IPU Medicines Counter Assistant (MCA) Course

Topic 6 – Pain Types and Treatments

Welcome to

Topic 6:
Pain Types and
Treatments

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Aim

The main aim of Topic 6: Pain Types and

Treatments is to equip you with the knowledge
and skill to demonstrate knowledge of OTC
products available for the treatment of minor
illness and conditions, advise on appropriate
treatment options, and give practical
recommendations to manage illness and
conditions.

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Topic 6 – Pain Types and Treatments

This topic contains three parts:

Part 1. An Introduction to Conditions
Topic Causing Pain

Content Part 2. Ingredients Used in the

Treatment of Pain and Fever
Part 3. When to Refer to a Pharmacist

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Learner Objectives

The learner objectives for this topic are:

• General conditions causing pain
• Describe the symptoms and possible causes of tension headache
• List common triggers and symptoms of migraine
• Describe the characteristics of chronic daily headache and medicine
overuse headache
• Describe the symptoms and causes of sinusitis, joint and muscle
pain and bruising
• Discuss period pain, its onset and duration
• Define fever, its causes and treatment for adults and children
• List primary analgesic ingredients used in OTC pain medications
• Explain primary analgesic actions, speed of onset, optimal use and
combination use in children
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Learner Objectives (contd.)

The learner objectives for this topic are:

• Generalise the role of, use, and side effects of codeine, caffeine,
buclizine and diphenhydramine in pain medication
• State and explain the codeine regulations impact, on the supply of
pain medication
• Explain the role, use and side effects of topical analgesics in the
management of soft tissue and joint pain
• Give examples of when and who, topical non-steroidal anti-
inflammatories and rubefacients/counter-irritants should not be
recommended
• Demonstrate using the 2WHAM approach to make appropriate
recommendations for various types of pain
• Identify and demonstrate when to refer standard and specific
patients to a Pharmacist
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Methodology

This topic is delivered using a blended format

of learning, including classroom teaching, case
studies, self-study, on-the-job coaching and
eLearning.

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Assessment
There are three assessments for this topic.
These include:
• On-line quizzes (summative test)
• Workplace assignment and skills demonstration
• Theory examination (formative test)

You are required to achieve a minimum grade of 80% for the

theory examination in order to achieve your certificate.
Successful students will receive an ATHE endorsed programme
certificate.

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Topic 6 – Pain Types and Treatments

1.1 The Causes of Tension Headache

1.2 Common Triggers and Symptoms
of Migraine
1.3 Chronic Daily Headache
Part 1. 1.4 Medicine Overuse Headache
1.5 Sinusitis, its Symptoms, Causes
An Introduction and Duration
to Conditions 1.6 Period Pain, its Onset and Duration
Causing Pain 1.7 Joint and Muscle Pain, its Causes
and Symptoms
1.8 Bruising and its Causes
1.9 Fever, its Causes and Treating
Children with Fever

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Part 1 Introduction

• Information is needed about the headache – just because

the customer describes it as ‘migraine’ for example, does
not mean that it is migraine
• Asking more about the headache will help you to decide
whether to refer to the pharmacist, and it will help you to
match the treatment to the customers needs.
• Three of the commonest types of headache are:
- Tension Headache
- Migraine
- Sinusitis
We will now briefly explain how they differ so that you know
the main points to look for

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Part 1.1: The Causes of Tension Headache

• Tension headache is the commonest type of headache

• The pain can be a constant aching feeling or a throbbing

pain

• More women than men complain of headaches of the

“tension headache” type - 4 times as many

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Part 1.1: The Causes of Tension Headache

We are not sure what causes a tension headache, but it is

most probably caused by tightening of the muscles of the neck
and upper back, and also those lining the scalp.

The main causes of a tension headache are:

• Stress/tension
• Work/home

The pain is usually described as:

• ‘Band around the head’
• ‘Weight pressing down’
• Aching feeling
• Throbbing pain

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Part 1.2: Common Triggers and Symptoms

of Migraine
• Migraine is a common neurological condition, virtually
always characterised by a severe pulsating, normally one
sided headache
• Often accompanied by nausea, vomiting and sensitivity to
light or smells
• Roughly 8% of men and 18% of women experience migraine
in any given year
• 75% of migraine sufferers just experience the headache
• 25% will also experience an ‘aura’ prior to the headache.
Symptoms of which may include:
̶ Visual disturbance
̶ Numbness or tingling (in lips, fingers, hands, face)
̶ Rarely difficulty speaking

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Part 1.2: Common Triggers and Symptoms

of Migraine
Triggers
• Stress is a trigger for 70% of sufferers
• Dietary (only about 20% have a dietary trigger)
̶ Dehydration
̶ Caffeine
̶ Long gaps between meals
̶ Foods rich in nitrates, tyramine, sulphites
• Red wine, certain cheeses, dark chocolate, MSG, artificial sweeteners
• Hormones
̶ Migraine with aura is three times more common in women
̶ Possibly due to oestrogen fluctuations around menstruation
• Changes in the weather
• Disrupted sleep patterns
• Medication overuse
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Part 1.2: Common Triggers and Symptoms

of Migraine
Questions to Ask Patients:
• Do you get headaches accompanied by nausea or vomiting?
• Is your headache severe or throbbing and usually on one
side of your head (not always the same side)?
• Does bright light hurt your eyes during an attack?
• Do you become particularly sensitive to loud sounds and/or
smells?
• Does your headache reduce your ability to work, study or
socialise?
If the answer is yes to two or more of these questions, then
the patient may have migraine

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Part 1.3: Chronic Daily Headache

• 5% of people suffer chronic daily headache

• This is a headache which:
- Lasts longer than 4 hours
- Occurs on more than 15 days per month
• Twice as common in women
• Can last months or even years

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Part 1.4: Medicine Overuse Headache

• Half of all chronic daily headache sufferers may end up

taking OTC painkillers regularly for long periods of time
• Some even take painkillers in an effort to ‘prevent’ a
headache
• Overuse of painkillers for headache can worsen the
problem
• It occurs most often where headache medication is taken
more than two days per week

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Part 1.5: Sinusitis, its Symptoms, Causes

and Duration
• Inflammation of the sinuses in the forehead and behind the
cheekbones
• Symptoms include:
- Early morning headache
- Tender forehead, cheekbones
- Fever
- Fatigue
- Runny nose or congestion
• Commonly caused by:
- Infection
- Allergy
• If chronic (lasting longer than 3 weeks), may require referral
to GP

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Part 1.6: Period Pain, its Onset and

Duration
• It is estimated that one in two women suffer from period
pain to some degree
• 10% will required time off work or school
• It is most common in women from 17 to 25
• The medical term for period pains is dysmenorrhoea – as
seen on some medicine packs and sometimes in
manufacturers literature or articles
• Period pains usually starts one or two days before period,
and lasts between one and three days

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Part 1.6: Period Pain, its Onset and

Duration (contd.)
• The pain is abdominal, and sufferers often describe it as
‘cramping’ or ‘spasms’
• The severity of the pain varies tremendously – some
women have very severe cramps, others hardly feel a thing
• Other symptoms often occur with period pains – the
customer may feel bloated, and have headache or
backache, fatigue, irritability and emotional symptoms
• In addition, some women feel nauseous when they get
period pains, and may actually be sick

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Part 1.7: Joint and Muscle Pain, Its Causes

and Symptoms
• Sprains and strains are common muscular injuries which
can be helped with a combination of simple practical advice
and over the counter treatment
• Strains and sprains may happen as a result of a fall or a
sudden twisting movement and often happen during sport
• Sports injuries are an increasing problem, as people
become more interested in health and fitness

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Part 1.7: Joint and Muscle Pain, Its Causes

and Symptoms (contd.)
Strains
• A strain happens when the muscle itself is torn or damaged
• This occurs most commonly in muscles which work over two
joints such as the hamstring
• Stiff and aching muscles can be the result of strenuous
activity such as sport or gardening
• This tends to be a problem when the person is not used to
the level of activity involved
• Back muscles most commonly affected
• Caused by lifting heavy objects / overuse

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Part 1.7: Joint and Muscle Pain, Its Causes

and Symptoms (contd.)
Sprains
• A sprain involves ligaments or the capsule of the joint
• Ligaments are strong tissues that connect bone together at a
joint
• It often involves the overstretching of ligaments and/or the
joint capsule, sometimes with tearing
• Damaged by sudden violent movement, most commonly
during sport and damage results in swelling / bruising / pain
• Most commonly this occurs in the ankle, although the knee
joint can often be affected, particularly in a sports injury
• If the joint is particularly painful or very swollen, then referral
to the pharmacist is the best option

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Part 1.7: Joint and Muscle Pain, Its Causes

and Symptoms (contd.)
Repetitive Strain Injury
• Overuse injury (sometimes called repetitive strain injury)
sometimes occur. Examples are tennis or golf elbow where
sport is the cause. Computer users may get repetitive strain
injuries of the fingers and wrists.
• The affected joints and muscles are stiff and painful, and rest
and painkillers are needed for the condition to improve.
• This is most often seen in the forearm, where the back of the
forearm is swollen, there may also be a creaking or grating
sound when the wrist is flexed.
• The term ‘bursitis’ is the result of pressure or friction leading
to inflammation around a joint – common examples include
housemaids knee and students elbow, where the joint is in
contact with a hard surface such as a floor desk or table for
prolonged periods of time

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Part 1.7: Joint and Muscle Pain, Its Causes

and Symptoms (contd.)
Low Back Pain
• Very common (60-80% of us will experience it at some stage)
• Mobilisation, stretching and exercise are often recommended
for its treatment
• Staying active with suitable pain relief often results in faster
recovery
Sciatica
• Sciatica is pain that runs along the sciatic nerve
• The sciatic nerve is the largest nerve in the human body and
runs from the back of the pelvis, across the buttock and down
the back of the thigh
• Sciatic pain can occur anywhere along the sciatic nerve
• In severe cases there may be a feeling of numbness and tingling
as well as pain
Sciatic pain should be referred to the pharmacist

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Part 1.8: Bruising and its Causes

• Bruising often appears after a fall or other injury and

happens because bleeding has taken place in the damaged
tissues under the skin
• Gradually the bruise changes colour as the blood is broken
down and moved from the injury
• Some OTC products can help reduce swelling and bruising,
but always beware of unexplained bruising

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Part 1.8: Bruising and its Causes (contd.)

• If a customer tells you that a bruise has appeared but they

did not bump or graze the area, or someone says that
recently they seem to bruise easily, ALWAYS refer them to
the pharmacist
• Sometimes unexplained bruising happens in people taking
medicine on prescription to thin the blood and the bruising
is a sign that the blood is being thinned too much and is not
clotting properly
• Sometimes bruising is due to serious conditions and it
therefore always needs to be checked out

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Part 1.9: Fever, its Causes and Treating

Children with Fever

• Treat fever when a febrile illness is suspected or

detected
• A temperature of 38oC would be considered
elevated
• Masking a serious illness by using antipyretics is
unlikely
• A 1oC drop in temperature is considered a good
response to therapy

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Topic 6 – Pain Types and Treatments

2.1 Primary Analgesic Ingredients Used in OTC Pain

Medications
2.2 Primary Analgesic Ingredients – Use in Combination
in Children
2.3 The Role of, Use and Side Effects of Additional
Ingredients in the Management of Pain
2.4 The Codeine Regulations Impact on the Supply of Pain

Part 2. 2.5
Medication
The Role and Supply of Sumatriptan for the
Ingredients Treatment of Migraine
2.6 The Role and Use of Topical Analgesics in the
Used in the Management of Soft Tissue and Joint Pain

Treatment of 2.7 The Role and Use of Topical Non-Steroidal Anti-

Inflammatories and Rubefacients/Counter-Irritants
Pain and Fever Action and Side Effects
2.8 Specific Populations where Topical Non-Steroidal
Anti-Inflammatories and Rubefacients/Counter-
Irritants should be Avoided
2.9 The Role of Massage, Heat and Ice in the
Management of Soft Tissue and Joint Pain
2.10 The Use of Rest, Ice, Compression and Elevation in
the Treatment of Joint Injury

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Part 2: Introduction

Ingredients Used in the Treatment of Pain and Fever

• There are essentially only three main oral OTC painkillers:
- Aspirin
- Paracetamol
- Ibuprofen
• Analgesics work by being taken up into the bloodstream,
travel throughout the body and affect the chemicals which
are produced by the body when pain is experienced
• There are however other ingredients sometimes used in
addition to paracetamol, ibuprofen or aspirin in analgesic
products, which include; caffeine, codeine, and
diphenhydramine

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Part 2.1: Primary Analgesic Ingredients Used in

OTC Pain Medications - Aspirin
Aspirin
• Aspirin has three actions:
- It is an analgesic (painkiller)
- It is an antipyretic (lower temperature in a fever)
- It is anti-inflammatory
• Generally a good, all-round painkiller
• Products include: Anadin, Disprin, Excedrin

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Part 2.1: Primary Analgesic Ingredients Used in

OTC Pain Medications - Aspirin (contd.)
Who Should Not Take Aspirin:
• Children under 16 (as linked to a disease called Reye’s syndrome,
where the brain is damaged, and the disease can be fatal in up to 50%
of cases)
• Anyone with a stomach ulcer (now or in the past)
• Allergic reactions:
- Skin problems
- Wheezing, breathlessness
• Asthmatic patients
• Patients on warfarin – or other anticoagulants or other
blood thinning medicines
• Pregnant or breastfeeding women
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Part 2.1: Primary Analgesic Ingredients Used in

OTC Pain Medications - Aspirin (contd.)
Side Effects of Aspirin
• Stomach upsets – indigestion
• Bleeding in the stomach
- people taking warfarin or other blood thinning medicines should only
take aspirin under the supervision of their doctor
- Should not be sold to anyone who has had a stomach ulcer or has had
one in the past
• Allergic reactions – blotchy skin and rashes, and also
breathlessness and wheezing (approximately 5% of asthma patients
have this problem which may cause wheezing and breathlessness)
• When choosing a painkiller, always ask the customer whether
they can take aspirin - this will prompt the customer to tell you
if they cannot tolerate aspirin

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Part 2.1: Primary Analgesic Ingredients Used in

OTC Pain Medications - Aspirin (contd.)
• Many people find aspirin a very effective analgesic
• Best taken after food, as food will line and therefore protect the
stomach
• Soluble aspirin is less likely to cause side effects and works more
quickly
• A special form of aspirin is enteric coated tablets:
- These are designed so that the coating won’t dissolve in the
stomach
- The tablet won’t dissolve until further down the gut so that the
aspirin in the tablet is only released after the stomach has been
passed
- This stops the stomach being irritated by the aspirin
- Enteric coated aspirin products are only available on prescription

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Part 2.1: Primary Analgesic Ingredients Used in

OTC Pain Medications - Aspirin (contd.)
In Summary:
• Aspirin is good for many patients
• Remember the side effects
• Never for children under 16

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Part 2.1: Primary Analgesic Ingredients Used in

OTC Pain Medications - Paracetamol
Paracetamol
• Paracetamol is a very effective analgesic and antipyretic
• It is not anti-inflammatory
• First line agent for pain and fever in children over 2 months
• Should not be overused
• It can be used for fever following vaccination at 2 months
• Products include: Panadol, Paralief, Paratabs, Calpol,
Paralink, Easilief Duo

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Part 2.1: Primary Analgesic Ingredients Used in

OTC Pain Medications - Paracetamol (contd.)
• No stomach problems associated with Paracetamol
• Can damage the liver if taken at higher doses than
recommended
• Symptoms of overdose can take up to 2 days to appear so
unintentional overdose may continue for a number of days
• Never recommend more than one paracetamol containing
product
• Remember paracetamol is found in many cold and flu
remedies
• It is very important to remind patients not to take more
than the recommended dose. If the pain is so bad that they
feel they need more than that, they should seek advice
• It is the analgesic of choice for children
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Part 2.1: Primary Analgesic Ingredients Used in

OTC Pain Medications - Paracetamol (contd.)
• Pharmacies may sell paracetamol in pack sizes up
to 24 without a prescription
• Quantities greater than 50 may only be supplied
on prescription
• Any customer requesting more than one pack of
24 paracetamol MUST be referred to the
pharmacist

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Part 2.1: Primary Analgesic Ingredients Used in

OTC Pain Medications - Ibuprofen
Ibupofen
• Ibuprofen has analgesic and anti-inflammatory properties
and helps to bring down temperature
• Good for pain where inflammation is involved (such as
period pains, toothache and muscular pains)
• Antipyretic
• Anti- inflammatory effect may take several doses, but
analgesic effect immediate
• Ibuprofen is also useful in children. It cannot be used in
children under the age of three months
• Remember, paracetamol is for three months and older,
except for fever after vaccination at 2 months.

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Part 2.1: Primary Analgesic Ingredients Used in

OTC Pain Medications - Ibuprofen (contd.)
• Available on prescription - check other medicines
• Higher doses of ibuprofen are prescribed to treat arthritis.
Many people are taking ibuprofen on prescription, so it is
ESSENTIAL to check whether the customer is taking any
medicines
• Side effects:
- Stomach upset
- Stomach bleeding
- Allergic reactions
• Products include: Nurofen, Easofen, Buplex, Easilief Duo

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Part 2.1: Primary Analgesic Ingredients Used in

OTC Pain Medications - Ibuprofen (contd.)
Who Should NOT take Ibuprofen
• People with stomach ulcers
• Elderly people more prone to side effects
• Children with Chickenpox
̶ Increased risk of skin infection
• People taking similar or the same medication on prescription
• People taking warfarin or similar medicines
• Allergy problems – anyone allergic to aspirin
• Asthmatic patients
• Pregnant or breastfeeding women

Ask whether the customer can take aspirin - this will help you decide if
they can safely take ibuprofen

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Part 2.1: Primary Analgesic Ingredients Used in

OTC Pain Medications - Ibuprofen (contd.)
Ibuprofen and Period Pains
• Ibuprofen is particularly useful for period pains due to its anti-
inflammatory action
• Paracetamol is used if ibuprofen is not suitable
• Take first dose as soon as pain begins or as soon as bleeding starts
• Take regularly for 2-3 days
• If still symptomatic then start ibuprofen 1 day before the period is due,
it can help reduce the pain even more
• If ibuprofen does not control symptoms, paracetamol may be added
but check with pharmacist first

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Part 2.1: Primary Analgesic Ingredients Used in

OTC Pain Medications - Ibuprofen (contd.)
In Summary:
• Ibuprofen is an excellent analgesic
• Some patients should not take it:
- People with stomach ulcers
- The elderly
- People with asthma
• Take with or after food

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Part 2.2: Primary Analgesic Ingredients -

Use in Combination in Children
Paracetamol and Ibuprofen in Combination
• Childhood pain and fever
- Common practice in Children’s Hospitals
- No clinical studies on efficacy or otherwise of
combination
- Should only be carried out on the advice of a doctor or
nurse
- If one product does not control fever within two doses,
referral is recommended

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Part 2.3: The Role of, Use and Side Effects of Additional
Ingredients in the Management of Pain
Caffeine
• Caffeine serves to elevate mood
• It is included in quite a few products; tea or coffee,
Panadol Extra, Anadin Extra, Excedrin
• It may improve the efficacy of the painkillers but also
serves to keep people awake, and acts as a stimulant
• This may not be beneficial, as sleep often has significant
restorative properties, especially in people suffering from
migraine
• Caffeine is also irritant to the lining of the stomach and
may enhance the irritant effect of aspirin

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Part 2.3: The Role of, Use and Side Effects of Additional
Ingredients in the Management of Pain
Diphenhydramine
• Causes drowsiness
• Useful where night time pain prevents sleep
• Product: Panadol Night

Buclizine
• Relieves nausea
• Found in Migraleve Pink Tablets along with paracetamol and codeine
• Maximum of 2 pink tablets in 24 hours
• If further pain relief required use Migraleve Yellow tablets (paracetamol
and codeine only)
• Refer to pharmacist due to codeine content

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Part 2.3: The Role of, Use and Side Effects of Additional
Ingredients in the Management of Pain
Codeine
• Codeine is a mild opioid analgesic
• It is used in small doses in some OTC analgesics in
combination with Paracetamol, Aspirin or Ibuprofen
• It is also used on its own or in combination with
antihistamines in cough suppressant preparations
• Codeine containing OTC medicines are subject to PSI
guidelines on their supply

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Part 2.3: The Role of, Use and Side Effects of Additional
Ingredients in the Management of Pain
Codeine – Unwanted Effects
• The recommended dose should not be exceeded
• Side effects include;
- Nausea
- Constipation
- Dizziness
- Drowsiness
• Excessive consumption in terms of dose or duration may:
- Cause tolerance or dependence
- Result in withdrawal symptoms such as:
• Restlessness
• Irritability

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Part 2.4: The Codeine Regulations Impact

on the Supply of Pain Medication
Codeine Regulations
• Requests for codeine containing OTC medicines should be
referred to the pharmacist
• Codeine medicines should only be supplied:
- When authorised by the pharmacist after consultation
- According to the pharmacy’s codeine policy and
procedures
- Where a simple analgesic has not controlled symptoms
- For the shortest period necessary or for a maximum of
3 days

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Part 2.4: The Codeine Regulations Impact

on the Supply of Pain Medication
Suitability Assessment Questions
• Does the patient present symptoms of short term
moderate pain?
• Has the patient tried a suitable first line treatment?
• Is the patient using the treatment to treat a pain that is
chronic?
• Are you aware of any pattern of overuse or dependence to
codeine containing medicines?
• Is the pharmacist satisfied that supply of a codeine
containing medicine is appropriate and in the patient’s best
interest?

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Part 2.4: The Codeine Regulations Impact

on the Supply of Pain Medication
Advise the patient to:
• Read the Patient Information Leaflet
• Use the lowest effective dose for the shortest possible time with
a maximum of 3 days use
• Store the medicine out of reach of children and not to share it
with anyone

Inform them that:

• Long term use of codeine containing medicines can lead to
tolerance and dependence
• Codeine causes nausea, constipation, dizziness and drowsiness
• Both paracetamol and ibuprofen are harmful if the
recommended dose is exceeded
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Part 2.4: The Codeine Regulations Impact

on the Supply of Pain Medication
Codeine Accessibility and Advertising
• Codeine containing medicines must be:
- In an area of the pharmacy under the pharmacists
direct management and supervision preferably the
dispensary
- Out of sight of the public

• Codeine containing medicines must not be:

- Advertised or promoted in any way

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Part 2.5: The Role and Supply of Sumatriptan

for the Treatment of Migraine
Sumatriptan 50mg tablets (Sumatran Relief)
• Can only be supplied by the pharmacist after consultation
• For the treatment of migraine with or without aura
• Adults between 18 and 65 years only
• Patients must have a diagnosis of migraine from their GP
and an established pattern of migraine attacks over at least
1 year
• Reverses some of the chemical changes that occur within
the brain during a migraine attack
• 50mg at onset of symptoms repeated after 2 hours if still
symptomatic
• Max 2 tablets in 24 hours

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Part 2.6: The Role and Use of Topical Analgesics in the

Management of Soft Tissue and Joint Pain
Rubefacients and counter-irritants produce sensation of warmth
which competes with the pain sensation
• Rubefacient – causes the blood vessels in the area where it is applied to
open or dilate (vasodilation). This produces a reddening and warming of the
area. This helps to mask the pain sensation by distracting the nerve endings
with sensations of warmth rather than pain.
• Counter-irritant – works in a similar way to the rubefacient, and some
people make no distinction between the two. It is mildly irritating to the
skin and distracts the nerve endings from the pain sensation. We all do
something similar when we bang our elbow for example. The first thing we
do is……we rub it. A counter irritant effect!

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Part 2.6: The Role and Use of Topical Analgesics in the

Management of Soft Tissue and Joint Pain
Rubefacient:
• Methylnicotnate (Deep Heat)
• Dilates the blood vessels in the skin
• Warms and reddens the skin

Counter-Irritants:
• Methylsalicylate (Deep Heat Cream, Wintergreen)
• Ethyl salicylate (Deep Heat Spray)
- Avoid in patients with asthma or allergy to aspirin
• Menthol (Biofreeze)
- Freeze gels and sprays

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Part 2.7: The Role and Use of Topical Non-Steroidal Anti-

Inflammatories and Rubefacients/Counter-
Irritants Action and Side Effects

• Several NSAIDs can be used topically, i.e. applied

directly to the painful areas, and are available in
preparations such as:
- Ibuprofen Nurofen Gel
- Diclofenac Voltarol P Emulgel, Diclac Gel
• These ingredients work in exactly the same way as oral
anti-inflammatory ingredients except that they are
applied directly onto the area requiring treatment
• The theory is that the anti-inflammatory is absorbed
through the skin directly to the painful area and that far
less gets into the bloodstream thus reducing side effects

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Part 2.8: Specific Populations where Topical Non-Steroidal

Anti-Inflammatories and Rubefacients/Counter-
Irritants should be Avoided

Should not be recommended for:

• Asthmatics
• Use on broken skin
• Use by patients allergic to aspirin, ibuprofen or other anti-
inflammatory agents
• Pregnant or breastfeeding women
• Children under 12

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Part 2.8: Specific Populations where Topical Non-Steroidal

Anti-Inflammatories and Rubefacients/Counter-
Irritants should be Avoided

• When a topical product is applied to the skin, a very small

amount can be taken in through the skin into the blood
stream.
• Can trigger an asthma attack in some asthmatics
• These products should not be applied to broken skin, lips or
near the eyes. Hands should be washed after application and
the affected area should not be covered by a dressing after
application of the product.
• These products should not be used on broken skin or under a
dressing
• They should not be recommended for children under 12

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Part 2.9: The Role of Massage, Heat and Ice in the

Management of Soft Tissue and Joint Pain
Massage and Pain Relief
• Increased blood flow
• Removal of inflammatory chemicals
• Stimulation of nerves competes with pain sensation
• Feeling of well-being

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Part 2.9: The Role of Massage, Heat and Ice in the

Management of Soft Tissue and Joint Pain
Heat and Cold
• Heat:
- Increases blood flow
- Do not use immediately after injury as can make injury
worse

• Cold:
- Decreases blood flow
- Use at once after injury to help reduce swelling and
bruising

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Part 2.10: The Use of Rest, Ice, Compression and

Elevation in the Treatment of Joint Injury

• REST • First 48 hours

- Ice a.s.a.p. for 10-30 minutes
- Ice for 10 minutes every two
• ICE hours while awake
- Do not apply ice directly to the
skin
• COMPRESSION - Compression bandage
- Elevate and rest the injured joint
• ELEVATION
• After 48 hours
- Stop ice and compression
- Start gentle exercise

61 Session Four: Pain & Fever

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3.1 Standard Referral Criteria

3.2 Condition-Specific Referral
Criteria for Pain
Part 3. 3.3 Condition-Specific Referral
When to Refer Criteria for Headache
to the 3.4 Condition-Specific Referral
Pharmacist Criteria for Period Pain
3.5 Condition-Specific Referral
Criteria for Muscle or Joint Pain

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Part 3.1: Standard Referral Criteria

• Always check with the pharmacist if the patient is taking

other medicines, either that they have bought over the
counter or that they get on prescription from the doctor.
• The length of time that the customer has had the
symptoms is very important:
- For headaches, the pharmacist should see the customer
if the pain has been recurrent
- For headache, any headache which has lasted longer
than a few hours is potentially serious

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Part 3.1: Standard Referral Criteria (contd.)

• If an OTC painkiller has been tried already, and the pain has
not got better, the customer should see the pharmacist
• Always check with the pharmacist whenever a customer
wants to buy a painkiller for a baby or a child under 3
• Always refer to the pharmacist if you think the customer
might be abusing an OTC product.
• Pregnant customers should always be referred

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Part 3.2: Condition-Specific Referral

Criteria for Pain
• Request for a codeine containing OTC medicine
• Patient taking other medicines
• Recurrent headache
• Tried OTC medicine, no improvement
• Medicine for baby or children under 3
• Suspected abuse of product
• Patient is pregnant

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Part 3.3: Condition-Specific Referral

Criteria for Headache
• Severe pain – any kind
• Head injury
• Headache lasting longer than 24 hours (4 hours if severe)
• Chronic daily headache
• Medicine overuse headache
• Photophobia
• Vomiting
• Neck stiffness
• Rash

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Part 3.4: Condition-Specific Referral

Criteria for Period Pain
• Abnormal vaginal discharge
• Abnormal or very heavy bleeding e.g with clots
• Symptoms return after several years of relatively painless
periods
• Severe pain or bleeding between periods
• Pain with a late period
• Fever

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Part 3.5: Condition-Specific Referral

Criteria for Muscle or Joint Pain
• Recent fall particularly in young children or the elderly
• Unexplained bruising
• Severe pain
• Lack of expected improvement after 5 days e.g. difficulty
weight bearing
• Worsening symptoms e.g. increased pain or swelling
• Severe or prolonged back pain
• Back pain in middle or upper back especially in older patients

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Part 1. An Introduction to Conditions

Causing Pain
Topic Part 2. Ingredients Used in the
Recall Treatment of Pain and Fever
Part 3. When to Refer to a Pharmacist

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