What this protocol covers
The pain query that reaches the counter with no diagnosis in an adult: headache, back pain, muscle, dental or period pain.
1. What to ask
- Where does it hurt, since when and how did it start? Pain that arrives suddenly is not the same as pain that comes and goes.
- Is this their usual pain or is it different: stronger, somewhere else or with other symptoms?
- What have they already taken, how much and how often? Including cold and flu remedies and combinations that contain paracetamol.
- Do they take other medicines? Above all anticoagulants, antiplatelets, blood pressure medicines, diuretics, corticosteroids or lithium.
- Have they had a stomach ulcer or gastrointestinal bleeding, kidney, liver or heart disease, asthma, or could they be pregnant?
2. Refer if any of these appear
- A sudden, very severe headache ("the worst of their life"), or one with fever and a stiff neck, confusion, weakness, or changes in speech or vision: emergency department.
- A headache after a blow to the head, one that gets worse day by day or one that wakes them at night.
- Pain in the chest, arm or jaw with sweating, nausea or shortness of breath: emergency department.
- Back pain with fever, weakness in the legs, numbness around the genitals or difficulty passing urine.
- Pain lasting more than 5 days without improving, or needing a painkiller more than 3 days a week.
3. If there are no red flags
Pain with no clear inflammatory component (for example, tension headache)
- Paracetamol 500 mg-1 g every 6-8 hours, no more than 3 g a day without medical advice.
- If there is no contraindication, ibuprofen 200-400 mg every 6-8 hours is an alternative (maximum 1,200 mg a day for self-care).
- What is not a medicine also counts: rest, fluids and breaks from screens.
Pain with an inflammatory component (muscle, joint, dental or period pain)
- An NSAID at the lowest effective dose for the shortest time: ibuprofen 200-400 mg every 6-8 hours or naproxen 220 mg every 8-12 hours.
- With food if it upsets the stomach, and never two NSAIDs together.
- For period pain, starting as soon as it appears works better than waiting until it gets bad.
- Local heat for muscle pain and period pain.
If NSAIDs are contraindicated
- Paracetamol at the usual dose. If that is not enough, refer: do not raise the dose or add another painkiller.
- Local measures: heat, relative rest and gentle movement as tolerated.
4. Adjust to who will take it
- Pregnancy
- Paracetamol at the lowest dose for the shortest time. NSAIDs are avoided from week 20 and are contraindicated in the third trimester; before that, only on medical advice.
- Older people
- Paracetamol is the better choice. An NSAID raises the risk of gastrointestinal bleeding, kidney damage and losing control of blood pressure: do not recommend one without reviewing their medicines.
- On anticoagulants
- No NSAID or aspirin on their own initiative. Paracetamol at usual doses; if they will take it for several days in a row with warfarin or acenocoumarol, whoever monitors their INR should know.
- Kidney disease
- Avoid NSAIDs. Paracetamol at usual doses; with advanced kidney disease, the dose is for their doctor to decide.
- Asthma
- Ask whether an anti-inflammatory has ever made their asthma worse: if so, none. Paracetamol is usually tolerated.
What not to recommend
- Paracetamol together with a cold and flu remedy or combination that already contains it: the most common way of overdosing without noticing.
- Two NSAIDs at once, or an NSAID with aspirin as a painkiller.
- Metamizole without a prescription: it needs one and carries a risk of agranulocytosis.
- Raising the dose or extending the treatment when it does not work: that is a reason to refer.
What to say at the counter. For this pain this works well, at this dose and for these days at most. If it has not improved in five days, or fever or anything new appears, they should see their doctor.
Pharmacy Pills · conveniodefarmacia.com
Patient sheet: mild pain at home
To print and hand over. It carries only what the patient needs at home.
- Take the painkiller at the recommended dose and keep to the time between doses.
- Do not take another medicine for pain or flu at the same time without asking: many contain the same active ingredient.
- If the pain lasts more than 5 days or gets worse, see your doctor.
- Go to the emergency department if the pain is sudden and very severe, or if fever with a stiff neck, weakness, difficulty speaking or chest pain appears.
Self-assessment
Three questions. When you check your answers you will see the explanation for each one.
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Many cold and flu remedies contain paracetamol. Added to another paracetamol product, the maximum dose is exceeded without anyone noticing.
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A sudden, very severe headache is a red flag: it could be a haemorrhage. It is not managed at the counter.
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An NSAID with an anticoagulant raises the risk of bleeding. Paracetamol is the option; taken for several days in a row it can raise the INR.
Training content. It does not replace the summary of product characteristics or clinical judgement.