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INTRODUCTION

Pharmacy technicians are valuable members of the health care team. The technician's role is expanding for several reasons. First is the current climate in which some pharmacies have chosen to control costs by reducing the total number of employee hours, including fewer days with 2 pharmacists working simultaneously. With reduced pharmacist hours, technicians are even more likely to be the primary contact for patients who enter the pharmacy seeking self-care. Further, the attention of pharmacists is being increasingly diverted to such tasks as providing medication therapy management and administering vaccines. As a result, pharmacists often have less time to spend in the front end of the pharmacy to discuss self-care issues with patients. Since headaches and minor pains are common reasons for patients to seek self-care counseling, it is critical for the pharmacy technician to gather relevant information.¹ Though technicians should not make recommendations to the patient, they can communicate the information gathered to the pharmacist to allow him of her to make a rapid and accurate triage decision and to decide when a nonprescription product or device might be helpful.

GATHERING INFORMATION FROM PATIENTS

Patients with headache and other painful conditions enter the pharmacy for numerous reasons.¹ Some patients have already decided which product they wish to purchase, perhaps, because of a recommendation from family or friends, an ad on the Internet or television, past successful use of the product, or having a coupon. Often, they choose the desired product and move directly to the register, not seeking assistance. This is a difficult group to counsel as they have preselected a product before entering the pharmacy.¹ Another group of patients may have a preferred product in mind, but patients in this group need help locating it or wish to ask if it is the best product for headache or other painful conditions. A final group of patients consists of those who do not have a product in mind but approach the technician or pharmacist to discuss their symptoms and preferable treatment options.¹ These latter two groups present opportunities for pharmacy technicians to gather and communicate useful information to the pharmacist, which will allow him or her to make a professional judgment regarding patient care. There are several useful pieces of information to be ascertained.¹

A useful tool that can aid the technician in conducting an efficient patient interview is a memory aid the author calls “CADCOM.” Each letter stands for a component of the patient interview process. “C” stands for the condition which prompted the patient to enter the pharmacy. In this lesson, the condition is pain, either due to headache or other medical problems. Much of the lesson will allow the technician to help the pharmacist determine which patients can safely use nonprescription products and which should be referred to a prescriber. “A” reminds the technician to ask about the age of the patient. “D” is a reminder to ask about the duration of the pain. The second “C” represents the interview step of asking the patient about contraindications and other medical conditions. The final two letters, “OM,” complete the structured interview by asking the patient about other medications they are taking, as well as nicotine and alcohol use. Each of these patient variables is discussed in more detail below.

Patient age

Early in the conversation, the pharmacy technician should inquire about the patient's age. It is easy to assume that the one asking the questions is the patient, but he or she may be a mother or father who wishes to administer the product to an infant. Age is critical because most nonprescription product labels have an age below which they should not be used without a physician recommendation.¹ These requirements exist because some medications can be unsafe in certain age groups or because there are no studies showing the active ingredients to be effective in certain groups. Thus, the pharmacist must know the age of the patient before making a decision.¹

Duration of the condition

Another critical piece of information that must be gathered is how long the symptoms have been present. For example, oral analgesics should not be used longer than 10 days without physician supervision.¹ If the patient has already been using nonprescription products on his or her own for 10 days or more, a physician referral is the best advice. This information must be communicated to the pharmacist.

Contraindications; Other medical situations

Products for headache and other painful conditions also carry numerous precautions against their use if the patient has additional medical issues (eg, pregnancy, breastfeeding) or symptoms (eg, redness, swelling).¹ Thus, the technician can ask a global question such as: Do you have any other medical conditions or symptoms that I should inform the pharmacist about?

Use of other medications, alcohol, or nicotine

Many nonprescription products carry warnings against their use if the patient is taking certain prescription medications or if he or she drinks alcoholic beverages.¹ Some should not be used if the problem is due to smoking (e.g., chronic cough). For these reasons, some relevant questions to ask might be: Are you taking any other medications at this time? Do you drink alcohol or smoke? However, it is important to remember that these personal questions should be addressed in an area of the pharmacy where others cannot overhear the discussion.¹

Presenting information to the pharmacist

Once the information is gathered, the technician can approach the pharmacist and offer a patient summary, such as the following: There is a 36-year-old female patient out front asking for help with headache. She thinks it might be migraine but she's never had a doctor diagnose it. She is taking birth control tablets and anxiety medications. This brief synopsis of the patient interview gives the pharmacist vital information. As a result, the pharmacist can approach the patient and delve more deeply into her medical issues, such as her history of headaches, triggers that bring it about, and additional issues.¹

Frequency of headache and conditions causing pain

Pharmacy technicians may quickly realize that headache and minor pains are frequent conditions for which patients request assistance. Fortunately, these common conditions are seldom due to serious causes, and careful questioning can often allow the technician to present the pharmacist with critical information that will help him or her reach a medically justified treatment decision. The majority of people have experienced headache or minor pains at one time or another.^1,2 In fact, data suggest that more than 90% of adults will have headache during his or her life, but the actual percentage is likely higher than reported because many people self-treat.³ The same is true of other common conditions causing pain, such as tendinitis, overuse syndromes, and minor sprains.¹

LISTENING FOR RED FLAGS OR ALARM SITUATIONS WHILE GATHERING INFORMATION

When the technician first speaks with a patient who is suffering from headache or common conditions causing pain, it is vital to listen for specific alarm situations that necessitate a physician visit. In many cases, the sooner the patient visits a physician the better, even if it means a trip to the emergency room. If the patient has any red flags (alarm situations), they must be communicated to the pharmacist.^1,3,4

Alarm situations for patients with headache

Headaches fall into 2 general categories.^1,3 One is the benign or primary headache, meaning that it is not caused by any underlying medical condition; nearly all (99%) headaches are the primary type.¹ Another type of headache is the organic or secondary headache, and this type is due to an underlying medical condition that can be very serious. In most cases of secondary headache, the patient can relate certain manifestations that point to an existing condition. These are known as red flag or alarm situations, which require medical referral. They include the following scenarios^1,3,4:

• This is the first headache of the patient's life, especially if it interferes with daily activities.
• The headache is accompanied by loss of balance, slurred speech, weakness, double vision, any other change in vision, stiff neck, light sensitivity, nausea, vomiting, or fever.
• The headache resulted from exertion or exercise such as jogging, sex, or weightlifting.
• The patient or his or her family noticed a period of reduced awareness of surroundings, loss of consciousness, reduced mental functioning, confusion, memory loss, a loss of sensation in any part of the body, or problems moving the arms or legs.
• This is the worst headache the patient has ever had.
• The headache was an excruciating pain of sudden onset, unprovoked by any activity; this is known as the thunderclap headache.
• The headache reached a peak pain level within 1 minute of onset and lasted for 1 hour or more.
• The headache began gradually but worsened over a period of days or weeks, perhaps also with fever.
• The patient has glaucoma.
• The headache awakened the patient from sleep.
• The patient is over the age of 50 and without a previous history of headache.
• The patient also had convulsions or shortness of breath.
• The headache follows a blow to the head. This is known as posttraumatic headache, and the patient must be referred to determine whether a concussion is present.
• The patient may have been exposed to carbon monoxide. This can cause a headache, and requires immediate referral to an emergency room. The technician should be acutely sensitive to this issue at the beginning of the cold season when patients first begin to heat their homes or apartments.
• The patient suspects that a medication might be the cause of headache.
• The patient's headache may be due to overuse of headache medications (eg, the patient indicates that they are already taking high doses of prescription or nonprescription medications, but they are not helping).¹

Alarm situations for patients with other common conditions causing pain

Just as headache has warning signs of danger, the technician should also listen carefully to patients complaining of other common conditions causing pain so that specific alarm situations can be communicated to the pharmacist. For example, in the case of backache, experts have developed another series of red flag situations, each of which requires a referral to a physician—and perhaps an emergency room. They include the following scenarios¹ :

• The patient is younger than 20 or older than 55 years of age.
• The patient is a young child with a history of previous fractures (eg, possible child abuse).
• The back pain is progressive pain and it is unrelieved by rest or medication.
• The back pain radiates down the back of the thigh to the patient's leg.
• The patient also complains of weakness, numbness, tingling, bowel and/or bladder incontinence, gait abnormalities, fever and/or chills, a urethral discharge, or pain and/or burning on urination.
• The patient has a history of cancer or a chronic disease (eg, HIV, diabetes, hepatitis) or immunosuppression.
• The back pain worsens at night or when lying down.
• The patient uses illegal intravenous drugs or is an alcoholic.
• The back pain occurred as a result of a traumatic event (eg, fall, car accident).
• The patient also mentions having undergone an unexplained weight loss (eg, 15 pounds in 90 days without dieting or exercising).
• The patient is at a high risk for fracture, perhaps having a diagnosis of osteoporosis.¹

Aches and pains other than headache or backache could also be dangerous. Products promoted for these conditions bear FDA-approved warnings and precautions to help ensure that the patient does not use them in potentially dangerous situations. These precautions are included in product labeling, which are discussed below.¹ Importantly, the nonprescription drugs that are mentioned in this article for headache and/or pain (with the exception of certain topical products) are those that have been deemed safe and effective by the US Food and Drug Administration—either through the over-the-counter (OTC) drug monograph system or a new drug application. Thus, dietary supplements, herbal products, and homeopathic medicines are not discussed. This information is important to keep in mind when responding to questions from patients and consumers about these products.

SELF-TREATABLE HEADACHES

Labeling for nonprescription pain relief products list the various types of pain that can be self-treated. Four types of primary headaches can be self-treated: migraine, tension-type, cluster, and chronic daily headaches.^1,3

Migraine headache (MH)

As the technician listens to the patient's recitation of symptoms, he or she may be able to recognize a MH through several clues.^1,3,5-7 First, MH is more common in females. Second, MH pain is a throbbing, pounding or pulsing pain that is worse on 1 side of the patient's head. It begins as a dull, aching pain but within a short time can progress to a full-intensity headache that lasts for 4 to 72 hours.^1,6 Third, MH patients often complain of additional symptoms, such as nausea, vomiting, sensitivity to light and sound, loss of appetite, tiredness, chills, sweating, increased need to urinate, numbness or tingling in the hands or feet, and difficulty concentrating. Patients with MH often find that rest and sleep help cope with the pain. Also, some patients indicate that they notice a set of changes before the start of migraine. This is known as an aura, and, perhaps 10 to 15 minutes before the onset of pain they may experience changes in vision, such as a blind spot, flashing lights, blurred vision, or flickering vision. They may also relate a history of numbness and tingling in the hands and feet, or they notice a specific event that triggers MH, such as missing a meal, drinking alcohol, or eating the following foods: chocolate, dairy products, nuts, onions, peanut butter, baked goods, and aged cheese—just to name a few.¹

Cluster headache (CH)

There are numerous clues to the presence of CH.^1,8 CH is most common in males, usually between the ages of 20 and 40 years. Patients with CH relate that the headache begins suddenly and lasts from 15 minutes to 3 hours.¹ Some patients are awakened by CH, but for many it begins during the day when they are awake. Further, CH attacks occur in sets known as clusters.¹ It is not uncommon for patients to have a cluster of 8 attacks each day for periods of 7 days to 1 year. Then, they may be pain-free for a period of time until another cluster of attacks begins. The pain of CH is extremely severe; it occurs on only 1 side of the head and is often described as a sharp, burning sensation in and around 1 eye.^1,8 Patients may inform the technician that it feels as though someone is pushing a red-hot piece of steel into their eye. Other factors may help the technician recognize CH. For instance, patients often notice a set of symptoms on the same side of the head as the eye pain. They may experience redness and tearing of the eye, runny or blocked nose, sweating or redness of the face and forehead, pinpoint pupils, and drooping or swelling of the eyelid. While patients with MH feel the need to rest, patients with CH often feel restless and pace the room continually.¹

Tension-type headache (TTH)

TTH is the most common of all headaches.^1,9-12 TTH pain is a dull pressure that feels as though a tight band is squeezing the painful areas. The pain is equally severe on both sides of the head, temples, back of the neck, and shoulders. Patients may describe increasing stress in their lives as well as depression or anxiety. TTH can be triggered by holding the head in a fixed position (eg, playing video games), alcohol, caffeine, caffeine withdrawal, clenching the jaw, grinding the teeth, eyestrain, cigarettes, overexertion, or glare. TTH may also cause sensitivity to heat and light, but it does not cause nausea or vomiting.¹

Chronic daily headaches (CDH)

This condition occurs on 15 or more days each month for 3 or more consecutive months, with each headache lasting 4 or more hours.^1,3 CDH has elements of both TTH and MH. The best action is to refer a patient with this history to a physician to rule out any secondary causes. However, if this has been done and the cause is primary CDH, nonprescription products can be helpful.¹

SELF-TREATABLE COMMON PAIN CONDITIONS

Nonprescription oral analgesics are labeled for the treatment of several common pain conditions other than headache. They include aches and pains of the common cold, sore throat, toothache, muscle aches, backaches, arthritis, and menstrual problems.¹ Acetaminophen is labeled for all of the previously mentioned conditions and also for relief of the minor aches and pains associated with influenza. Topical analgesics are labeled for temporary relief of minor aches and pains of muscles and joints associated with simple backache, arthritis, strains, bruises, and sprains.¹

ORAL ANALGESICS

Oral analgesics are potentially dangerous if misused. For this reason, technicians can ask patients several questions to help the pharmacist make decisions regarding correct usage. On occasion, product labeling differs from one active ingredient to the next, so the following discussion will frequently mention both the active ingredient(s) and trade name: aspirin 81 mg, 325 mg, and 500 mg tablets (eg, Bayer Aspirin), ibuprofen 200 mg tablets (eg, Advil), naproxen sodium 220 mg tablets (eg, Aleve), and acetaminophen 325mg, 500 mg, and 650 mg tablets (eg, Tylenol Regular Strength, Tylenol Extra Strength, and Tylenol 8HR, respectively).^13-15 Also, the pharmacy technician should understand that if a specific warning applies to Bayer Aspirin, it will apply to all other products containing aspirin. The same is true when the following discussion uses trade names, such as Advil, Aleve, or Tylenol. Brand names are used to help familiarize the technician with examples of top-selling products.

Oral analgesic products may also include additional ingredients.¹ For example, Excedrin Tension Headache contains 500 mg of acetaminophen and 65 mg of caffeine per caplet.¹ It should be noted that Advil and Advil Migraine are 2 separate products, even though each contains 200 mg of ibuprofen per tablet.¹ In this case, Advil Migraine is a better choice for patients with migraine as it has specific labeling that addresses MH.

Time limits for self-treatment

The maximum recommended duration for nonphysician-supervised use of oral analgesics for headache and other types of pain is usually 10 days.¹ However, product labeling for migraine-specific products (eg, Excedrin Migraine, Advil Migraine) indicate that patients should contact their physician if the pain is not relieved or gets worse after the first dose¹; products with phenylephrine (eg, Excedrin Sinus) are limited to 7 days.¹ The recommended duration of use for pediatric oral analgesic products varies. Pediatric acetaminophen products (for pain) are not recommended to be used beyond 5 days. However, pediatric ibuprofen products (eg, PediaCare IB, Infants' Advil, Children's Advil) recommend ceasing use and consulting a physician if the pain worsens or lasts longer than 3 days.^16,17 Consequently, it is important that pharmacy technicians emphasize the importance of reading product labeling for all nonprescription drugs.

Age limits for headache self-treatment

The technician should always ask the age of the patient for whom the oral analgesic is intended and communicate this information to the pharmacist. All oral analgesics have age restrictions because of the lack of safety and efficacy information in younger age groups. When the technician tells the pharmacist that the age of a patient is below the lowest recommended age on the label of a specific product, the pharmacist should suggest an alternative product that is age-appropriate. If there is no product labeled for that age grouping, referral to a physician is mandatory to ensure patient safety.¹ Pediatric ibuprofen suspensions can be recommended for patients as young as 6 months old. However, nonprescription pediatric acetaminophen products can only be safely recommended for patients aged 2 years and above.^1,17 Ibuprofen and acetaminophen are also available in dosage forms that are appropriate for older children (eg, chewable tablets and "junior strength" tablets) as well as a full range of adult products. Most aspirin products no longer carry labeling for patients under the age of 12 years, even though they still have the misleading word baby on the label. Naproxen tablets should not be recommended for patients under the age of 12 years.¹⁴ Migraine-specific products carry higher age restrictions; neither Advil Migraine nor Excedrin Migraine are recommended for unsupervised self-care in patients under the age of 18 years.¹

Further, the technician must also be alert for the ages of older patients since some ingredients carry specific precautions for this population. For instance, product labels for aspirin, ibuprofen, and naproxen include statements that direct patients who are aged 60 years and older to speak to a physician before use because of the increased risk of stomach bleeds.^1,13,14 This warning appears on labeling for Excedrin Migraine, Advil, Advil Migraine, and Aleve. Adult acetaminophen products do not carry such a warning.¹

Requirement for a diagnosis

Migraine products are required to carry a label that states they are not recommended for unsupervised use if the patient has never had migraine diagnosed by a health care professional.¹ The word diagnosis implies consultation with a physician or another prescriber.

Stomach bleeding warnings

Technicians should be alert to certain conditions that may cause or exacerbate stomach bleeding if patients wish to purchase any nonsteroidal anti-inflammatory drug (NSAID)-containing product (eg, Bayer Aspirin, Advil, Aleve, Advil Migraine and Excedrin Migraine).^1,13,14 Labels state the following: This product contains an NSAID, which may cause severe stomach bleeding. The chance is higher if you: are aged 60 years or older, have had stomach ulcers or bleeding problems, take a blood thinner or steroid drug, take other drugs containing prescription or nonprescription NSAIDs, have 3 or more alcoholic drinks every day while using this product, or take NSAIDs for a longer period of time than directed. Patients should be instructed to consult a physician before use if any of these circumstances apply. Acetaminophen products do not carry a stomach bleeding warning.¹

Liver warning

Technicians should be aware that products containing acetaminophen (eg, Excedrin Migraine, Tylenol) carry labeling about the potential risk of liver injury.¹⁵ Product labeling states that severe liver damage may occur if: the patient has 3 or more alcoholic drinks every day while using the product; takes the product with other acetaminophen-containing drugs; or if the patient exceeds a specific daily dose. Also, the pharmacy technician should be aware that there are different maximum daily doses for products that contain acetaminophen (eg, Tylenol Extra Strength vs Excedrin Migraine). There are several reasons why maximum limits differ among products. They have to do with such issues as additional ingredients and the specific indication for which a product is sold. Thus, the technician should warn patients to read every product label and follow the dosing information therein.¹

Identifying contraindications for self-use and drug interactions

Technicians must be fully aware of situations that contraindicate unsupervised self-use of nonprescription drugs; this information must be communicated to the pharmacist so an alternate product can be recommended. If no product is appropriate, the pharmacist will refer the patient to a physician. No internal analgesic is safe for a woman who is pregnant or breast-feeding without a physician recommendation. With regard to NSAIDs, product labeling states that it is especially important not to use aspirin, ibuprofen, or naproxen during the last 3 months of pregnancy unless directed to do so by a physician because it can cause problems for the unborn child or complications during delivery.^1,13,14 This particular warning is not required for acetaminophen products since acetaminophen is not an NSAID and has no anti-inflammatory activity.

Product labels for NSAID headache products indicate that a physician should be consulted before use if a patient meets any of the following criteria: a history of stomach problems, such as heartburn; high blood pressure, heart disease, liver cirrhosis, or kidney disease; is taking a diuretic; has had problems or serious side effects from taking pain relievers or fever reducers; has asthma (Bayer Aspirin, Aleve, and Excedrin Migraine only).^1,13,14 Advil Migraine and Excedrin Migraine carry migraine-specific warnings that direct patients to ask a physician before using if they have any of the following: a headache that differs from their usual migraines; the worst headache of their life; fever and stiff neck; headache beginning after or caused by head injury, exertion, coughing or bending; daily headache; a headache first appearing after the age of 50 years; migraine so severe as to require bed rest; liver disease (Excedrin Migraine and Tylenol only); or vomiting with the migraine (Excedrin Migraine only).¹

Patients contemplating a purchase of NSAID-containing products should consider a consultation with a physician or pharmacist before use in the following situations: if they are under a physician's care for any serious condition or taking any other drug; taking aspirin for heart attack or stroke because ibuprofen may decrease its benefit (Advil and Advil Migraine only); taking prescription medications for anticoagulation, diabetes, gout or arthritis (Excedrin Migraine only); taking a prescription medication for gout, diabetes, or arthritis (Bayer Aspirin only); taking any other product that contains aspirin, acetaminophen, or any other pain reliever/fever reducer (Excedrin Migraine only).^1,13,14

Labeling for products containing acetaminophen as the sole ingredient state that patients should check with a physician or pharmacist if they are taking warfarin.¹⁵

When a product label warns generally against use with anticoagulants (seen on the label of NSAIDS), or specifically against the anticoagulant known as warfarin, it is a critical warning to prevent a potentially deadly interaction. If the anticoagulant’s activity is increased, the patient’s blood cannot clot, and he/she may experience spontaneous, severe and uncontrollable bleeding. Anticoagulants of concern include warfarin (Coumadin), rivaroxaban (Xarelto), dabigatran (Pradaxa), and apixaban (Eliquis), among others. The patient should ask the pharmacist to be sure there is no interaction with the current medication regimen.

Product labeling also states that the use of acetaminophen with any other drug containing acetaminophen (prescription or nonprescription) is not recommended, pointing out that patients should speak with their physician or pharmacist if they are unsure whether acetaminophen is any medication that they currently take.¹

Labeling for nonprescription drugs containing caffeine (eg, Excedrin Migraine) indicate that the product's recommended dose contains about as much caffeine as a cup of coffee, and they should limit the use of caffeine-containing medications, foods, and beverages while using the product to prevent nervousness, irritability, sleeplessness, and accelerated heart rate.¹

Stop use precautions

Labeling for nonprescription analgesics carry alerts intended to direct patients when to stop use of the product and speak to a physician.^1,13,15,18 Technicians can stress these points at the time of sale. They include the following: if pain worsens or lasts longer than the time limits explained above (Bayer Aspirin, Aleve, Advil and Tylenol only); if they experience specific signs of stomach bleeding (feeling faint, vomiting blood, bloody or black stools, stomach pain that does not get better [NSAIDs only]); if new symptoms appear; if redness or swelling is present (Bayer Aspirin, Tylenol, Aleve and Advil only); or if ringing in the ears or loss of hearing occurs (Bayer Aspirin, Excedrin Migraine only).

TOPICAL ANALGESICS

The indications for topical analgesics include temporary relief of minor aches and pains of muscles and joints associated with simple backache, arthritis, strains, bruises, and sprains.¹ The labels of these products are not as detailed as those of oral analgesics.¹ For example, the technician should tell purchasers to closely scrutinize labeling for the minimum age of use, usually 2 or 12 years (labels vary as to the minimum ages recommended for use). Products should not be applied more than 3 to 4 times daily. Further, they are for topical use only and should not be used in the eyes or on mucous membranes. Patients should not place topical analgesics on wounded or damaged skin, and they should not place a bandage tightly over the application site. Additionally, these products should not be used with any topical source of heat, such as heating pads or heat lamps. Patients should stop use and see a physician if: the condition worsens or the symptoms last for more than 7 days; symptoms clear up but recur again within a few days; or excessive skin irritation occurs. Patients should also be urged to keep the products away from children because they can cause significant harm if ingested.¹

Topical analgesic ingredients and products

Topical analgesics are available in ointments, creams, liniments, and patches. Some topical analgesics, such as methyl salicylate and turpentine oil, redden the skin to produce warmth.¹ (Methyl salicylate should not be used by patients who are allergic to aspirin; if it reaches the blood in detectable levels, it can be toxic; methyl salicylate may also interact with warfarin.) Methyl salicylate is the single ingredient in Thera-Gesic cream, and it is found in some combination products (noted below).¹

Capsaicin is another category of topical analgesic, which is found in pepper creams such as Capzasin•P, Capzasin•HP, Zostrix and Zostrix HP.¹ Occasionally, the technician might notice methyl nicotinate or histamine in a product; these 2 ingredients belong to a final type of topical analgesic that enlarges surface blood vessels to warm the area.¹

Camphor and menthol produce a cool sensation when first applied to the skin, and the cool sensation can eventually become warmth.¹ Menthol is the single ingredient in Mineral Ice and Flexall, and both ingredients are found in combination products, as shown below:

• Menthol and methyl salicylate is the combination in Salonpas Pain Relief Patch and Salonpas Arthritis Pain Relief Patch. (These are the only topical analgesic patches that are proven to be safe and effective.) This is also the combination in Icy Hot and BENGAY Greaseless Cream.
• Menthol, methyl salicylate, and camphor is the combination found in Flexall Plus and BENGAY Ultra Strength Cream.
• Menthol and histamine are the ingredients in ActivOn.
• Trolamine is an ingredient with no known topical analgesic effect. It is found in Aspercreme, Sportscreme, Mobisyl and Myoflex.¹

Home TENS Units

A recent development in pain control is the advent of transcutaneous electrical nerve stimulation (TENS) units for home use. Products currently available include Aleve Direct Therapy and Icy Hot Smart Relief. Their place in self-care is not firmly established enough to allow a full evaluation of their safety and efficacy for pain control in patients who choose not to seek professional medical advice.

CONCLUSION

When the technician speaks to a patient about headache or other common pain conditions, the initial contact should consist of closely questioning the patient about important self-care matters. Bringing relevant information to the attention of the pharmacist is one of the most valuable services the technician performs in regard to nonprescription products. By so doing, the technician allows the pharmacist to rapidly and accurately make defensible triage decisions for patients who entrust their care to the pharmacy.

Pharmacy practice

A male patient who appears to be approximately 30 years of age asks the technician whether the pharmacy has a nonprescription product that will help his headache. It woke him up from sleep early this morning and he was thereafter unable to sleep. He describes the pain as like a tight band around my head. He has had a lot of stress due to an upcoming divorce. He does not have nausea or vomiting, and says light and sound do not bother him. He had no visual changes and he is not taking any medications. He has allergies, for which he takes Allegra 24HR. What questions might the technician and/or pharmacist ask this patient?

Questions to Consider

1. Is this the first time you have had a headache of this type?
2. Did you have a blow to the head?
3. Are there any other symptoms you have not mentioned?

Solving the Case

At first, the clues point to a tension-type headache, especially in light of the stress due to his upcoming divorce. The lack of ancillary symptoms points away from migraine or cluster headache. There is one red flag, however. The patient stated that the headache awakened him from sleep. This requires a referral to a physician for a full evaluation, and is the most important bit of information the pharmacist will need to make a defensible triage decision.

REFERENCES

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16. PediaCare IB. Prestige Brands Holdings website. http://www.pediacare.com/otc-medicines/fever-reducers-for-kids/infant-fever-reducer-ibuprofen/. Accessed November 24, 2018.
17. Infants' Advil Drops. Pfizer Consumer Healthcare website. http://childrens.advil.com/infants-advil-drops. Accessed November 24, 2018.
18. Bayer Aspirin. Bayer Healthcare LLC website. http://www.wonderdrug.com/products/products.htm. Accessed November 24, 2018.

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