What is the management for symptoms of pain, headaches, dizziness, and fatigue?

Management of Pain, Headaches, Dizziness, and Fatigue

Begin by screening for red flags that indicate life-threatening secondary causes requiring immediate neuroimaging or emergency referral, then systematically assess each symptom using validated scales, identify and treat underlying causes (inflammation, anemia, sleep disturbance), and escalate from conservative management to pharmacologic interventions based on severity and response.

Initial Red Flag Assessment for Headaches

When evaluating headaches with associated symptoms, immediately screen for dangerous secondary etiologies that require urgent intervention:

Critical Warning Signs Requiring Immediate Action

• Thunderclap headache (sudden onset reaching maximum intensity within seconds to minutes) suggests subarachnoid hemorrhage 1
• "Worst headache of life" with abrupt onset indicates serious vascular pathology 1
• Headache awakening patient from sleep may indicate increased intracranial pressure 1, 2
• Headache worsened by Valsalva maneuver, coughing, sneezing, or exercise suggests secondary pathology 1, 2
• Focal neurological symptoms or signs mandate urgent evaluation 1, 2, 3
• New headache onset after age 50 requires consideration of temporal arteritis 1
• Progressive headache worsening over time could indicate space-occupying lesion 1
• Persistent headache following head trauma may indicate intracranial injury 1
• Neck stiffness with fever suggests meningitis or subarachnoid hemorrhage 1

Ottawa SAH Rule Application

For alert patients >15 years with new severe nontraumatic headache reaching maximum intensity within 1 hour, obtain neuroimaging if any of: age ≥40 years, neck pain/stiffness, witnessed loss of consciousness, onset during exertion, thunderclap headache, or limited neck flexion 1

If red flags present: Obtain noncontrast head CT immediately; if negative and suspicion remains high, proceed to lumbar puncture 1. MRI is preferred over CT for non-emergent evaluation due to higher resolution, except when acute hemorrhage is suspected 1

Systematic Symptom Screening and Assessment

Structured Screening Approach

Use a visual analog scale (VAS) 0-10 for each symptom to quantify severity 4:

• Mild symptoms (0-3): Basic education and counseling
• Moderate to severe symptoms (4-10): Comprehensive evaluation and targeted intervention

Physicians must routinely use brief assessment tools to ask about pain, depression, and fatigue, then initiate evidence-based treatments 4

Identifying and Treating Underlying Causes

Inflammation Assessment

Active disease inflammation significantly contributes to fatigue and pain 4. Evaluate disease activity through clinical, radiological, and endoscopic assessments when applicable 4. Optimize treatment of underlying inflammatory conditions as this directly impacts symptom burden.

Anemia Evaluation

Anemia is a common, treatable contributor to fatigue 4. Check complete blood count and investigate causes including:

• Chronic bleeding
• Malabsorption
• Impaired dietary intake
• Medication effects

Treat established anemia regardless of cause 4. Note that isolated iron deficiency without anemia is not a clinically relevant contributor to fatigue 4

Nutritional Deficiencies

Test and correct deficiencies in: ferritin, copper, zinc, folate, phosphate, magnesium, vitamin B6, vitamin B12, calcium, and vitamin D 4. Refer to dietitian when appropriate 4

Sleep Disturbance

Assess and address sleep quality, as sleep disturbance significantly contributes to fatigue 4. Consider formal sleep evaluation if indicated.

Medication Review

Evaluate all medications for side effects contributing to symptoms 4. Consider alcohol and drug use as potential contributors 4

Headache-Specific Management

For Mild to Moderate Headaches

Start with oral NSAIDs 2, 3:

• Ibuprofen 400-800 mg every 6 hours
• Naproxen sodium 275-550 mg every 2-6 hours
• Combination analgesics containing caffeine may be used 2

For Moderate to Severe Migraines

Add a triptan to an NSAID if NSAID alone fails to provide adequate relief 3. Options include sumatriptan, rizatriptan, or naratriptan 3

Medications to Avoid

Avoid opioids and butalbital-containing analgesics for regular management due to dependency risk and rebound headaches 2. Closely monitor analgesic use to prevent medication-overuse headache 2

Preventive Therapy

Consider prophylaxis if headaches occur more than twice weekly 2. Evidence-based options include topiramate, gabapentin, amitriptyline, and valproate 2

Pain Management Algorithm

For Inflammatory Pain

• NSAIDs or glucocorticoids for acute inflammatory episodes 4
• Consider hydroxychloroquine for recurrent articular pain in appropriate contexts 4
• Do not use biological agents solely for musculoskeletal pain as off-label use is not warranted based on lack of efficacy in trials 4

For Chronic Non-Inflammatory Pain

Avoid repeated use of NSAIDs or glucocorticoids 4. Instead:

• First-line: Physical activity and aerobic exercise to reduce pain severity and improve function 4
• Second-line: Antidepressants and anticonvulsants for chronic musculoskeletal pain 4
• For neuropathic pain: Gabapentin, pregabalin, or amitriptyline (monitor for exacerbation of dryness symptoms) 4
• Never use opioids for chronic pain management 4

Fatigue Management

Non-Pharmacological Interventions

Physical activity and aerobic exercise improve fatigue, aerobic capacity, and depression 4. These interventions have few adverse events and should be emphasized 4

Addressing Concurrent Symptoms

Fatigue management requires treating all contributing factors identified above: inflammation, anemia, nutritional deficiencies, sleep disturbance, and medication effects 4

Dizziness Evaluation

For Post-Concussion Dizziness

Consider vestibular rehabilitation for persistent symptoms, though evidence quality is low 4. Interdisciplinary coordinated rehabilitative treatment may be beneficial for persistent postconcussion symptoms including dizziness 4

General Approach

Evaluate for:

• Vestibular dysfunction
• Medication effects
• Orthostatic hypotension
• Cardiovascular causes

Immune Checkpoint Inhibitor Considerations

If patient is receiving immunotherapy, consider hypophysitis when headache and fatigue present together 4:

• Check morning (8 AM) TSH, free T4, ACTH, cortisol
• Low TSH with low free T4 suggests central hypothyroidism
• MRI of sella with pituitary cuts if suspected
• Always start steroids before thyroid hormone replacement to avoid adrenal crisis 4

Monitoring and Reassessment

Cancer symptom management and all symptom control should be reassessed periodically 4. Use the same VAS scales at follow-up to track response objectively 4. Adjust treatment based on response, escalating therapy for inadequate symptom control while monitoring for medication overuse.