Pain Management and Headaches

Pain is classified into two general categories, acute and chronic pain, though combinations of both can exist as well.
An accurate and thorough pain assessment is essential to creating an appropriate treatment regimen. Nonpharmacologic therapy is often an important component of a pain treatment regimen.
Acetaminophen dosing should not exceed 4 grams per day in healthy adults, though lower daily maximums may be used in high risk patients such as elderly or those with hepatic disease.
Aspirin should rarely be used for pain management as the risk (GI side effects, bleeding risks) outweighs the benefits. Aspirin still may be used in migraines, often in combination with other agents (eg.caffeine, codeine).
NSAIDs are useful for pain associated with inflammation.
Patients on opioid therapy should be monitored closely for side effects and toxicities. Bowel regimens are often required to counteract constipation.
Adjuvant therapy (including TCAs, SNRIs, SSRIs, etc) often need titrated to a goal dose for efficacy. These agents also have multiple drug interactions which should be monitored and/or avoided if possible.
Patients and healthcare providers should be aware of "Headache Red Flags" (table 35-1) to help distinguish a benign headache from something more severe.
Treatment of headaches varies by type of headache as well as the indication: treatment of an acute headache or prophylaxis of future headaches. Some prophylactic treatment may take several weeks to reach maximum benefit. Frequency of attacks is important for determining the need for prophylactic therapy. Route of administration of headaches medications (especially migraine) is important as often patients will not be able to tolerate oral administration for acute headaches with nausea/vomiting.
For the first unit of somatic disorders, we will discuss general pain management principles as well as the specific treatment for headaches disorders. Pain is described by the International Association for the Study of Pain (discussed in your book chapter) as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage." The key to appropriate pain management is to conduct a thorough pain assessment. Simply asking a patient what their pain is on a scale of 1-10 will not give an accurate depiction of their pain. Ask for descriptions such as: burning, aching, stabbing, radiating, tingling. Consider asking questions to evaluate the course of the pain over time, such as: What is the best/worst your pain has been in the past 24 hours (acute pain)? What is the best/worst your pain has been in the past week (chronic pain)? A comprehensive assessment will set the stage for a beneficial treatment regimen.
Once an accurate assessment is obtained, various treatment options can be utilized, both nonpharmacologic and pharmacologic. Non-pharmacologic treatment can include heat, ice, massage, chiropractic therapy, yoga, etc. Pharmacologic treatment is divided into three main categories: non-opioid analgesics, opioid analgesics, and adjuvant therapy. We will learn more about all three this week.
In addition, this topic discusses the treatment of headache disorders. Headache disorders are classified into three broad categories: migraine, cluster and tension type. As with general pain management, assessment is important to appropriate treatment in headaches as well. Determining the type of headache, what works and doesn't work (medication history), the frequency of attacks, other problematic symptoms, etc will help greatly with choosing the right treatment regimen. The treatment should be patient specific and patients should be monitored closely for safety and efficacy.
Headache Disorders | Basicmedical Key
Dipiro, J. T., Yee, G. C., Posey, L. M., Haines, S. T., Nolin, T. D., Ellingrod, V. (2019). Pharmacotherapy A Pathophysiologic Approach (11th ed.). McGraw-Hill Education.
Objectives
At the completion of this module the student will be able to:
Pain Management
Classify analgesic medications by mechanism of action.
Manage adverse side effects of analgesic medications.
Produce an equianalgesic dose of morphine, oxycodone, hydromorphone and hydrocodone (table 34-3).
Construct an appropriate pharmacological treatment plan based on patient specific characteristics.
Incorporate CDC / WHO guidelines for prescribing opioids into rational treatment plan (table 34-4)
Headaches
Identify the various types of headaches and recognize potential "triggers" that may be present
Recommend nonpharmacologic therapy for both treatment and prevention of headaches.
Determine the appropriate use of pharmacologic therapy for treatment and prophylaxis headaches using a step-wise approach and taking into consideration possible co-morbidities.
Recognize common side effects and interactions for medications used for headaches.
Module V: Pain Management Discussion
There are hundreds of opioid conversion calculators available online, though they are not all of good quality. I would like to direct you to one of the opioid conversion calculators that I find to be most useful and evidence based. Locate http://opioidcalculator(dot)practicalpainmanagement(dot)com/ and evaluate the following case using the calculator as necessary. Discuss your approach to the overall case and results of your calculation.
A 79 year old white male is taking hydrocodone/APAP 10/325 for lower back pain (pt diagnosed with degenerative disc disease several months ago). The physician had written a prescription for Vicodin® 10/325 i-ii Q4-6h prn pain with a quantity of 120. Her expectation was that this would last the patient for one month. The patient is now requesting refills about every 10-14 days. He states he has been taking 2 tabs Q4h (12 tablets per day) because “the pain is so bad I just can’t stand it!”.
What is the problem with the way the patient is taking this medication versus the way it was prescribed
Based on your assessment, it is determined this patient should be converted to extended release morphine for better, more consistent pain control. Perform this conversion and provide an appropriate recommendation (drug, dose, frequency).
Migraine is a major neurological disease that affects more than 36 million men, women and children in the United States. There is no cure for migraine. Most current treatments aim to reduce headache frequency and stop individual headaches when they occur. Let's look at a case example:
CM is 20 years old female with severe, prolonged 2 to 3 day migraines twice per month. She has difficulty sleeping and is mildly anxious. She occasionally utilizes an inhaler for asthma.
Provide an evaluation of CM's condition including non-pharmacological interventions and treatment options
Is Cm a candidate for prophylactic therapy, and if so, what option would be best suited to her?