Headache – NEPHA

Require Medical Referral

Headaches in the late stages of pregnancy can be a symptom of preeclampsia.

NSAIDs like ibuprofen and naproxen can have adverse effects on the fetal cardiovascular system, particularly if used in the third trimester. They can cause premature closure of the ductus arteriosus.

Require Medical Referral

Persistent or worsening headache (Indicate Increased ICP, a developing infection, a structural abnormality, a chronic headache disorder that needs specific management
Headache that awakens the child from sleep (may indicate Increased ICP)
Vomiting especially in the morning (may indicate Increased ICP (e.g., from a brain tumor or hydrocephalus),or migraines.
Fever, stiff neck, rash (strongly suggest meningitis)
Changes in behavior, personality, or school performance (may be due to neurological dysfunction, psychological or emotional distress, effects of a chronic headache condition
Problems with vision, balance, or coordination (Indicates dysfunction in the brain or nervous system, Possible increased ICP, a neurological condition)
History of head trauma (may indicate post-concussion syndrome, other complications from the trauma, such as a subdural hematoma (bleeding in the brain).
Failure of OTC treatment to provide relief.

Require Medical Referral

Any New or Persistent Headache (may be indication of temporal arteritis, Cerebrovascular disease, ICH, brain tumor, subdural hematoma)
Headache with Cognitive Impairment or Confusion ( underlying cause may be dementia-related changes, Intracranial hemorrhage., Infections (e.g., meningitis, encephalitis), Metabolic imbalances)
Headache with Neurological Symptoms (symptoms include weakness or numbness on one side of the body, Difficulty speaking or understanding speech, Vision changes (e.g., double vision, vision loss), Problems with balance or coordination; could indicate Stroke or TIA., Brain tumor, Other neurological conditions)
Temporal Headaches with Tenderness especially when coupled with visual disturbances or Jaw claudication, it can be a symptom of Giant Cell Arteritis.

Recommendation: REQUIRE MEDICAL REFERRAL

Rational: Severe pain (pain intensity >7) is indicative of

Subarachnoid hemorrhage (SAH) often presents with "thunderclap" headache (sudden, excruciating).
Meningitis, brain tumors, and other conditions can cause severe pain.
Severe pain is less likely to respond adequately to OTC analgesic.

requires medical referral for further assessment

Recommendation: REQUIRE MEDICAL REFERRAL

Rational:

Thunderclap headache is a medical emergency often necessitates immediate neuroimaging (CT scan or MRI) ! It can be a hallmark symptom of

Subarachnoid Hemorrhage (SAH) (other symptoms: Neck stiffness, Nausea and vomiting, Loss of consciousness, Neurological deficits (e.g., weakness, numbness)
Other Vascular Disorders like Cerebral venous sinus thrombosis, Arterial dissection

Recommendation: REQUIRE MEDICAL REFERRAL

Rational:

The long headache (>10 days) is not a typical, self-limiting event and may be a symptom of a more serious underlying condition like Chronic Daily Headache (CDH), Medication-Overuse Headache (MOH),sinusitis, Temporomandibular Joint (TMJ) Disorder, Underlying Medical Conditions like brain tumor, cerebrovascular disorder, requiring medical referral.

Recommendation: REQUIRE MEDICAL REFERRAL

Rational:

Increased frequency may indicate developing chronic daily headache, medication-overuse headache, or an underlying condition. Self-treatment may become less effective and less appropriate
Increased intensity suggests that the current treatment regimen is inadequate and that a more serious condition might be developing (Progression of migraine, Developing intracranial pathology (e.g., tumor), Hypertensive crisis
Alteration in characteristic indicates a possible change in the underlying cause of the headache 9(New-onset migraine, Tension-type headache evolving into chronic migraine, Sinusitis, Giant cell arteritis (in older adults), Intracranial pathology)

Recommendation: REQUIRE MEDICAL REFERRAL

Rational:

Elevated BP: A severely elevated BP during a headache (hypertensive crisis) requires immediate medical attention to prevent stroke or other organ damage.
Elevated Temperature: A fever indicates an infection, which may need specific treatment (e.g., antibiotics).
Altered HR: While less specific, a markedly elevated HR with headache warrants evaluation, especially if associated with other symptoms

Recommendation: REQUIRE MEDICAL REFERRAL

Rational:

These are secondary headache causes
- Diagnostic criteria: Evidence of causation demonstrated by at least two of the following:
  - Headache has developed in temporal relation to the onset of the presumed causative disorder
  - either or both of the following:
    - headache has significantly worsened in parallel with worsening of the presumed causative disorder
    - Headache has significantly improved in parallel with improvement of the presumed causative disorder.

Visual deficits may be due to Migraine with Aura (Can cause various visual disturbances (e.g., flashing lights, zigzag lines, temporary vision loss), Giant Cell Arteritis (GCA), Ocular Migraine (A rare type of migraine that causes temporary vision loss in one eye), Angle-Closure Glaucoma ( Can cause severe eye pain, headache, and visual disturbances), Orbital Cellulitis: An infection of the tissues surrounding the eye, which can cause pain, swelling, and vision changes)
Foreign body sensation in the eye may be due to corneal abrasion or other eye injury, which can indirectly cause a headache.

Recommendation: REQUIRE MEDICAL REFERRAL

Rational:

These are secondary headache causes
- Diagnostic criteria: Evidence of causation demonstrated by at least two of the following:
  - Headache has developed in temporal relation to the onset of the presumed causative disorder
  - either or both of the following:
    - headache has significantly worsened in parallel with worsening of the presumed causative disorder
    - Headache has significantly improved in parallel with improvement of the presumed causative disorder.

Dizziness and Imbalance associated with headache may be due to Migraine, vertebrobasilar Insufficiency, cerebellar Disorders, Brainstem Lesions

Recommendation: REQUIRE MEDICAL REFERRAL

Rational:

These are secondary headache causes
- Diagnostic criteria: Evidence of causation demonstrated by at least two of the following:
  - Headache has developed in temporal relation to the onset of the presumed causative disorder
  - either or both of the following:
    - headache has significantly worsened in parallel with worsening of the presumed causative disorder
    - Headache has significantly improved in parallel with improvement of the presumed causative disorder.

Sense of Restlessness along with headache may be due to migraine, anxiety disorders that trigger or exacerbate headaches, Medication side effects or withdrawal

Recommendation: REQUIRE MEDICAL REFERRAL

Rational:

These are secondary headache causes
- Diagnostic criteria: Evidence of causation demonstrated by at least two of the following:
  - Headache has developed in temporal relation to the onset of the presumed causative disorder
  - either or both of the following:
    - headache has significantly worsened in parallel with worsening of the presumed causative disorder
    - Headache has significantly improved in parallel with improvement of the presumed causative disorder.

Neurologic Symptoms or Abnormal Signs may be due to Stroke (Sudden onset of headache with focal neurological deficits (e.g., weakness, numbness, speech difficulties), transient Ischemic Attack, Brain Tumor, Encephalitis (Inflammation of the brain, which can cause confusion, altered consciousness, seizures), Meningitis, Subdural Hematoma and Multiple Sclerosis

Recommendation: REQUIRE MEDICAL REFERRAL

Rational:

These are secondary headache causes
- Diagnostic criteria: Evidence of causation demonstrated by at least two of the following:
  - Headache has developed in temporal relation to the onset of the presumed causative disorder
  - either or both of the following:
    - headache has significantly worsened in parallel with worsening of the presumed causative disorder
    - Headache has significantly improved in parallel with improvement of the presumed causative disorder.

Papilledema may be due to brain tumor, Meningitis, Encephalitis, Hydrocephalus (fluid buildup in the brain), Cerebral venous sinus thrombosis, Idiopathic intracranial hypertension (pseudotumor cerebri)

Recommendation: REQUIRE MEDICAL REFERRAL

Rational:

These are secondary headache causes
- - - - Diagnostic criteria: Evidence of causation demonstrated by at least two of the following:
        
        Headache has developed in temporal relation to the onset of the presumed causative disorder
        
        either or both of the following:
        
        headache has significantly worsened in parallel with worsening of the presumed causative disorder
        
        Headache has significantly improved in parallel with improvement of the presumed causative disorder.

Systemic symptoms, illness, or condition may be due to infection or autoimmune cause

Recommendation: REQUIRE MEDICAL REFERRAL

Rational:

These are secondary headache causes
- Diagnostic criteria: Evidence of causation demonstrated by at least two of the following:
  - Headache has developed in temporal relation to the onset of the presumed causative disorder
  - either or both of the following:
    - headache has significantly worsened in parallel with worsening of the presumed causative disorder
    - Headache has significantly improved in parallel with improvement of the presumed causative disorder.

These require further medical evaluation and prescription medicines

Recommendation: REQUIRE MEDICAL REFERRAL

Rational:

These are secondary headache causes
- Diagnostic criteria: Evidence of causation demonstrated by at least two of the following:
  - Headache has developed in temporal relation to the onset of the presumed causative disorder
  - either or both of the following:
    - headache has significantly worsened in parallel with worsening of the presumed causative disorder
    - Headache has significantly improved in parallel with improvement of the presumed causative disorder.

Headache with postural aggravation may be due to Cerebrospinal fluid (CSF) pressure abnormalities (avoid self treatment), Sinus issues (use with caution)

Recommendation: REQUIRE MEDICAL REFERRAL

Rational:

These are secondary headache causes
- Diagnostic criteria: Evidence of causation demonstrated by at least two of the following:
  - Headache has developed in temporal relation to the onset of the presumed causative disorder
  - either or both of the following:
    - headache has significantly worsened in parallel with worsening of the presumed causative disorder
    - Headache has significantly improved in parallel with improvement of the presumed causative disorder.

Precipitated by Valsalva (e.g., coughing, bearing down) can suggest increased intracranial pressure due to brain tumor (avoid), Arnold Chiari malformation (avoid), Sinus issues (use with caution)

Recommendation: REQUIRE MEDICAL REFERRAL

Rational:

These are secondary headache causes
- Diagnostic criteria: Evidence of causation demonstrated by at least two of the following:
  - Headache has developed in temporal relation to the onset of the presumed causative disorder
  - either or both of the following:
    - headache has significantly worsened in parallel with worsening of the presumed causative disorder
    - Headache has significantly improved in parallel with improvement of the presumed causative disorder.

Aggravated by Routine Physical Activity or Exercise may indicate classic migraine symptom (no need to avoid), Vascular headache (avoid), Exertional headache (rule out)

Recommendation: REQUIRE MEDICAL REFERRAL

Rational:

These are secondary headache causes
- Diagnostic criteria: Evidence of causation demonstrated by at least two of the following:
  - Headache has developed in temporal relation to the onset of the presumed causative disorder
  - either or both of the following:
    - headache has significantly worsened in parallel with worsening of the presumed causative disorder
    - Headache has significantly improved in parallel with improvement of the presumed causative disorder.

These require further medical evaluation and prescription medicines

Recommendation: REQUIRE MEDICAL REFERRAL

Rational:

These are secondary headache causes
- Diagnostic criteria: Evidence of causation demonstrated by at least two of the following:
  - Headache has developed in temporal relation to the onset of the presumed causative disorder
  - either or both of the following:
    - headache has significantly worsened in parallel with worsening of the presumed causative disorder
    - Headache has significantly improved in parallel with improvement of the presumed causative disorder.

These medications might cause migraine headache. follow-up with prescriber

Recommendation: REQUIRE MEDICAL REFERRAL

Rational: Need further evaluation for proper diagnosis

Recommendation: REQUIRE MEDICAL REFERRAL

Rational: Require prescription medicine

Recommendation: Non-pharmacological and pharmacological therapy as previously prescribed.

Pharmacological treatment for migraine

Ask patients regarding previous OTC medication for migraine and if it was working earlier, dispense as such with adequate counselling.

Non-pharmacological treatment for migraine

Preventive measures for migraine headache
- Identify and Avoid Triggers:
  - Keep a headache diary to track potential triggers: Foods (e.g., aged cheese, chocolate, alcohol, caffeine, MSG, tyramine (e.g., aged cheese and red wine)), Drinks, Smells, Activities, Environmental factors (e.g., weather changes, bright lights), nitrites (e.g., cured meats).
- When onset of migraine headache is predictable, take two days before headache is expected and continue regular use throughout the time the headache might occur (e.g., menstrual migraine during menstruation)
- Resting in quiet, dark room may help relieve migraine pain
Regular Sleep and Meal Schedule: Eat regularly to avoid hunger and low blood sugar
- Irregular sleep or skipping meals can cause fluctuations in blood sugar and hormone levels, which can trigger attacks.
  - Specific Recommendations:
    - Consistent Sleep: same bedtime and wake-up time
    - Adequate Sleep: 7-9 hours
    - Regular Meals: Don't skip meals, especially breakfast.
    - Balanced Diet
Stress Management: Stress is a very common migraine trigger.
- Specific Techniques:
  - Relaxation Techniques:Deep breathing exercises
  - Progressive muscle relaxation
  - Meditation or mindfulness
  - Yoga or tai chi
  - Cognitive Behavioral Therapy (CBT):
  - Biofeedback: Uses sensors to monitor physiological responses (e.g., muscle tension, heart rate) and teaches techniques to control them.
  - Time Management: Prioritize tasks, delegate when possible, and avoid overcommitting.
  - Healthy Coping Mechanisms: Engage in enjoyable activities, exercise regularly, and maintain social connections.
Ice Packs: Applying cold to the head or neck can help constrict blood vessels and reduce pain.
- Apply a cold compress to the forehead, temples, or back of the neck.
- Wrap the ice pack in a cloth to protect the skin.
- Apply for 15-20 minutes at a time, with breaks in between.
Regular exercise: reduce migraine frequency and intensity.
- Choose low-impact activities like walking, swimming, or cycling.
- Avoid strenuous exercise, which can sometimes trigger migraines.
Hydration: Dehydration can trigger migraines, so drink plenty of water throughout the day.
Magnesium Supplementation: Some studies suggest that magnesium supplements may help prevent migraines.

Diagnosis: Medication overuse headache

It is related with use of nonprescription analgesic including acetaminophen, aspirin, caffeine, triptans, opioids, butalbital, or ergotamines.

Action

Identify the offending agent(s):
- Regular intake on 10 days/month for >3 months: Ergotamine, Triptan, Opioid, Combination-analgesic
- Regular intake on 15 days/month for >3 months: Non-opioid analgesic (Paracetamol (Acetaminophen), Acetylsalicylic acid, NSAIDS)
Taper and eliminate the offending agent(s): Gradually reduce the dose of the overused medication(s) over a period of time, rather than abruptly stopping them. Then completely discontinue their use.
Medical referral if headache persists

Recommendation: Remove exacerbating factors and use Pharmacological and non-pharmacological treatment

Diagnosis: Tension headache Causes of tension headache: It is due to myofascial pain that manifests in response to stress, anxiety, depression, emotional conflicts, fatigue and repressed hostility. Tight muscles in the upper back, head, and neck area can cause headaches.

Inquire: First inquire about the exacerbating factor and relieving factors which may include alcohol, caffeine intake, improper sleep habit, Nicotine and other stimulant use, Menstrual cycle and proximity to menopause, hydration.

Pharmacological treatment

Recommend salicylates, acetaminophen, ibuprofen, naproxen or ketoprofen as appropriate (<=3 times/week)

Acetaminophen.
- Dosing: 10-15 mg/kg every 4-6 hours, not to exceed 4000 mg/day.
- Time to effect: 30-60 min to reduce 1-2F with maximum reduction with 2 hours
- Caution:
  - Liver toxicity with high doses or in patients with liver disease.
    - Overdose symptoms (>4gm per day)- N/V, rashes (rare) and eventually hepatic failure (may appear only after 4-6 days)
    - A/E: Nausea, hepatotoxicity, rash (rare)
  - Safe in
    - Pregnancy (safe if used <8 days. Emerging evidence in ADHD in child when used >29 days)
    - breastfeeding: crosses breast milk but safe. A rare occurrence of maculopapular rash in infants but will subside with discontinuation
    - aspirin hypersensitive patients,
    - GI ulceration,
    - Patient on anticoagulants, methotrexates or thiazides,
    - pt with renal, cardiac impairment in
    - conjunction of diuretics or ACE inhibitors;
    - elderly and
    - babies over 3 months.
  - A/E monitoring: If signs of liver toxicity occur (jaundice, right upper quadrant pain)- Refer

Does the patient have NSAID contraindication like GI ulcers, renal diseases? If no use NSAID (Ibuprofen/Naproxen) otherwise use acetaminophen or NSAID with PPI.
- Dosing:
  - Ibuprofen: 5-10 mg/kg every 4 to 6 hours as needed, not to exceed 1200 mg/day (OTC)
    - It takes 30-60 min to reduce 1-2F with maximum reduction with 2 hours
  - Naproxen: 220 mg every 8-12 hours as needed, not to exceed 660 mg/day (OTC).
    - preferred among NSAIDs for those patients having cardiovascular risks (use minimum dose for shortest duration)
- Onset: Naproxen/ibuprofen: 30 minutes
- CI: naproxen: <12 years age; salicylates: <18 years; ketoprofen: < 16 years
- Special consideration
  - COX-2 selective preferred for patients having GI issues
  - Pregnancy: avoid (esp third semested) due to risk of bleeding potential, pregnancy prolongation and teratogenic effect.
  - Breastfeeding: Naproxen avoid in lactating mothers. Ibuprofen is considered safe.
  - Elderly: Cautiously use in elderly above 65 years (short term use is likely less problematic)
  - Children: Ibuprofen can be used for patients above 6 months age; Naproxen can be used for children above 12 years
- Caution:
  - Causes GI irritation, bleeding risk, renal effects. Avoid in patients with a history of Asthma with nasal polyps, chronic/recurrent GI ulcers, gout, coagulation disorders or anticoagulant therapy, high blood pressure, CHF, kidney disease, or aspirin allergy.
- A/E monitoring:
  - GI: Heartburn, nausea, abdominal pain, black stools (melena), vomiting blood.
    - Action: Take with food.
    - Referral: If signs of GI bleeding occur.
  - Renal: Decreased urine output, swelling in legs/ankles.
    - Referral: In patients with pre-existing renal disease.
Patient may report a better response to one NSAIDs than to another for unknown reason. if one NSAIDs fail to provide relief, another may be tried.

Non-pharmacological treatment

Relaxation Techniques: Tension-type headaches are often triggered or exacerbated by stress, anxiety, and muscle tension.
- Deep Breathing Exercises: Slow, deep breaths can help to relax muscles and reduce stress.
- Progressive Muscle Relaxation: Tensing and then relaxing different muscle groups in the body, to identify and release tension.
- Meditation/Mindfulness: Focusing on the present moment can help to quiet the mind and reduce stress.
- Yoga/Tai Chi: These practices combine physical postures, breathing exercises, and meditation
Physical Therapy: Tension-type headaches are frequently associated with tight muscles in the neck, shoulders, and upper back.
- Stretching: Specific stretches can help to lengthen and relax tight muscles in the neck and shoulders.
- Strengthening Exercises: Strengthening weak muscles can improve posture and reduce muscle strain.
- Manual Therapy: A physical therapist may use hands-on techniques such as massage, joint mobilization, or manipulation to release muscle tension and improve joint function.
- Postural Correction: Improving posture can reduce strain on the muscles of the head, neck, and shoulders.
- Trigger Point Therapy: Trigger points are tight knots in muscles that can refer pain to other areas. Physical therapists can use various techniques to release trigger points.
Stress Management: Identify stressors, develop coping mechanisms (Time management, Regular exercise, Hobbies, Adequate sleep)
Sleep Hygiene:
- Regular sleep schedule: Aim for consistent sleep and wake times.
- Adequate sleep duration: Most adults need 7-9 hours of sleep per night.
- Relaxing bedtime routine: Create a calming routine before bed to promote sleep.
Ergonomics:
- Proper workstation setup: Ensure your chair, desk, and computer monitor are positioned correctly to minimize strain.
- Regular breaks: Take breaks from prolonged sitting or computer work to stretch and move around.
Heat or Cold Therapy: Applying a heating pad or ice pack to the neck or shoulders can help to relieve muscle tension and pain.

Drug interaction

Acetaminophen
- With alcohol
  - Potential effect: Increased hepatotoxicity risk
    - Management and preventive measure: avoid concurrent use, minimize alcohol intake when acetaminophen use
- With warfarin
  - Potential effect: Increase bleeding risk (elevate INR)
    - Management and preventive measure: limit acetaminophen to occasional use; monitor INR for several weeks when acetaminophen 2-4 gm is added or discontinued in patients on warfarin. Acetaminophen < 2gm may not alter INR
Aspirin
- With NSAIDS including COX-2 inhibitors
  - Potential effect: increased risk of GI bleeding and ulcers
    - Management and preventive measure: avoid
Ibuprofen
- With Aspirin (CV prophylaxis)
  - Potential effect: decreased antiplatelet effect of aspirin
    - Management and preventive measure: take aspirin 30 minutes before or 8 hours after ibuprofen. Use acetaminophen or other analgesic instead
NSAIDs
- With Bisphosphonates
  - Potential effect: increased GI ulceration
    - Management and preventive measure: use with caution and monitor
- With Digoxin
  - Potential effect: decreased digoxin renal clearance
    - Management and preventive measure: monitor digoxin, adjust dose
- With agents with antiplatelet properties (SSRIs, NSAIDs, P2Y12 inhibitors)
  - Potential effect: increased bleeding risk
    - Management and preventive measure: monitor therapy
- With antihypertensive agents (e.g., beta blockers, ACEIs, vasodilators, diuretics)
  - Potential effect: antihypertensive effect inhibited; possible hyperkalemia with potassium-sparing diuretics and ACEIs
    - Management and preventive measure: monitor BP, cardiac function and potassium level
- With Anticoagulants
  - Potential effect: increased bleeding risk (esp. GI)
    - Management and preventive measure: avoid
- With Alcohol
  - Potential effect: increased bleeding risk
    - Management and preventive measure: avoid concurrent use, minimize alcohol intake when NSAIDs use
- With Methotrexate
  - Potential effect: decreased methotrexate clearance
    - Management and preventive measure: avoid NSAIDs with high-dose methotrexate therapy, monitor levels
- With Sulfonylureas
  - Potential effect: increased hypoglycemia risk
    - Management and preventive measure: avoid concurrent use, if possible monitor blood glucose level when changing dose
- With Caffeine
  - Potential effect: have additive effect
    - Management and preventive measure: monitor for side effect such as nausea, headache, insomnia

Recommendation: Non-pharmacological and pharmacological therapy as prescribed previously

Recommendation: Non-pharmacological and pharmacological therapy

Pharmacological therapy Oral decongestant (Pseudoephedrine/Phenylephrine) + Nasal Saline Irrigation.

- - Dosing
    - Pseudoephedrine for adults: 30-60 mg every 4-6 hours, not to exceed 240 mg/day.
    - Phenylephrine for adults: 10 mg every 4 hours, not to exceed 60 mg/day. less effective than pseudoephedrine in some individuals.
  - Avoid in pregnancy
  - CI: < six years and treatment for children aged six to 12 years should be restricted to five days or less.
  - pseudoephedrine max dose: 240 mg/day

** For rapid relief (≤ 3-5 days): Nasal Decongestant Spray (Oxymetazoline/Xylometazoline) may be added.

Dosing: 1-2 sprays in each nostril every 10-12 hours for no more than 3-5 days
Use cautiously in patients with hypertension

Patient information

When to See a Doctor?

While many cases of acute sinusitis resolve with self-care, seek medical attention if:

You have severe symptoms.
Your symptoms don't improve after 7-10 days of self-treatment.
You have a high fever.
You have changes in vision.
You have severe headache or facial pain.
You have neurological symptoms (e.g., confusion).
You have recurrent sinusitis.

Non-Pharmacological Treatment for relieving symptoms and promoting sinus drainage.

Saline Nasal Irrigation :Rinses nasal passages and sinuses with saline solution, sterile water or distilled water using a squeeze bottle, neti pot, or bulb syringe.
Steam Inhalation: Breathing in steam from a bowl of hot water or taking a hot shower.
Apply Warm Compresses
Drink plenty of fluids helps to thin mucus and promote drainage.
Rest allows the body to focus its energy on fighting the infection.
Humidification: Use a humidifier can help to keep nasal passages moist.

Pharmacological Information

Decongestants: Reduce nasal congestion by constricting blood vessels, improving sinus drainage.
- Oral decongestants
  - Compatible with breast feeding
  - Avoid taking at bedtime, because of potential to cause insomnia and restlessness
  - Use cautiously with patients taking MAOIs and antidepressants.
  - A/E monitoring
    - Cardiovascular: Increased heart rate, palpitations, increased blood pressure.
      - Action: Monitor BP and HR, especially in susceptible individuals.
      - Referral: If severe chest pain, irregular heartbeat, or significantly elevated BP occur.
    - Central Nervous System: Anxiety, nervousness, insomnia, dizziness, headache.
      - Action: Advise to take the last dose several hours before bedtime.
      - Referral: If severe agitation or seizures occur.
    - Urinary: Difficulty urinating (especially in men with prostate enlargement).
      - Action: Advise patients about this potential side effect.
      - Referral: If acute urinary retention develops.
- Nasal Decongestant Sprays:
  - Avoid use for more than 3-5 days to avoid rebound congestion
  - Pregnancy: may be used during pregnancy owing to low systemic absorption
  - A/E monitoring
    - Local: Nasal dryness, irritation, burning, sneezing.
      - Action: Advise on proper spray technique.
    - Rebound congestion: Worsening congestion with prolonged use.
      - Action: Emphasize the 3-5 day limit of use.
      - Referral: If severe rebound congestion develops and does not resolve with discontinuation.
Nasal Corticosteroids: Reduce inflammation in the nasal passages and sinuses.
- They are effective for both acute and chronic sinusitis, especially when allergies are a contributing factor. Generally safe for long-term use at recommended doses.
- A/E monitoring
  - Local: Nasal dryness, irritation, burning, sneezing, epistaxis (nosebleeds).
    - Action: Advise on proper spray technique (aiming away from the septum).
  - Systemic: Although rare with nasal sprays, high doses or prolonged use could lead to systemic corticosteroid effects.
    - Referral: If signs of systemic effects (e.g., Cushing's syndrome) are suspected with long-term use.
Analgesics: Acetaminophen (paracetamol) and nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen or naproxen can relieve pain and fever.
- patient may report a better response to one NSAIDs than to another for unknown reason. if one NSAIDs fail to provide relief, another may be tried.
- Caution:
  - Acetaminophen: Liver toxicity with high doses or in patients with liver disease.
    - Overdose symptoms (>4gm per day)- N/V, rashes (rare) and eventually hepatic failure (may appear only after 4-6 days)
    - A/E: Nausea, hepatotoxicity, rash (rare)
    - Safe in
      - Pregnancy (safe if used <8 days. Emerging evidence in ADHD in child when used >29 days)
      - breastfeeding: crosses breast milk but safe. A rare occurence of maculopapulat rash in infants but will subscide with discontinuation
      - aspirin hypersensitive patients,
      - GI ulceration,
      - pt on anticoagulants, methotrexates or thiazides,
      - pt with renal, cardiac impairment in
      - conjunction of diuretics or ACE inhibitors;
      - elderly and
      - babies over 3 months.
  - NSAIDs: GI irritation, bleeding risk, renal effects. Avoid in patients with a history of ulcers, bleeding disorders, or renal disease.
- A/E monitoring
  - Acetaminophen: Referral: If signs of liver toxicity occur (jaundice, right upper quadrant pain).
  - NSAIDs:
    - GI: Heartburn, nausea, abdominal pain, black stools (melena), vomiting blood.
      - Action: Take with food.
      - Referral: If signs of GI bleeding occur.
    - Renal: Decreased urine output, swelling in legs/ankles.
      - Referral: In patients with pre-existing renal disease.
Antibiotics: Most cases of acute sinusitis are caused by viruses and do not require antibiotics.
- Antibiotics are indicated if:
  - Symptoms are severe.
  - Symptoms worsen after initial improvement.
  - Symptoms persist for more than 10 days.
  - Bacterial sinusitis is suspected.
- First-line antibiotics: Amoxicillin (with or without clavulanate). Antibiotic choice depends on local resistance patterns and individual patient factors (allergies, etc.).

Recommendation: Non-pharmacological and pharmacological therapy

Pharmacological therapy Since patient has history of hypertension/ cardiovascular disease/ prostrate disease/ diabetes/ hyperthyroidism/ increased intraocular pressure, the patient is contraindicated to oral decongestant. Therapy: Nasal Saline Irrigation ± Nasal Corticosteroid.

Dosing: Fluticasone Propionate/ Mometasone Furoate/ Budesonide: 2 sprays in each nostril once or twice daily.

** For rapid relief (≤ 3-5 days): Nasal Decongestant Spray (Oxymetazoline/Xylometazoline) may be added.

Dosing: 1-2 sprays in each nostril every 10-12 hours for no more than 3-5 days
Use cautiously in patients with hypertension

Patient information

When to See a Doctor?

While many cases of acute sinusitis resolve with self-care, seek medical attention if:

You have severe symptoms.
Your symptoms don't improve after 7-10 days of self-treatment.
You have a high fever.
You have changes in vision.
You have severe headache or facial pain.
You have neurological symptoms (e.g., confusion).
You have recurrent sinusitis.

Non-Pharmacological Treatment for relieving symptoms and promoting sinus drainage.

Saline Nasal Irrigation :Rinses nasal passages and sinuses with saline solution, sterile water or distilled water using a squeeze bottle, neti pot, or bulb syringe.
Steam Inhalation: Breathing in steam from a bowl of hot water or taking a hot shower.
Apply Warm Compresses
Drink plenty of fluids helps to thin mucus and promote drainage.
Rest allows the body to focus its energy on fighting the infection.
Humidification: Use a humidifier can help to keep nasal passages moist.

Pharmacological Information

Decongestants: Reduce nasal congestion by constricting blood vessels, improving sinus drainage.
- Oral decongestants
  - Compatible with breast feeding
  - Avoid taking at bedtime, because of potential to cause insomnia and restlessness
  - Use cautiously with patients taking MAOIs and antidepressants.
  - A/E monitoring
    - Cardiovascular: Increased heart rate, palpitations, increased blood pressure.
      - Action: Monitor BP and HR, especially in susceptible individuals.
      - Referral: If severe chest pain, irregular heartbeat, or significantly elevated BP occur.
    - Central Nervous System: Anxiety, nervousness, insomnia, dizziness, headache.
      - Action: Advise to take the last dose several hours before bedtime.
      - Referral: If severe agitation or seizures occur.
    - Urinary: Difficulty urinating (especially in men with prostate enlargement).
      - Action: Advise patients about this potential side effect.
      - Referral: If acute urinary retention develops.
- Nasal Decongestant Sprays:
  - Avoid use for more than 3-5 days to avoid rebound congestion
  - Pregnancy: may be used during pregnancy owing to low systemic absorption
  - A/E monitoring
    - Local: Nasal dryness, irritation, burning, sneezing.
      - Action: Advise on proper spray technique.
    - Rebound congestion: Worsening congestion with prolonged use.
      - Action: Emphasize the 3-5 day limit of use.
      - Referral: If severe rebound congestion develops and does not resolve with discontinuation.
Nasal Corticosteroids: Reduce inflammation in the nasal passages and sinuses.
- They are effective for both acute and chronic sinusitis, especially when allergies are a contributing factor. Generally safe for long-term use at recommended doses.
- A/E monitoring
  - Local: Nasal dryness, irritation, burning, sneezing, epistaxis (nosebleeds).
    - Action: Advise on proper spray technique (aiming away from the septum).
  - Systemic: Although rare with nasal sprays, high doses or prolonged use could lead to systemic corticosteroid effects.
    - Referral: If signs of systemic effects (e.g., Cushing's syndrome) are suspected with long-term use.
Analgesics: Acetaminophen (paracetamol) and nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen or naproxen can relieve pain and fever.
- patient may report a better response to one NSAIDs than to another for unknown reason. if one NSAIDs fail to provide relief, another may be tried.
- Caution:
  - Acetaminophen: Liver toxicity with high doses or in patients with liver disease.
    - Overdose symptoms (>4gm per day)- N/V, rashes (rare) and eventually hepatic failure (may appear only after 4-6 days)
    - A/E: Nausea, hepatotoxicity, rash (rare)
    - Safe in
      - Pregnancy (safe if used <8 days. Emerging evidence in ADHD in child when used >29 days)
      - breastfeeding: crosses breast milk but safe. A rare occurence of maculopapulat rash in infants but will subscide with discontinuation
      - aspirin hypersensitive patients,
      - GI ulceration,
      - pt on anticoagulants, methotrexates or thiazides,
      - pt with renal, cardiac impairment in
      - conjunction of diuretics or ACE inhibitors;
      - elderly and
      - babies over 3 months.
  - NSAIDs: GI irritation, bleeding risk, renal effects. Avoid in patients with a history of ulcers, bleeding disorders, or renal disease.
- A/E monitoring
  - Acetaminophen: Referral: If signs of liver toxicity occur (jaundice, right upper quadrant pain).
  - NSAIDs:
    - GI: Heartburn, nausea, abdominal pain, black stools (melena), vomiting blood.
      - Action: Take with food.
      - Referral: If signs of GI bleeding occur.
    - Renal: Decreased urine output, swelling in legs/ankles.
      - Referral: In patients with pre-existing renal disease.
Antibiotics: Most cases of acute sinusitis are caused by viruses and do not require antibiotics.
- Antibiotics are indicated if:
  - Symptoms are severe.
  - Symptoms worsen after initial improvement.
  - Symptoms persist for more than 10 days.
  - Bacterial sinusitis is suspected.
- First-line antibiotics: Amoxicillin (with or without clavulanate). Antibiotic choice depends on local resistance patterns and individual patient factors (allergies, etc.).

Recommendation: Non-pharmacological and pharmacological therapy

Pharmacological therapy

Nasal Saline Irrigation + Nasal Corticosteroid + Analgesic

Pain/Fever Only: Acetaminophen.
- Dosing: 10-15 mg/kg every 4-6 hours, not to exceed 4000 mg/day.
- Time to effect: 30-60 min to reduce 1-2F with maximum reduction with 2 hours
Inflammation Component: Does the patient have NSAID CI like GI ulcers, renal diseases? If no use NSAID (Ibuprofen/Naproxen) otherwise use acetaminophen or NSAID with PPI.
- Dosing:
  - Ibuprofen: 5-10 mg/kg every 4 to 6 hours as needed, not to exceed 1200 mg/day (OTC)
    - It takes 30-60 min to reduce 1-2F with maximum reduction with 2 hours
  - Naproxen: 220 mg every 8-12 hours as needed, not to exceed 660 mg/day (OTC).
    - preferred among NSAIDs for those patients having cardiovascular risks (use minimum dose for shortest duration)
- Onset: Naproxen/ibuprofen: 30 minutes
- CI: naproxen: <12 years age; salicylates: <18 years; ketoprofen: < 16 years
- Special consideration
  - COX-2 selective preferred for patients having GI issues
  - Pregnancy: avoid (esp third semested) due to risk of bleeding potential, pregnancy prolongation and teratogenic effect.
  - Breastfeeding: Naproxen avoid in lactating mothers. Ibuprofen is considered safe.
  - Elderly: Cautiously use in elderly above 65 years (short term use is likely less problematic)
  - Children: Ibuprofen can be used for patients above 6 months age; Naproxen can be used for children above 12 years
Nasal Corticosteroid: Fluticasone Propionate/ Mometasone Furoate/ Budesonide: 2 sprays in each nostril once or twice daily.

Patient information

When to See a Doctor?

While many cases of acute sinusitis resolve with self-care, seek medical attention if:

You have severe symptoms.
Your symptoms don't improve after 7-10 days of self-treatment.
You have a high fever.
You have changes in vision.
You have severe headache or facial pain.
You have neurological symptoms (e.g., confusion).
You have recurrent sinusitis.

Non-Pharmacological Treatment for relieving symptoms and promoting sinus drainage.

Saline Nasal Irrigation :Rinses nasal passages and sinuses with saline solution, sterile water or distilled water using a squeeze bottle, neti pot, or bulb syringe.
Steam Inhalation: Breathing in steam from a bowl of hot water or taking a hot shower.
Apply Warm Compresses
Drink plenty of fluids helps to thin mucus and promote drainage.
Rest allows the body to focus its energy on fighting the infection.
Humidification: Use a humidifier can help to keep nasal passages moist.

Pharmacological Information

Decongestants: Reduce nasal congestion by constricting blood vessels, improving sinus drainage.
- Oral decongestants
  - Compatible with breast feeding
  - Avoid taking at bedtime, because of potential to cause insomnia and restlessness
  - Use cautiously with patients taking MAOIs and antidepressants.
  - A/E monitoring
    - Cardiovascular: Increased heart rate, palpitations, increased blood pressure.
      - Action: Monitor BP and HR, especially in susceptible individuals.
      - Referral: If severe chest pain, irregular heartbeat, or significantly elevated BP occur.
    - Central Nervous System: Anxiety, nervousness, insomnia, dizziness, headache.
      - Action: Advise to take the last dose several hours before bedtime.
      - Referral: If severe agitation or seizures occur.
    - Urinary: Difficulty urinating (especially in men with prostate enlargement).
      - Action: Advise patients about this potential side effect.
      - Referral: If acute urinary retention develops.
- Nasal Decongestant Sprays:
  - Avoid use for more than 3-5 days to avoid rebound congestion
  - Pregnancy: may be used during pregnancy owing to low systemic absorption
  - A/E monitoring
    - Local: Nasal dryness, irritation, burning, sneezing.
      - Action: Advise on proper spray technique.
    - Rebound congestion: Worsening congestion with prolonged use.
      - Action: Emphasize the 3-5 day limit of use.
      - Referral: If severe rebound congestion develops and does not resolve with discontinuation.
Nasal Corticosteroids: Reduce inflammation in the nasal passages and sinuses.
- They are effective for both acute and chronic sinusitis, especially when allergies are a contributing factor. Generally safe for long-term use at recommended doses.
- A/E monitoring
  - Local: Nasal dryness, irritation, burning, sneezing, epistaxis (nosebleeds).
    - Action: Advise on proper spray technique (aiming away from the septum).
  - Systemic: Although rare with nasal sprays, high doses or prolonged use could lead to systemic corticosteroid effects.
    - Referral: If signs of systemic effects (e.g., Cushing's syndrome) are suspected with long-term use.
Analgesics: Acetaminophen (paracetamol) and nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen or naproxen can relieve pain and fever.
- patient may report a better response to one NSAIDs than to another for unknown reason. if one NSAIDs fail to provide relief, another may be tried.
- Caution:
  - Acetaminophen: Liver toxicity with high doses or in patients with liver disease.
    - Overdose symptoms (>4gm per day)- N/V, rashes (rare) and eventually hepatic failure (may appear only after 4-6 days)
    - A/E: Nausea, hepatotoxicity, rash (rare)
    - Safe in
      - Pregnancy (safe if used <8 days. Emerging evidence in ADHD in child when used >29 days)
      - breastfeeding: crosses breast milk but safe. A rare occurrence of maculopapular rash in infants but will subside with discontinuation
      - aspirin hypersensitive patients,
      - GI ulceration,
      - pt on anticoagulants, methotrexates or thiazides,
      - pt with renal, cardiac impairment in
      - conjunction of diuretics or ACE inhibitors;
      - elderly and
      - babies over 3 months.
  - NSAIDs: GI irritation, bleeding risk, renal effects. Avoid in patients with a history of ulcers, bleeding disorders, or renal disease.
- A/E monitoring
  - Acetaminophen: Referral: If signs of liver toxicity occur (jaundice, right upper quadrant pain).
  - NSAIDs:
    - GI: Heartburn, nausea, abdominal pain, black stools (melena), vomiting blood.
      - Action: Take with food.
      - Referral: If signs of GI bleeding occur.
    - Renal: Decreased urine output, swelling in legs/ankles.
      - Referral: In patients with pre-existing renal disease.
Antibiotics: Most cases of acute sinusitis are caused by viruses and do not require antibiotics.
- Antibiotics are indicated if:
  - Symptoms are severe.
  - Symptoms worsen after initial improvement.
  - Symptoms persist for more than 10 days.
  - Bacterial sinusitis is suspected.
- First-line antibiotics: Amoxicillin (with or without clavulanate). Antibiotic choice depends on local resistance patterns and individual patient factors (allergies, etc.).

Drug Interaction

Acetaminophen
- With alcohol
  - Potential effect: Increased hepatotoxicity risk
    - Management and preventive measure: avoid concurrent use, minimize alcohol intake when acetaminophen use
- With warfarin
  - Potential effect: Increase bleeding risk (elevate INR)
    - Management and preventive measure: limit acetaminophen to occasional use; monitor INR for several weeks when acetaminophen 2-4 gm is added or discontinued in patients on warfarin. Acetaminophen < 2gm may not alter INR
Aspirin
- With NSAIDS including COX-2 inhibitors
  - Potential effect: increased risk of GI bleeding and ulcers
    - Management and preventive measure: avoid
Ibuprofen
- With Aspirin (CV prophylaxis)
  - Potential effect: decreased antiplatelet effect of aspirin
    - Management and preventive measure: take aspirin 30 minutes before or 8 hours after ibuprofen. Use acetaminophen or other analgesic instead
NSAIDs
- With Bisphosphonates
  - Potential effect: increased GI ulceration
    - Management and preventive measure: use with caution and monitor
- With Digoxin
  - Potential effect: decreased digoxin renal clearance
    - Management and preventive measure: monitor digoxin, adjust dose
- With agents with antiplatelet properties (SSRIs, NSAIDs, P2Y12 inhibitors)
  - Potential effect: increased bleeding risk
    - Management and preventive measure: monitor therapy
- With antihypertensive agents (e.g., beta blockers, ACEIs, vasodilators, diuretics)
  - Potential effect: antihypertensive effect inhibited; possible hyperkalemia with potassium-sparing diuretics and ACEIs
    - Management and preventive measure: monitor BP, cardiac function and potassium level
- With Anticoagulants
  - Potential effect: increased bleeding risk (esp. GI)
    - Management and preventive measure: avoid
- With Alcohol
  - Potential effect: increased bleeding risk
    - Management and preventive measure: avoid concurrent use, minimize alcohol intake when NSAIDs use
- With Methotrexate
  - Potential effect: decreased methotrexate clearance
    - Management and preventive measure: avoid NSAIDs with high-dose methotrexate therapy, monitor levels
- With Sulfonylureas
  - Potential effect: increased hypoglycemia risk
    - Management and preventive measure: avoid concurrent use, if possible monitor blood glucose level when changing dose
- With Caffeine
  - Potential effect: have additive effect
    - Management and preventive measure: monitor for side effect such as nausea, headache, insomnia

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Calculations

Symptom Management

Recommendation: Remove exacerbating factors and use Pharmacological and non-pharmacological treatment

Patient information

Recommendation: Non-pharmacological and pharmacological therapy

Patient information

Recommendation: Non-pharmacological and pharmacological therapy

Pharmacological therapy

Patient information

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Calculations

Symptom Management

Recommendation: Remove exacerbating factors and use Pharmacological and non-pharmacological treatment

Patient information

Recommendation: Non-pharmacological and pharmacological therapy

Patient information

Recommendation: Non-pharmacological and pharmacological therapy

Pharmacological therapy

Patient information

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