CASE 1: CARPAL TUNNEL SYNDROME
Q: MG is a 28-year-old woman who comes to the pharmacy questioning which vitamins are important to take daily. She has been suffering from pain, numbness, and tingling in the thumb and wrist area for the past few months. She works at a doctor’s office as a receptionist at the front desk. Upon questioning, she said that she works on a computer most of the day. She spoke to her physician about her pain, and he said that based on her symptoms, she suffers from carpal tunnel syndrome. He recommended that she try to avoiding using a computer, which is not an option for her. Some friends have advised her to take vitamin B daily to reduce her pain. She comes to the pharmacy to inquire about the safety of vitamin B6 and the data associated with it regarding pain relief. What recommendations do you have for MG?
A: Vitamins and minerals play an important role in daily function. MG can take a daily vitamin if she prefers. Vitamin B6 has been shown to help alleviate carpal tunnel—related pain. However, research shows that the vitamin doesn’t reduce pain in all patients.1,2 If MG is concerned about her vitamin B levels, she should speak to her physician about being tested. If her vitamin B levels are low, it may be helpful to take vitamin B supplementation. In addition, she can try using a splint to reduce her pain, perhaps at night so that her movement is not restricted while she works. A splint may help initially, but the long-term solution is typically surgery. Another way to manage the pain is by taking OTC analgesics such as ibuprofen and acetaminophen.3
CASE 2: NATURAL TREATMENT FOR MIGRAINES
Q: RG is a 47-year-old woman who comes to the pharmacy looking for something to alleviate the severe headache she has had since waking up. She took 400 mg of ibuprofen twice 6 hours apart, but that is not really helping. Upon questioning, she says that she has a unilateral headache, which suddenly came on. This type of headache has happened previously, and she usually turns the lights off. Today, the pain is not tolerable, with her pain a 6 on a scale of 1 to 10. She has no medical conditions and no drug allergies and takes no medications. She typically avoids medications because she feels unsafe with them. She heard that a product called feverfew can reduce head pain and is natural. What recommendations do you have for RG?
A: RG seems to be suffering from a migraine, which usually occurs with unilateral pain and throbbing. Sometimes a warning sign, known as an aura, may occur prior to the onset of pain. RG should be educated on what types of warning signs to look for and start treatment immediately to prevent the onset of the migraine. Symptoms for an aura can include nausea, muscle weakness, and light sensitivity. RG should be informed that a primary care physician should formally diagnose migraines. Once the migraine is diagnosed, she can discuss with her physician if feverfew would be the right treatment option. Some studies suggest that feverfew can be beneficial in reducing migraines as well as reducing symptoms of pain, nausea, and sensitivity to light. Cross-sensitivity to the Asteraceae or Compositae family can occur, so patients with a ragweed allergy should avoid feverfew. If the physician is comfortable with RG using feverfew, she can use the powder 50 to 150 mg once daily. Long-term treatment and efficacy has not been assessed; therefore, patients should not use this for more than 6 months.4,5
CASE 3: LOWER BACK PAINQ: DM is a 30-year-old man who comes to the pharmacy complaining of lower back pain. He says that he decided to do some cleaning yesterday and lifted a few boxes that were heavy. Last night, he did not feel any pain prior to going to bed, but he woke up sore. He describes an aching pain and puts the level of discomfort at a 3 on a scale of 1 to 10. He denies taking any medications and says he has no medical conditions. What recommendations do you have for DM?
A: DM appears to be a candidate for self-treatment because his back pain does not seem to be chronic. Acute back pain is defined as pain experienced for less than 4 weeks. Guidelines indicate that acute back pain should be treated with heat, massage, acupuncture, or spinal manipulation. He can try using heat patches on his back to see if they relieve the pain. DM should also consider a nonsteroidal anti-inflammatory drug such as ibuprofen or naproxen. The guidelines no longer recommend acetaminophen as first-line therapy. Studies show that acetaminophen versus a placebo showed similar results in terms of the effect on pain and function. It is important for practitioners to follow up with patients who self-treat pain to ensure that they seek appropriate medical attention. If symptoms do not resolve in 7 to 10 days, patients should follow up with a physician.
CASE 4 MYALGIA PAINQ: LV is a 19-year-old woman who comes to the pharmacy looking for something for her muscle pain. She plays basketball for her college, and she recently sprained her ankle. She was asked to not play basketball or exercise for 8 weeks. Her sports medicine physician cleared her last week but encouraged her to slowly return to the game. She decided to start off by exercising 3 to 4 days a week and plans to return to playing basketball in 2 to 3 weeks. She says that she can usually exercise with no problem, but the 8-week break has made it difficult to perform at her previous level. She complains that her arms and back have felt sore for the past 3 days. She complains of a dull, constant ache. She says her pain is a 4 to a 5 on a scale of 1 to 10 around the clock. She is having some trouble sleeping because of the discomfort. She has finals coming up next week and needs to be able to control her pain so that she can sleep. She says she doesn’t have any swelling and is not having any trouble with her ankle. She is taking a daily vitamin but has no medical conditions. What recommendations do you have for LV?
A: LV may have some musculoskeletal pain such as myalgia possibly due to her inactivity. LV should be informed that stretching is important before and after exercise. Within the first 24 to 72 hours, she can use non-pharmacologic approaches such as rest, ice, compression, and elevation (RICE). However, since her back is also involved, it may be difficult for her to do RICE. In addition, because sleep is being disrupted, she may benefit from taking a nonprescription oral analgesic such as acetaminophen or ibuprofen to help her feel more comfortable. Most patients who have musculoskeletal injuries should be referred to a physician if they report a pain score of higher than a 6 on a scale of 1 to 10 or if the pain lasts longer than 7 to 10 days. LV should be educated to follow up with a physician if the pain lasts more than 7 days from its onset or if it worsens with therapy.