Pain

Question 1

What are the first-line analgesics for mild-to-moderate pain?

Answer 1

Paracetamol, NSAIDs (e.g., ibuprofen, naproxen), aspirin, and weak opioids (e.g., codeine, dihydrocodeine, tramadol).

Question 2

What is the initial analgesic choice for children under 16 years old?

Answer 2

Paracetamol or ibuprofen alone.

Question 3

What is the recommended stepwise approach for managing mild-to-moderate pain in adults and children over 16?

Answer 3

Step 1: Paracetamol

Step 2: Switch to ibuprofen or a weak opioid

Step 3: Add paracetamol to ibuprofen or weak opioid

Step 4: Continue paracetamol and replace ibuprofen with another NSAID

Step 5: Add a weak opioid to paracetamol and/or NSAID

Question 4

What are the steps of the WHO analgesic ladder?

Answer 4

Step 1: Non-opioids (e.g., paracetamol, NSAIDs)

Step 2: Weak opioids (e.g., codeine) + non-opioids

Step 3: Strong opioids (e.g., morphine) + non-opioids

Question 5

How is chronic pain defined?

Answer 5

Pain persisting or recurring for more than 3 months.
Back pain (53%), headache (48%), joint pain (46%).

Question 6

What non-drug interventions are recommended for chronic primary pain?

Answer 6

Supervised group exercise

Self-management education

CBT or ACT

Acupuncture or dry needling

Question 7

Which medications should NOT be used for chronic primary pain?

Answer 7

Paracetamol, NSAIDs, opioids, benzodiazepines, antipsychotics, antiepileptics (e.g., gabapentinoids), corticosteroid trigger point injections, ketamine, local anaesthetics (except in trials).

Question 8

What antidepressants may be considered for chronic primary pain?

Answer 8

Duloxetine, amitriptyline, citalopram, fluoxetine, paroxetine, sertraline (off-label use).

Question 9

How is nociceptive pain best treated? (Pain resulting from tissue damage, injuries etc.)

Answer 9

With conventional analgesics like NSAIDs or paracetamol.

Question 10

What is nociplastic pain?

Answer 10

Pain that arises from altered nociception without clear evidence of tissue damage

Question 10

What type of medication is added at Step 2 of the WHO pain ladder?

Answer 10

A weak opioid is added to a non-opioid.

Codeine

Dihydrocodeine

Tramadol

Question 10

What type of medication is used at Step 1 of the WHO pain ladder?

Answer 10

Non-opioid analgesics — e.g., paracetamol (acetaminophen) or NSAIDs like ibuprofen or naproxen.

Question 11

Give examples of strong opioids used at Step 3 of the WHO pain ladder.

Answer 11

Morphine

Oxycodone

Fentanyl

Question 12

What anatomical area does low back pain usually affect?

Answer 12

The lumbosacral area, from the 12th ribs to the iliac crest, sometimes including the buttocks and gluteal folds.

Question 13

How is acute vs chronic low back pain defined?

Answer 13

Acute < 3 months; Chronic ≥ 3 months.

Question 14

Is non-specific low back pain usually self-limiting?

Answer 14

Yes, it usually resolves within a few weeks.

Question 15

What is the first-line drug treatment for non-specific low back pain?

Answer 15

NSAIDs, such as ibuprofen.

Question 16

When should codeine be considered for back pain?

Answer 16

Short-term use if NSAIDs are contraindicated or ineffective.

Question 17

Should paracetamol be used alone for low back pain?

Answer 17

No, it is not recommended alone.

Question 18

What is the hallmark feature of cluster headaches?

Answer 18

Severe, unilateral headaches with autonomic symptoms.

Question 19

How long do cluster periods typically last?

Answer 19

2 weeks to 3 months.

Question 20

What differentiates episodic from chronic cluster headache?

Answer 20

Episodic: pain-free periods ≥ 3 months; Chronic: pain-free < 3 months.

Question 21

What is the first-line acute treatment for cluster headache?

Answer 21

Subcutaneous or intranasal sumatriptan or zolmitriptan.

Question 22

Is oral triptan effective for cluster headache?

Answer 22

No, oral triptans are not recommended.

Question 23

What is used for cluster headache prophylaxis (by specialist)?

Answer 23

Verapamil is commonly used.

Question 24

What is the most common primary headache disorder?

Answer 24

Tension-type headache.

Question 25

How long can a tension-type headache last?

Answer 25

From 30 minutes to 7 days.

Question 26

What symptoms are not associated with tension-type headaches?

Answer 26

Nausea and vomiting.

Question 27

What acute medications are recommended?

Answer 27

Paracetamol, aspirin, or NSAIDs.

Question 28

What should be avoided in treatment?

Answer 28

Opioids and overuse of acute analgesics.

Question 29

What prophylactic medication is recommended?

Answer 29

Amitriptyline (off-label).

Question 30

What non-drug therapy may help chronic tension headaches?

Answer 30

Acupuncture, CBT, physiotherapy, relaxation techniques.

Question 31

What defines medication overuse headache (MOH) according to the ICHD?

Answer 31

Headache occurring ≥15 days/month in someone with a pre-existing headache disorder, due to regular overuse of acute/symptomatic headache meds for >3 months, usually resolving after withdrawal.

Question 32

What is the threshold for overuse of ergotamines, triptans, opioids, or combination analgesics in MOH?

Answer 32

≥10 days per month.

Question 33

What is the threshold for overuse of simple analgesics (paracetamol, NSAIDs) in MOH?

Answer 33

≥15 days per month.

Question 34

What is the initial step in managing MOH?

Answer 34

Abrupt withdrawal of overused medication(s) for at least 1 month, with counseling on withdrawal symptoms.

Question 35

What are the typical features of migraine headache?

Answer 35

Unilateral, throbbing/pulsating pain lasting 4–72 hours, often with nausea, vomiting, photophobia, and phonophobia.

Question 36

What is the difference between episodic and chronic migraine?

Answer 36

Episodic: <15 headache days/month. Chronic: ≥15 headache days/month.

Question 37

When should triptans be taken during a migraine with aura?

Answer 37

At the start of the headache, not the aura.

Question 38

What is the first-line triptan for acute migraine in adults?

Answer 38

Oral sumatriptan 50–100 mg.

Question 39

What preventive drugs are recommended for migraine prophylaxis?

Answer 39

Propranolol, topiramate, amitriptyline. Others include candesartan, sodium valproate, and CGRP inhibitors.

Question 40

What is the first-line treatment for acute migraine during pregnancy?

Answer 40

Paracetamol.

Question 41

Which triptan is preferred during pregnancy and breastfeeding?

Answer 41

Sumatriptan.

Question 42

What is the typical cause of trigeminal neuralgia?

Answer 42

Vascular compression of the trigeminal nerve.

Question 43

What is the first-line treatment for trigeminal neuralgia?

Answer 43

Carbamazepine.

Question 44

What is neuropathic pain?

Answer 44

Pain due to damage or dysfunction of the somatosensory system.

Question 45

What are the first-line drugs for neuropathic pain (excluding trigeminal neuralgia)?

Answer 45

Amitriptyline, duloxetine, gabapentin, pregabalin.

Question 46

What is post-herpetic neuralgia (PHN)?

Answer 46

Pain that persists >3 months after shingles. Typically - Stabbing/burning pain, allodynia, hyperalgesia, itching.

Question 47

What are first-line treatments for mild PHN pain?

Answer 47

Paracetamol ± codeine.

Question 48

What topical treatment is useful for PHN with allodynia or in elderly patients?

Answer 48

Lidocaine plasters.