Pain

Pain

Pain

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Types of Headache

  • Most likely - Tension-type headache
  • Likely - Migraine, sinusitis, eye strain
  • Unlikely - Cluster headache, medication-overuse headache, temporal arteritis, trigeminal neuralgia, depression
  • Very unlikely - Glaucoma, meningitis, subarachnoid haemorrhage, raised intracranial pressure
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Tension Headache Causes

  • Stress and anxiety
  • Squinting
  • Poor posture
  • Tiredness
  • Dehydration
  • Missing meals
  • Lack of physical activity
  • Bright sunlight
  • Noise 
  • Certain Smells
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Migraine

  • Moderate or severe headache felt as a throbbing pain on one side of the head
  • Common condition affecting around 1 in 5 women and 1 in 15 men that usually begin in early adulthood
  • Several types including migraine with aura, without aura or migraine aura without headache
  • Exact cause unknown but thought to be due to abnormal brain activity temporarily affective nerve signals, chemicals and blood vessels
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Migraine Stages

  • Premonitory 24 hours prior to headache
    • changes in mood/alertness/appetite
  • Aura up to 1 hours before (only in migraine with aura)
    • visual hallucinations in 1/3 of patients
  • Headache lasts 4-72 hours if untreated
    • unilateral in 2/3 of patients (may move), 90% nausea
  • Resolution
    • headache goes, sleepiness
  • Recovery can last several days
    • exhaustion, lethargy
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Medication Over-Use Headache

  • Daily high use of analgesic causes headache
  • Wake with headache, lasts through day, no associated symptoms
  • Also withdrawal or analgesic causes rebound headache
  • But NICE advice is to stop abruptly
  • Refer to GP: advice/follow-up/prophylaxis for primary headache
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Drug Induced Headaches: Examples

  • Nitrates (angina)
    • Throbbing, bilateral
    • Wears off, but if troublesome then refer
  • Drug interactions, e.g. MAOI (monoamine oxidase inhibitor) & sympathomimetic
    • Can lead to increased blood pressure
    • Refer
  • Combined Oral Contraceptives
    • Refer if 1st time or worsening of migraine-type
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Questions to Ask

  • Who?
  • Onset of headache?
  • Frequency and timing?
  • Location of pain?
  • Severity of pain?
  • Triggers? 
  • Attack duration?
  • Associated symptoms?
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When to Refer

  • Meningitis - headache in children under 12 who have a stiff neck or skin rash
  • Haematoma - headache occurring after recent trauma (1 to 3 months)
  • Nausea and vomiting in absence of migraine
  • Neurological symptoms, e.g. change in consciousness, slurred speech, weakness
  • New or severe headache in patients over 50
  • Progressive worsening of symptoms
  • Very sudden and/or severe onset of headache
  • Headache that has lasted more than 2 weeks
  • Headache unresponsive to analgesia
  • Headache associated with combined oral contraceptive use
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Treatment Options: Headache and Migraine

  • Headache
    • Simple analgesics - paracetamol, ibuprofen
  • Migraine
    • Migraleve
    • Midrid
    • Buccastem M
    • Imigran Recovery
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Treatment - Self Help

  • Keep a diary
  • Avoid aggravating factors
  • Apply pressure/cold compress/hot application as appropriate
  • Sleep it off
  • Whatever seems to help 
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Migraine Treatment

  • Aims
    • to identify and remove triggers (diary)
    • to give most appropriate treatment
    • to achieve normal activity without disruption
  • Management
    • simple analgesics - soluble best
    • anti-emetics, e.g. Bucastem M
    • combination products (do not offer opioids
    • motility stimulants (e.g. domperidone POM)
    • triptans
    • prophylaxis
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Dentail Pain: Toothache

  • Pain in and around the teeth normally caused by tooth decay
  • Intermittent or constant
  • Mild or severe pain
  • Difficult to pinpoint location of pain
  • Periodontal disease is a bacterial infection affecting soft and hard structures that support teeth
  • If left untreated pulp inside tooth will become infected leading to dental abscess
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Dental Pain: Common Causes

  • Pulpitis - inflammation of the pulp caused by tooth decay, mechanical trauma (cracked tooth) or filling with imperfect seal
  • Dentine hypersensitivity - short, sharp pain in response to triggers such as cold, heat or sweet/spicy foods. Normally caused by lack of insultion due to gingival recession
  • Periodontitis - chronic inflammation of the apex of the tooth
  • Periodontal abscess - collection of puss in gingival crevices as a result of chronic periodontitis where crevices are deeper than 3mm.
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Dental Pain: Treatment

  • Paracetamol
  • Ibuprofen
  • Topical local anaesthetics
  • Refer to dentist
  • Emergency dental helplines available
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Musculoskeletal Pain

  • Sprains - a sprain occurs when or more ligaments have been stretched, twisted or torn, usually as a result of excessive force being applied to a joint
  • Strains - occur when muscle fibres stretch or tear. It is usally the result of the muscle being stretched beyond its limits or forced to contract (shorten) too quickly
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Sprains

  • Common locations for sprains include:
    • Ankles
    • Knees
    • Wrists
    • Thumbs
  • Common symptoms include:
    • Pain around the affected joint
    • Inability to use the joint normally or put weight on it
    • Swelling, bruising and tenderness
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Strains

  • Common location for strains include:
    • Leg (hamstring)
    • Back (lumbar strains)
  • Common symptoms include:
    • Swelling, bruising or redness
    • Pain in the affected muscles at rest
    • Pain during use
    • Muscle spasms
    • Weakness and loss of some or all of the function in the affected muscle
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Lower Back Pain

  • Self-limiting
  • >90% will get better within 6 weeks
  • Extremely common
  • Most common between 30-55 years
  • 50-90% of pregnant women develop lower back pain
  • Management
    • Keep active
    • Simple analgesia
    • Heat wraps of some benefit in short term
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When to Refer

  • Sciatica (referred pain)
  • Numbness
  • Bowel or bladder incontinence
  • Pain above lumbar region
  • Persistent or progressively worsening pain
  • Failure of symptoms to improve after 4 weeks
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Musculosketal Advice

  • Protection - protect from further injury (e.g. support or high-top, lace up shoes)
  • Rest - avoid activity for the 1st 48-72 hours following injury
  • Ice - apply ice wrapped in a damp towel for 15-20 minutes every 2-3 hours for 1st 48-72 hours
  • Compression - with a simple elastic bandage which should be snug not tight, to help control swelling and support injury. Taken off at night
  • Elevation - keep injured area elevated until swelling is controlled
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Musculoskeletal Advice

Avoid HARM in the 1st 72 hours after the injury:

  • Heat - e.g. hot baths, saunas and heat packs
  • Alcohol - increases bleeding and swelling and decreases healing
  • Running - or any other form of exercise which may cause further damage
  • Massage - may increase bleeding and swelling
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Musculoskeletal Pain Managment

  • Paracetamol - initial management
  • Topical NSAID, e.g. ibuprofen gel
  • Rubefacients
  • Avoid oral NSAIDs during first 48 hours after injury because of concerns that they may delay healing

Referral:

  • Elderly or <12 years old
  • Referred pain
  • Marked reduction in range of movement
  • Excessive range of movement in joint
  • Marked swelling, bruising straight after injury
  • Unable to bear any weight
  • Irregular shape
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