Pain

Pain

• 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

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

• 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

• 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

• 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

• 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

• Who?

• Onset of headache?

• Frequency and timing?

• Location of pain?

• Severity of pain?

• Triggers? 

• Attack duration?

• Associated symptoms?

• 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

• Headache
  • Simple analgesics - paracetamol, ibuprofen

• Migraine
  • Migraleve
  • Midrid
  • Buccastem M
  • Imigran Recovery

• Keep a diary

• Avoid aggravating factors

• Apply pressure/cold compress/hot application as appropriate

• Sleep it off

• Whatever seems to help 

• 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

• 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

• 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.

• Paracetamol
• Ibuprofen
• Topical local anaesthetics

• Refer to dentist

• Emergency dental helplines available

• 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

• 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

• 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

• 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

• 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

• 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

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

• 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:

• 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