
marketed OTC to aid relief from pain and nausea associated with migraine. Prochlorperazine in packs of 10 or
less tablets is approved for OTC use in the treatment of
nausea associated with migraine.
A systematic review investigating comparative efficacy of simple analgesics for episodic tension-type headache concluded that all simple analgesics had similar
efficacy (measured as >50% pain relief) (Verhagen et al
2006). However, the authors did suggest that ibuprofen
might be more effective than paracetamol. Combinations
of simple analgesics with codeine have been promoted
for ‘strong pain’. However, there is doubt whether the
amount of codeine in these preparations is sufficient to
provide any additional pain relief. Further, there is
growing evidence of problems with the over-use of these
products resulting from dependence on the codeine components (Frei et al 2010). In response to the ongoing
concerns about the over-use of codeine-containing products, all non-prescription analgesic products containing
codeine were rescheduled in Australia and New Zealand
in 2010 to require their sale only with the involvement
of the pharmacist. Combinations of paracetamol and caffeine are also promoted for strong pain relief. However,
Prochlorperazine given parenterally has been shown in
trials to be effective in reducing pain in migraine headaches when used without any analgesics (Coppola et al
1995). However, there is limited evidence of the efficacy
of oral prochlorperazine in migraine headaches. Despite
this, the Therapeutic Guidelines recommend the addition
of prochlorperazine to simple analgesics if nausea is a
problem in patients with a migraine.
Summary
Simple analgesics are suitable for tension headaches and
for some patients with migraines. There is insufficient
evidence to support the claim that non-prescription combination analgesics containing low doses of codeine are
stronger than simple analgesics alone, and they are likely
to cause more side-effects. From the limited trial data
reviewed it appears that paracetamol plus metoclopramide, or the addition of prochlorperazine to simple analgesics such as paracetamol or ibuprofen, may be useful
in patients with mild to moderate migraine who suffer
nausea/vomiting as part of their migraine attack.
However, if nausea or vomiting were a prominent feature
of a migraine attack, referral to a doctor would be
required as rectal or parenteral routes for administering
metoclopramide or prochlorperazine are required.
Practical prescribing and product selection
Prescribing information relating to specific products used
to treat migraine in the section ‘Evidence base for nonprescription medicines’ is discussed and summarised in
Table 4.5, and useful tips relating to medication overuse
headaches are given in Hints and Tips Box 4.1. Prescribing information relating to simple analgesics used for
episodic tension headaches can be found in Chapter 8
under acute low back pain (page 246) and in Table 8.2.
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Table 4.5
Practical prescribing: Summary of medicines for migraine
Drug interactions
of note
Patients in whom
care should be
exercised
Medicine
Use in children
Likely side-effects
Pregnancy
Paracetamol and
metoclopramide
>12 years
Sedation; occasional
dystonic reactions
Increased sedation
with alcohol,
opioid analgesics,
anxiolytics,
hypnotics and
antidepressants
Young adults,
particularly young
women
Category A, but
manufacturer
warns against
use
Prochlorperazine
>2 years; >12
years for buccal
preparation
Sedation, dry mouth,
possible Parkinsonlike symptoms
Drugs that
prolong QT
interval, levodopa
Very young and
elderly
Category C;
avoid
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
Codeine-containing
preparations
Doses of codeine of greater than 30 mg are generally needed to provide any additional
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
The non-prescription products are approved for use in
adults, and children over 12 years of age. The recommended dose for adults is one or two tablets/capsules to
start, then one or two tablets/capsules every 4 hours as
required, with a maximum of six tablets in 24 hours. The
dose for adolescents aged 12 to 17 years is one tablet to
start and then one tablet every 4 hours as required, with
a maximum of three tablets per day. At therapeutic doses
metoclopramide and paracetamol are generally well tolerated. However, up to 10% of people may suffer drowsiness and fatigue due to the metoclopramide. A rare
side-effect of metoclopramide is dystonic reactions. These
are more common in younger people (<20 years of age),
especially women. Metoclopramide and paracetamol
have a pregnancy category of A and should be safe to
use in pregnancy. However, the manufacturers of both
products warn against the use in pregnancy.
Prochlorperazine
The OTC preparations in Australia contain 5mg of
prochlorperazine, and in New Zealand it is available
as a 5mg tablet or 3mg buccal preparation. The
recommended adult dose is one or two tablets (5–10mg),
two or three times a day. In an acute attack four tablets
(20mg) can be taken. The dose for children over 2 years
is 250 micrograms/kg two or three times a day. However,
given the increased risk of extra-pyramidal side-effects
in children it is probably best avoided. The buccal dose
for adults and children over 12 years is one to two tablets
(3–6mg) placed in the buccal cavity twice a day. Like
metoclopramide it can cause dystonic reactions, and
occasionally can prolong QT interval. Prochlorperazine is
best avoided in patients who are pregnant or breast
feeding.
Complementary therapies
Feverfew (Tanacetum parthenium) is a medicinal herb
used for the treatment of fever, headaches and digestive
problems. It is available in a number of commercially
produced herbal products to prevent migraine. A Cochrane
Review identified five randomised, double-blind trials (n
= 343) comparing feverfew extract or powdered feverfew
to placebo in the prevention of migraine (Pittler & Ernst
2004). The trials ranged from 1 to 6 months, and used a
range of outcome measures and therefore a quantitative
analysis could not be undertaken. However, the authors
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summarised the individual studies and found the results
were mixed, and did not conclusively establish the efficacy of feverfew. The authors concluded that there was
not enough evidence that feverfew was more effective
than placebo in preventing migraine, however there were
no safety issues with its use.
References
Coppola M, Yealy D M, Leibold R A 1995 Randomized,
placebo-controlled evaluation of prochlorperazine versus
metoclopramide for emergency department treatment of
migraine headache. Annals of Emergency Medicine
26(5):541–546
Frei M Y, Nielsen S, Dobbin M D, Tobin C L 2010 Serious
morbidity associated with misuse of over-the-counter
codeine-ibuprofen analgesics: a series of 27 cases. The
Medical journal of Australia 193(5):294
Heywood J, Jolgan T, Coffey C 1998 Prevalence of headache
and migraine in an Australian city. Journal of Clinical
Neuroscience 5:485
Parry T G 1992 The prevalence and costs of migraine in
Australia. Centre for Applied and Economic Research
working paper. CAER, University of New South Wales,
Sydney
Pittler MH, Ernst E 2004 Feverfew for preventing migraine.
Cochrane Database of Systematic Reviews, Issue 1.
Art. No.: CD002286. DOI: 10.1002/14651858.CD002286.
pub2
Verhagen AP et al 2006 Is any one analgesic superior for
episodic tension-type headache? Journal of Family
Practice 55(12):1064
Further reading
[Anonymous] 1973 Reports from the general practitioner
clinical research group. Migraine treated with an
antihistamine-analgesic combination. Practitioner
211:357–361
Adam E I 1987 A treatment for the acute migraine attack.
Journal of International Medical Research 15:71–75
Analgesic Expert Group 2002 Acute Migraine Attack. In:
Therapeutic guidelines: Analgesic. Version 4. Therapeutic
Guidelines Limited, Melbourne, pp 281–283
Carasso R L, Yehuda S 1984 The prevention and treatment of
migraine with an analgesic combination. British Journal
of Clinical Practice 38:25–27
Coutin I B, Glass S F 1996 Recognizing uncommon headache
syndromes. American Family Physician 54:2247–2252
Dowson A J 2002 Headache (1) Migraine. Pharmaceutical
Journal 268:141–143
Dowson A J 2002 Headache (2) Non-migraine headache.
Pharmaceutical Journal 268:176–178
Headache Classification Committee of the International
Headache Society 1998 Classification and diagnostic
criteria for headache disorders, cranial neuralgia and
facial pain. Cephalalgia 8:S1–S96
Mathew N T 1997 Cluster headache. Seminars in Neurology
17:313–323
NPS 2005 Headache and Migraine: NPS News 38. Online.
Available: www.nps.org.au Dec 2006
Silberstein S D, Lipton R B, Goadsby P J et al 1999 Headache
in primary care. Isis Medical Media, Oxford
Williams D 2005 Medication Overuse Headache. Australian
Prescriber 28:143–145
Web sites
International Headache Society: www.i-h-s.org
Information on medication overuse headache: www.prodigy.
nhs.uk/qrg/headache_medication_overuse.pdf
General information on headache and migraine:
www.headache.com.au
NSW Therapeutic Assessment Group patient information
leaflet: www.clininfo.health.nsw.gov.au/nswtag/
publications/guidelines/migraine_patient.pdf
Insomnia
Background
The length of sleep people need varies but typically
people aged between 20 and 45 years require 7 to 8 hours
per day, although 10% of people can function on less
than 5 hours per night. Sleep requirements also decrease
with increasing age and people over 70 commonly have
6 hours sleep per day. Insomnia is classified by its duration: transient (a few days), short-term (up to 3 weeks)
or chronic (greater than 3 weeks). It is likely that everyone at some point will experience insomnia because this
can arise from many different causes (Figure 4.3) but for
most people the problem will be of nuisance value only,
affecting next-day alertness. The pharmacist can manage
most patients with transient or short-term insomnia;
however, cases of chronic insomnia are best referred to
the GP, as there is usually an underlying cause.
Prevalence and epidemiology
Up to 25% of Australians report having sleep difficulty
(Tiller 2003). Similar rates have been found in New
Zealand. However a study found rates in Maori populations to be significantly higher than those in non-Maori
populations (33% vs 26.4%) (Paine et al 2005). Insomnia
is more common in women and is more prevalent, in
both sexes, with increasing age.
Aetiology
Sleep is essential to allow the body to repair and restore
brain and body tissues. The mechanisms controlling sleep
are complex and not yet fully understood but reflect
disturbances of arousal and/or sleep systems in the brain.
Their relative activities determine the degree of alertness
during wakefulness and the depth and quality of sleep.
Therefore insomnia may be caused by any factor that
increases activity in arousal systems or decreases activity
in sleep systems.
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Insomnia
Underlying medical
conditions
Biological:
Ageing, pregnancy
Medicines
Insomnia
Environment
Noise
Altered patterns
e.g. shifts
87
Behavioural
e.g. children
Poor sleep hygiene
Psychological
e.g. stress
Mental health
e.g. depression
4
Fig. 4.3 Causes of insomnia.
Table 4.6
Specific questions to ask the patient: Sleep
Question
Relevance
Pattern of sleep
An emotional disturbance (predominantly anxiety) is commonly associated in patients who find it
difficult to fall asleep; patients who fall asleep but wake early and cannot fall asleep again, or
who are then restless, are sometimes suffering from depression
Daily routine
Has there been any change to the work routine – changes to shift patterns, additional workload
resulting in longer working hours and greater daytime fatigue
Too much exercise of intellectual arousal prior to going to bed can make sleep more difficult
Underlying
medical
conditions
Medical conditions likely to cause insomnia are gastrooesophageal reflux disease, pregnancy,
pruritic skin conditions, pregnancy, asthma, Parkinson’s disease, painful conditions (e.g.
osteoarthritis), hyperthyroidism (night sweats), menopausal symptoms (hot flushes) and depression
Recent travel
Time zone changes will affect the person’s normal sleep pattern and it can take a number of days
to re-establish normality
Daytime sleeping
Elderly people might ‘nap’ through the day, which results in less sleep needed in the evening,
making patients think they have insomnia
Arriving at a differential diagnosis
The key to arriving at a differential diagnosis is to take
a detailed sleep history. Asking symptom-specific questions will help the pharmacist to determine if referral is
necessary (Table 4.6). Two key features of insomnia need
to be determined: the type of insomnia and how it affects
the person. Transient insomnia is often caused by a
change of routine, for example time zone changes or a
change to shift patterns, excessive noise, light, sleeping
in a new environment (e.g. hotel room) or extremes of
temperature. Short-term insomnia is usually related to
acute stress such as sitting exams, bereavement, loss of
job, forthcoming marriage or house move. Asking the
patient to tell you what they are thinking about before
they fall asleep and when they awake will give you a
clue to the cause of the insomnia. Often it can be difficult
to determine a cause of the insomnia and getting the
patient to keep a sleep diary (retiring and waking times,
time taken to fall asleep, etc.) is sometimes beneficial as
it allows an objective measure of the person’s habits
compared to their subjective perceptions.
Clinical features of insomnia
Insomnia is a subjective complaint of poor sleep in
terms of its quality and duration. Patients will complain
of difficulty in falling asleep, staying asleep or lack
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refreshment by sleep. Sometimes patients will experience
daytime fatigue but not generally sleepiness. This tiredness can lead to poor performance at work.
Conditions to eliminate
Insomnia in children
Bedwetting is the most common sleep arousal disorder in
children. If this is not the cause, then insomnia invariably
stems from a problem such as fear of the dark, insecurity
or nightmares. Children should not be given sleep aids
but referred to their GP for further evaluation, as the
underlying cause needs to be addressed.
Depression
It is well known that between one-third and two-thirds
of patients suffering from chronic insomnia will have a
recognisable psychiatric illness, most commonly depression. Many of these patients do not seek medical help
and will self-medicate. The patient will complain of
having difficulty in staying asleep and suffer from early
morning waking. The pharmacist should look for other
symptoms of depression, such as fatigue, loss of interest
and appetite, feelings of guilt, low self-esteem, difficulty
in concentrating and constipation.
TRIGGER POINTS indicative of referral: Insomnia
Medicine-induced insomnia
Medicines can cause all three types of insomnia (Table
4.7). The mild stimulant effects of caffeine, contained in
chocolate, tea, coffee and cola drinks, are frequently
implicated in causing transient insomnia. The same is
seen with some of the selective serotonin re-uptake
inhibitors (SSRIs), particularly fluoxetine. It is therefore
advisable to instruct patients to avoid products containing caffeine and SSRIs after 2 p.m. Abruptly stopping
some medicines can also lead to insomnia. This is particularly seen with the long-term use of sedative drugs
such as benzodiazepines and the tricyclic antidepressants.
Underlying medical conditions
Many medical conditions can precipitate insomnia. It is
therefore necessary to establish a medical history from
the patient. A key role for the pharmacist in these situations is to ensure that the condition is being treated
optimally and check that the medicine regimen is appropriate. If improvements to prescribing could be made
then the prescriber should be contacted to discuss possible changes to the patient’s medicines.
●
●
●
●
●
Children under 12
Duration of more than 3 weeks
Insomnia for which no cause can be ascertained
Previously undiagnosed medical conditions
Symptoms suggestive of anxiety or depression
Figure 4.4 will help in the differential diagnosis of the
different types of insomnia.
Evidence base for
non-prescription medicines
Many cases of transient and short-term insomnia should
be managed initially by non-pharmacological measures.
If these fail to rectify the problem then short-term use of
sedating antihistamines can be tried.
Sleep hygiene
Once a diagnosis of insomnia has been reached, underlying causes ruled out and any misconceptions about
normal sleep addressed, then education about patient
Table 4.7
Medicine that can cause insomnia
Type of medicine
Comments
Stimulants
Caffeine, theophylline, sympathomimetic amines (e.g. pseudoephedrine), MAOIs (especially early
in treatment)
Antiepileptics
Carbamazepine, phenytoin
Alcohol
Low to moderate amounts can promote sleep but when taken in excess or over long periods it
can disturb sleep
Beta-blockers
Can cause nightmares, especially propranolol. Limit by swapping to a beta-blocker that does
not readily cross the blood-brain barrier (e.g. atenolol)
SSRIs
Especially fluoxetine
Diuretics
Ensure the last dose is not taken after midday to stop the need to urinate at night
Griseofulvin
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Insomnia
Patient presents
with insomnia
❶
Treat
❷
Yes
Environmental
factors
< 3 weeks
Duration
> 3 weeks
Signs of anxiety or
depression
No
Treat
❷
Yes
❸
Yes
Altered sleep
pattern
Drug induced
❸
Yes
Yes
Contact GP to
review the
management
of the patient
No
Underlying
condition
Stress related
No
Treat
Refer
No
No
Treat
Yes
Yes
No
Poor sleep
hygiene
Refer
No
Refer
No
Yes
Drug induced
Fig. 4.4 Primer for differential diagnosis of insomnia.
❶ No cases of insomnia lasting longer than 3 weeks should be
treated with non-prescription medicine. If a previously undiagnosed
medical condition is suspected, most often anxiety or depression,
or if insomnia has been possibly caused by the patient’s preexisting condition/medicines, then the GP should be consulted and
treatment options discussed/suggested.
behaviour and practice that affects sleep should be
tackled (Table 4.8).
❷ Patients should not take antihistamines for more than 7 to 10
continuous days as tolerance to their effect can develop.
❸ In the first instance, strategies to manage the patient’s
insomnia should be suggested rather than issuing medicines.
Table 4.8
Steps to good sleep hygiene
● Maintain a routine, with a regular bedtime and
Medicines
wakening time
The sedating antihistamines diphenhydramine and doxylamine are the mainstay of pharmacological treatment.
Diphenhydramine
At doses of 50 mg diphenhydramine has been shown to
be superior to placebo in inducing sleep, and as effective
as 60 mg of sodium pentobarbitone (Rickels et al 1983;
Teutsch et al 1975). Doses higher than 50 mg diphenhydramine do not produce statistically superior clinical
effects and night-time doses should therefore not exceed
this amount.
● Food snacks, alcoholic and caffeine-containing drinks
should be avoided
Avoid sleeping in very warm rooms
Daytime and not evening exercise
No daytime naps
No sleeping in to catch up on sleep
No strenuous mental activity at bedtime (e.g. doing a
crossword in bed)
● No watching television in bed
● Solve problems before retiring
● If unable to get to sleep, get up and do something
●
●
●
●
●
Doxylamine
Doxylamine has been studied in a few small trials and
has been shown to be superior to placebo, and compared
favourably with secbutobarbitone (Rickels et al 1984;
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Central nervous system
Sjoqvist & Lasagna 1967). Like diphenhydramine, doxylamine has a flat dose-response with a 25 mg dose being
similar to 50 mg. Although doxylamine and diphenhydramine have not been compared head-to-head, the
shorter half-life of diphenhydramine may give it an
advantage.
Summary
Of the two sedating antihistamines, diphenhydramine has
a shorter half-life and therefore may be the treatment of
choice. However, it should be noted that the Australian
Medicines Handbook and the National Prescribing Service
(NPS) caution against the use of sedating antihistamines
to treat sleep disorders due to the limited evidence of
efficacy, the rapid development of tolerance, and their
potential to produce adverse effects.
Complementary therapies
Herbal remedies containing hops, German chamomile,
skullcap, wild lettuce, passiflora and valerian are available and widely used. A US study found 4.5% of people
had used a complementary therapy to treat insomnia
(Pearson et al 2006). However, there is little evidence to
support their use. The majority of information available
in the literature relates to the hypothesised action of
chemical constituents or studies in animals. Valerian
appears to be the only product for which more than
one trial has been conducted on humans, a number of
whom reported a sedative effect. A review by Stevinson
and Ernst (2000) found some evidence of efficacy in
long-term studies (14–28 nights of therapy) but inconclusive evidence in short-term trials (1–4 nights’
therapy). In addition, the trials were often of short
duration, used volunteers or patients with different criteria, and were usually methodologically poor. A number
of branded products containing combinations of herbal
ingredients are available OTC.
Practical prescribing and
product selection
Prescribing information relating to medicines for insomnia in the section ‘Evidence base for non-prescription
medicine’ is discussed and summarised in Table 4.9 and
useful tips relating to patients presenting with insomnia
are given in Hints and Tips Box 4.2.
Both the antihistamines that are used for insomnia are
first-generation antihistamines and interact with other
sedating medicines, resulting in potentiation of sedation.
Additionally, they possess antimuscarinic side-effects,
which commonly lead to dry mouth and possibly to
constipation. It is these antimuscarinic properties that
mean patients with glaucoma and prostate enlargement
should ideally avoid their use as it could lead to increased
intraocular pressure and precipitation of urinary retention. Both diphenhydramine and doxylamine should not
be used for more than 10 consecutive nights. Patients
should also be warned about possible next day sedation
Table 4.9
Practical prescribing: Summary of medicines for insomnia
Medicine
Diphenhydramine
Doxylamine
Use in
children
Likely
side-effects
Drug interactions of
note
Patients in whom
care should be
exercised
Pregnancy
>12 years
Dry mouth,
sedation and
grogginess
next day
Increased sedation with
alcohol, opioid analgesics,
anxiolytics, hypnotics and
antidepressants
Open-angle
glaucoma,
prostate
enlargement
Category A,
although
manufacturers
advise avoidance
HINTS AND TIPS BOX 4.2: INSOMNIA
Antihistamines
Tolerance can develop with continuous use. It is recommended that they should not be
used for more than 10 consecutive nights. Patients should also be aware of possible
next-day sedation
Patients who self-treat
for depression
St John’s Wort (hypericum) is used by many patients to treat depression. There is a growing
body of evidence that it is more effective than placebo for mild depression and is
comparable in effect to tricyclic antidepressants. However, pharmacists should not
recommend it routinely. If depression is suspected then the patient should be referred for
further assessment. St John’s Wort also interacts with other medicines, including warfarin,
SSRIs, antiepileptics, digoxin, cyclosporin, theophylline and some contraceptives
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Insomnia
as both antihistamines have long half-lives (8–10 hours),
which are even longer in older populations.
Diphenhydramine
Diphenhydramine is approved only for adults and children over 12 years of age, and one capsule or tablet
should be taken 20 minutes before going to bed.
Doxylamine
Adults and children over 12 years of age should take one
or two tablets 20 minutes before bedtime.
References
Paine S, Gander P, Harris R et al 2005 Prevalence and
consequences of insomnia in New Zealand: disparities
between Maori and non-Maori. Australian and New
Zealand Journal of Public Health 29:22–28
Pearson N J, Johnson L L, Nahin R L 2006 Insomnia, trouble
sleeping, and complementary and alternative medicine:
Analysis of the 2002 national health interview survey
data. Archives of Internal Medicine 166(16):1775–1782
Rickels K, Ginsberg J, Morris R et al 1984 Doxylamine
succinate in insomniac family practice patients: a
double-blind study. Current Therapeutic Research
35:532–540
Rickels K, Morris R J, Newman H et al 1983
Diphenhydramine in insomniac family practice patients:
a double-blind study. Journal of Clinical Pharmacology
23:234–242
Sjoqvist F, Lasagna L 1967 The hypnotic efficacy of
doxylamine. Clinical Pharmacology and Therapeutics
8:48–54
Stevinson C, Ernst E 2000 Valerian for insomnia: a
systematic review of randomized clinical trials. Sleep
Medicine 1:91–99
Teutsch G, Mahler D L, Brown C R et al 1975 Hypnotic
efficacy of diphenhydramine, methapyrilene and
91
pentobarbital. Clinical Pharmacology and Therapeutics
17:195–201
Tiller J W G 2003 The management of insomnia: an update.
Australian Prescriber 26:78–81
Further reading
Adam K, Oswald I 1986 The hypnotic effects of an
antihistamine: promethazine. British Journal of Clinical
Pharmacology 22:715–717
Anderson E G 1992 Night people: avoiding the quick fix for
insomnia. Geriatrics 47:65–66
Gillin J C, Byerley W F 1990 The diagnosis and management
of insomnia. New England Journal of Medicine
322:239–248
Mellinger G D, Balter M B, Uhlenhuth E H 1985 Insomnia
and its treatment. Prevalence and correlates. Archives of
General Psychiatry 42:225–232
Newall C A, Anderson L A, Phillipson J D 1996 Herbal
medicines: a guide for health-care professionals.
Pharmaceutical Press, London
NPS Prescribing Practice Review 49: Management options
for improving sleep. [Online] Available: http://
www.nps.org.au/health_professionals/publications/
prescribing_practice_review/current/prescribing_practice_
review_49 [1 August 2010]
Sproule B A, Busto U E, Buckle C et al 1999 The use of
non-prescription sleep products in the elderly.
International Journal of Geriatric Psychiatry 10:851–857
Web sites
National Sleep Foundation: www.sleepfoundation.org/
Newcastle Sleep Disorders Centre: www.newcastle.edu.au/
centre/nsdc/pamphlets.html
Further resources for this chapter are available online at:
http://evolve.elsevier.com/AU/Newby/community/
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Central nervous system
Self-assessment questions
The following questions are intended to supplement the text. Two levels of question are provided; multiple choice questions
and case studies. The multiple choice questions are designed to test factual recall and the case studies allow knowledge to be
applied to a practice setting.
4.6. Which trigger sign or symptom warrants referral?
Multiple choice questions
a. Headache lasting 7 to 10 days
b. Headache described as ‘vice like’
c. Headache associated with the workplace
environment
d. Headache in a child under 12 with no sign of
infection
e. Headache associated with fever
4.1. An important neurotransmitter in the
pathogenesis of migraine is:
a.
b.
c.
d.
e.
Histamine
5HT
Dopamine
Acetylcholine
Adrenaline
4.7. The amount of sleep needed with increasing age:
4.2. Dystonic reactions are a rare side-effect of
metoclopramide that occur most commonly in
which group of patients?
a.
b.
c.
d.
e.
Males over 40 years of age
Females over 40 years of age
Females over 65 years of age
Females under 20 years of age
Males under 20 years of age
a. Increases
b. Decreases
c. Stays the same
4.8. Which of these statements is true when giving
advice on sleep hygiene?
a.
b.
c.
d.
e.
4.3. Cluster headache could be best described as:
a. Bilateral piercing pain behind the eyes that
lasts for a matter of only minutes
b. Unilateral piercing pain behind an eye that
lasts for a matter of only minutes
c. Unilateral orbital piercing pain with associated
unilateral nasal congestion
d. Bilateral orbital piercing pain with associated
nasal congestion
e. Bilateral orbital piercing pain only
4.4. Nausea and vomiting are associated with:
a.
b.
c.
d.
e.
Tension headache
Trigeminal neuralgia
Cluster headache
Subarachnoid haemorrhage
Sinusitis
Golden rod
Tolu balsam
Burdock
Mugwort
Passion flower
Questions 4.9 to 4.11 concern the following
anatomical locations of the brain:
A.
B.
C.
D.
E.
Orbital
Temporal
Occipital
Generalised
Unilateral and frontal
Select, from A to E, which of the above locations:
4.9. Is associated with cluster headache
4.10. Is associated with subarachnoid haemorrhage
4.11. Is associated with tension headache
4.5. What herbal remedy is used to help treat
insomnia?
a.
b.
c.
d.
e.
Drinking coffee and tea is OK before bedtime
Try to vary the time when you go to bed
Sleep in a warm room
Try not to nap through the day
Take moderate exercise before going to bed
Questions 4.12 to 4.14 concern the following
medicines:
A.
B.
C.
D.
E.
Domperidone
Doxylamine
Metoclopramide
Oral contraceptive
Metoclopramide with paracetamol
© 2012 Elsevier Australia
Self-assessment questions
Select, from A to E, which of the above medicines:
4.12. Should be avoided by patients taking paracetamol
4.13. Is only licensed in combination with paracetamol
for nausea associated with migraine
4.14. Has been linked to causing migraine
4.15. Which of the following is a feature of a tension
headache:
a.
b.
c.
d.
e.
Dull ache, not normally throbbing
Occurs about the same time each day
Unilateral
Worse in the night
Worse when you lie down
4.16. Which of the following is not a symptom of the
aura associated with migraine:
a.
b.
c.
d.
e.
93
4.18. Which of the following is a primary headache
disorder:
a.
b.
c.
d.
e.
Alcohol-induced headache
Analgesic-overuse headache
Cervicogenic headache
Chronic post-traumatic headache
Migraine with aura
4.19. Which of the following are true regarding the
non-prescription treatments for insomnia:
a. They have short half-lives
b. They should not be used in patients with
prostate enlargement
c. They should not be used for more than 14
consecutive nights
d. They should be taken 1–2 hours before
bedtime
e. They are third-generation antihistamines
4.20. Which of the following is a commonly reported
trigger of migraine attacks:
Taste disturbances
Flashing lights
Pins and needles
Scotomas
Zig-zag lines
4.17. Which statement relating to headache is true:
a. Headache with aura is the most common type
of migraine headache
b. Cluster headache is more common in women
than men
c. Temporal arteritis affects mainly middle-aged
men
d. Migraine is more common in women than men
e. Cluster headaches are usually bilateral
a. Alcohol
b. Lying down
c. Staring at computer screens for extended
periods
d. Over eating
e. Menstrual cycle
© 2012 Elsevier Australia
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Central nervous system
Case studies
CASE STUDY 4.1
Mr AM, a male patient in his early thirties, presents to the pharmacy at lunch time complaining of
headaches. The following questions are asked and responses received.
Information gathering
Data generated
Presenting complaint
(possible questions)
What symptoms/describe the symptoms
How long had the symptoms
Other symptoms
Where exactly
Any time worse/better
Severity of pain (1–10)
Frequency of pain
Eye test; recent trauma
Previous history of presenting complaint
Past medical history
Drugs (OTC, Rx and compliance)#
Allergies
General aching feeling all over the head
Had for the last week
No problems with lights, etc. No sickness. No recent trauma
All over the head
Seems to get worse as day goes on
4
Most of the time
Eyes OK, no need for glasses; no
None
None
None
Penicillin
Social history
Smoking
Alcohol
Drugs
Employment
Relationships
Family history
On examination
Non-smoker
Drinks red wine (a couple of glasses each night)
Works in marketing. Job OK but busy with new promotion
Married with two young children
Not known
Not applicable
Epidemiology dictates that tension-type headache is the
most likely cause in primary care. However, other
conditions are possible and are noted below:
Probability
Cause
Most likely
Likely
Unlikely
Tension headache
Migraine, sinusitis, eye strain
Cluster headache, temporal arteritis,
trigeminal neuralgia, depression
Glaucoma, meningitis, subarachnoid
haemorrhage, raised intracranial pressure
Very
unlikely
Diagnostic pointers with regard to symptom
presentation
The expected findings for questions when related to
the different conditions that can be seen by
community pharmacists are summarised on the
following page.
© 2012 Elsevier Australia
Case studies
Duration
Tension-type
headache
Can last
days
Migraine
Average
attack
lasts 24
hours
Cluster
headache
1–3
hours
Sinusitis
Days
Eye strain
Days
Temporal
arteritis
Trigeminal
neuralgia
Depression
Hours to
days
Minutes
Glaucoma
Days to
months
Hours
Meningitis
Hours to
days
Subarachnoid
haemorrhage
Raised
intracranial
pressure
Minutes
to hours
Days to
months
Timing and
nature
Relative
severity (pain
score from 0
to 10)*
Location
95
Precipitating
factors
Who is
affected
Stress due to
changes in
work or home
environment
Food (in 10%
of sufferers)
& family
history
All age groups
and both
sexes equally
affected
Three times
more common
in women.
Rare in
children
Three to five
times more
common in
men
Adults
Symptoms worsen
as day progresses.
Non-throbbing
pain
Associated with
menstrual cycle
and weekends.
Throbbing pain &
nausea. Dislike of
bright lights and
loud noise
Attacks occur at
same time of day.
Intense boring
pain
Dull ache that
starts off being
unilateral
Aching
Bilateral &
most often at
back of head
2–5
Usually
unilateral
4–7
Unilateral
>7
Alcohol
Frontal
2–6
Valsava
movements
Frontal
2–5
All ages
Variable
Unilateral
around temples
Face
3–6
Close vision
work
None
>7
None
Adults
Generalised
2–5
Social factors
Adults
Unilateral and
orbital
>7
Darkness
Older adults
Generalised
>7
None
Children
Variable
Occipital
>7
None
Adults
Worse in the
mornings
Variable
>4/5
None
Older adults
Lancing pain at
any time
Non-throbbing
pain
Often in the
evening and
sudden onset
Associated with
systemic infection
Elderly
*Scores set by the authors and are not evidence-based
When this information is applied to that gained
from our patient (below) we see that his symptoms
most closely match tension-type headache, which
may (or may not) be triggered by extra pressure at
work. Depression is also a possibility, although less
likely.
© 2012 Elsevier Australia
4
96
Central nervous system
Duration
Timing
and
nature
Location
Severity (pain
score from 0
to 10)
Precipitating
factors
Who is
affected
Tension
✓
Migraine
✓
✓
✓
✓
✓
Cluster
✗
✗
✗
✓
✗
✗
✗
✗
?
✓?
✗
Sinusitis
✓
✓?
✗
✓
✗
✓
Eye strain
✓
✓
✗
✓
✓
✓?
✗
✓
✗
N/A
✓
Temporal arteritis
Trigeminal neuralgia
✗
✗
✗
✗
N/A
✓
✓
✗
Depression
✓
✓?
✓
✓
✓?
✓
Glaucoma
✗
✗
✗
✗
✗
Meningitis
✗
✗
✓
✗
✗
N/A
Subarachnoid haemorrhage
✗
✗
✗
✗
N/A
✓
Raised intracranial pressure
✓
✗
✓
✓
N/A
✗
Danger symptoms/signs (trigger points for referral)
As a final double check it might be worth
making sure the person has none of the ‘referral
✗
signs or symptoms’; this is the case with this
patient.
Headache unresponsive to analgesics
Not yet tried
Headache in children under 12 with no signs of systemic infection or who have
a stiff neck or skin rash
Headache occurs after recent (1 to 3 months) trauma injury
✗
Headache that has lasted for more than 2 weeks
✗
Nausea and/or vomiting in the absence of migraine symptoms
✗
Neurological symptoms, if migraine excluded, especially change in consciousness
✗
New or severe headache in patients over 50
✗
Progressive worsening of headache symptoms over time
✗
Very sudden and/or severe onset of headache
✗
© 2012 Elsevier Australia
✗
Case studies
97
CASE STUDY 4.2
Mrs PC, a 36-year-old woman, asks you for
something to treat her headache. On questioning
you find out the following:
● She has had the headache for about 5 days.
● The pain is located mainly behind left eye and
front of head but is also at back of head.
● Mrs PC is experiencing aching, but no sickness or
visual disturbances.
● She has tried paracetamol, which helps for a
while but the pain comes back after a few hours.
● She has not had this type of headache before.
● Work at the moment is busy because of a
conference she is organising.
● She takes nothing from her GP except the
mini-pill (levonorgestrel).
● There is no recent history of head trauma.
● The pain gets worse as the day goes on.
a. What is the likely differential diagnosis, and why?
b. From the above responses, which symptoms
allowed you to rule out other conditions?
4
CASE STUDY 4.3
Mr FD, a 55-year-old man, asks you for a strong
painkiller for his headache. He has had the headache
for a few days but it doesn’t seem to be going away.
After talking to Mr FD, you find out the following:
● The headache is located in the frontal area and
is bilateral.
● He describes the pain as throbbing.
● He has never had a headache like this before.
● He has not suffered from migraines in the past.
● There are no associated symptoms of upper
respiratory tract infection.
● He is retired and has a non-stressful lifestyle.
● He has tried paracetamol but without much
success.
● He takes atenolol for hypertension.
a. Using the information on epidemiology and data
on signs and symptoms of each condition from
Case Study 4.1, what is the likely differential
diagnosis?
b. What extra questions could you ask to support
your diagnosis?
© 2012 Elsevier Australia
98
Central nervous system
CASE STUDY 4.4
Mrs SP, the wife of a 54-year-old man, enters the pharmacy and asks for Panadeine (paracetamol 500 mg/
codeine 8mg); her husband has a bad ‘migraine’ and her neighbour told her it was for ‘strong’ pain.
Information gathering
Presenting complaint (Possible questions)
Describe symptoms
Data generated
Allergies
Very painful headache. Worst towards the back of the head; feels
nauseous and vomited twice but vomiting seems to have subsided
12–24 hours
Very painful (7–8 out of 10)
Just said it is very painful
Can’t do anything. Painful even to do ‘normal’ things like shower,
dress, etc.
Not had eye test for a year but eyes OK; no recent trauma
No
Tried a couple of paracetamol but did not seem to ease the pain
None
Hypercholesterolaemia
Simvastatin/ezetimibe 40 mg/10 mg – one at night
Uses antihistamines OTC during spring/summer
No allergies to medicines, only hayfever
Social history
Smoking
Alcohol
Drugs
Employment
Relationships
Family history
On examination
Smokes 20 a day
Occasional
Executive for a marketing firm
Approx 20 units a week alcohol
Married
None for presenting complaint
He generally looks tired and pain is aggravated by light
How long had you had the symptoms
Severity of pain
Nature of the pain
Other symptoms/provokes
Eye test; recent trauma
Any symptoms before headache
Tried anything for the pain
Previous history of presenting complaint
Past medical history
Drugs (OTC, Rx and compliance)
a. Given the information the lady has given you,
would you recommend Panadeine?
Answers to multiple choice questions
4.1 = b 4.2 = d
4.3 = c
4.4 = d
4.5 = e
4.11 = D 4.12 = E 4.13 = A 4.14 = D 4.15 = a
b. Would you recommend anything else at this stage
to treat the headache?
4.6 = d 4.7 = b
4.8 = d 4.9 = A 4.10 = C
4.16 = a 4.17 = d 4.18 = e 4.19 = b 4.20 = e
Answers to case study questions – see page 308
© 2012 Elsevier Australia