The multiplicity of differing presentations can make it difficult to ascertain what form of headache or migraine a patient is experiencing, but making the correct diagnosis is crucial for effective treatment
Headache is one of the commonest symptoms experienced by humans. It is actually unusual for humans not to have at least an occasional headache.
In a clinical setting, the most important initial step is to actually which type of headache a patient is presenting with.
A multiplicity of types
A review of Headache Australia’s guide to types of headache reveals the multiplicity of forms and causes of headaches.
A brief listing of some of these headache types includes: Aneurysm, Chinese Restaurant Syndrome (linked to MSG), Chronic Daily Headache, Chronic Migraine, Cluster Headache, Cough Headache, Exertional Vascular Headache and Eyestrain – and that only takes us up to the E’s.
Diagnosing headache involves differentiating between the most common forms of headache and those that may indicate an underlying illness. The types of headache can be categorised in various ways.
One method of differentiation recommended by Headache Australia is:
- ‘Normal’ headaches such as goggle headache (excessive nerve stimulation), ice-cream headache, hot-dog headache (food reaction), Chinese restaurant syndrome (reaction to MSG), hangover, marijuana headache, fasting headache, rebound headache, exercise headaches, coital headaches, cough headache and mountain sickness.
- Recurring headaches include tension-type headache, migraine and cluster headache.
- ‘Nerve’ headaches ie produced by direct irritation or compression of the nerves supplying the head, face, or neck such as trigeminal neuralgia, glossopharyngeal neuralgia, neuralgia after shingles, atypical face pain, pain from the eye, sinusitis, head pain caused by teeth, temporomandibular joint dysfunction, and neck headache
- Muscle-contraction headaches.
- Medication-misuse headaches.Head injury headache
- Serious causes of headache such as hydrocephalus, sub-arachnoid haemorrhage, meningitis, encephalitis, brain tumour, cerebral oedema, high blood pressure, stroke, temporal arteritis and benign intracranial hypertension.
The scale of the issue
According to Headache Australia, about 15% of the population suffers from migraine at some stage in their lives.
Migraine often first appears in childhood, adolescence or early adulthood, but affects the greatest number of people between 35 and 45 years of age. Migraine is less common in children (about 2-5%) but affects girls and boys about equally. However, in adolescents and adults the disease disproportionately affects women (22% vs 10% lifetime prevalence).
In women, migraine frequency and severity are affected by hormones and, as a result, often change during adolescence, pregnancy and menopause. Beginning around menarche (the first menstrual cycle), its prevalence increases during reproductive years and then decreases around menopause. In women the symptoms of migraine tend also to be more severe and longer lasting.
Women often experience an improvement in migraine during pregnancy, however, unfortunately it typically reappears following birth. After about 70 years of age the prevalence of migraine decreases to that of the middle teen years. At this stage there are less women suffering from migraine, but those who are may experience them more frequently, though accompanying symptoms such as nausea and photophobia are usually less pronounced.
Taking it seriously
Clinical pharmacist Karalyn Huxhagen told AJP that headache needs to be taken seriously in a pharmacy setting, especially given that the variety of presentations for headache in pharmacy result in such a variance of cures and ideas for preventions.
“There are many ‘off licence’ use of medications for treatment of headache and it is worth noting a few of these before you put your foot in your mouth by saying something like “I am sorry to hear you have developed epilepsy” when the patient is using Topirimate for headache,” she said.
“Not all headaches have a sinister background but complacency to the management of the patients health and/or a poor health literacy could lead to a dismissal of the headache as being a normal part of their life,” Ms Huxhagen said.
The problems of diagnosis are exacerbated by many headache patients self-medicating and choosing their preferred analgesic from a range of acute analgesics available in non-pharmacy settings, often without seeking any form of medical diagnosis.
A 2016 Irish study found that of 1023 patients seeking treatment in a pharmacy for headache, 53.3% (n=542) were not previously diagnosed by a GP and 49.6% (n=502) had never sought advice from a pharmacist.
According to the symptoms described by the patients, 32% had episodic migraine and a further 15.2% had probable episodic migraine. Another 30.3% had tension type headache. And 10.7% had chronic daily headache.
Codeine based products were the preferred treatment choice for 43.1% of these patients. However, Triptans were the most effective (in 68.6% of patients) among those for whom they were previously prescribed.
More than one in ten (11.8%) of these patients experienced medication-overuse.
“The community pharmacist is an important resource in headache management,” the study authors concluded.
“An expanded role incorporating best practice management guidelines has the potential to improve the outcomes for many headache sufferers”.
Migraine and chronic tension headache
Despite the fact that migraine, compared to other types of headache, receives a substantial amount of media and academic attention, it’s not the most prevalent headache. Migraine is a common neurological disorder that can be very distressing and disabling.
Typically it is a one-sided throbbing or pulsating headache that is at least moderately intense and can be aggravated by physical activity. It is very often associated with nausea and vomiting, as well as increased sensitivity to light, sound and even some types of smell.
In contrast, tension headache, another common headache type, is milder and is usually felt on both sides of the head. It is a pressing or tightening sensation rather than a throbbing headache and is not made worse by activity or accompanied by nausea
Pharmacist and director of PainWise Joyce McSwan told AJP last year that: “By and large what is presenting over the counter is chronic tension headache, not migraine.
“Migraine features about 15% of the time. You hear ‘migraine’ used as a terminology more often than it should be. True migraine relates to a fairly small percentage of patients, whereas chronic tension headache applies to about 80%.”
She says the problem is that patients come to the pharmacy saying they have a migraine because a chronic tension headache can look, feel and have as much intensity as a migraine.
“Pharmacists need to be astute. Migraine is very unilateral. It will come with an aura most of the time, but not always. There’s light sensitivity, nausea, and the intensity.
“In comparison chronic tension headache is often described as feeling like a tight band around the forehead. It tends to come with light and sound sensitivity as well, but it’s rarely unilateral.
“Differential diagnosis is important as a starting point, but again this relies on an appropriate understanding by the diagnostician. Pharmacists can really help by questioning whether what the patient is telling them, for example that it’s a migraine, is correct.”
Working it out
While patients may consider headache to be a simple solution requiring just a remedy of paracetamol or ibuprofen, Karalyn Huxhagen says even simple headache requires a discussion of probable cause, contributing factors, length of headache, frequency, is there a pattern or reason to the recurrence; and what has been taken already.
According to the International Headache Society, when diagnosing migraine secondary headaches must be ruled out and certain factors must be present.
The criteria for diagnosing migraine without aura is:
- At least five attacks fulfilling B-D
- Attacks lasting 4-72 hours if untreated or unsuccessfully treated
- Headache has at least two of the following characteristics
- Unilateral location
- Pulsating quality
- Moderate or severe pain intensity
- Aggravation by or causing avoidance of routine physical activity
- During headache, at least one of the following
- Nausea and/or vomiting
- Headache not attributable to any other disorder
Criteria for diagnosing migraine with aura is:
- At least two attacks fulfilling criteria B-D
- Aura consisting of at least one of the following, but no motor weakness:
- Fully reversible visual symptoms including positive features (e.g. flickering lights, spots or lines) and /or negative features (i.e. loss of vision)
- Fully reversible sensory symptoms including positive features (i.e. pins and needles) and / or negative features (i.e. numbness)
- Fully reversible dysphasic speech disturbance
- At least two of the following:
- Homonymous visual symptoms and / or unilateral sensory symptoms
- At least one aura symptom develops gradually over ≥5 minutes and / or different aura symptoms occur in succession over ≥5 minutes.
- Each symptom lasts ≥5 and ≤60 minutes
- Headache fulfilling criteria B-D for Migraine without Aura begins during the aura or follows aura within 60 minutes
- Headache not attributed to another disorder
Jopyce McSwan says the worry is when patients use the term ‘migraine’ without a proper diagnosis.
“Migraine is something that has to be diagnosed. If they’re living through days of relentless unilateral headache or just pain in the head, this needs professional judgment.”
She says that as part of the assessment process pharmacists should identity:
- Whether the patient has been diagnosed by a GP
- The affect of headaches on ability to function
- Number of headache-free days a month
- Symptoms beyond headache pain
- Previous response to over-the-counter medications
What to do?
Headache Australia says that “while there is still no absolute cure for headache, there are a number of treatment options, both medications and other forms including complementary therapies”.
Over-the-counter medications taken to treat headache include
- pain killers or analgesics such as aspirin and paracetamol
- pain killers or analgesics combined with codeine
- pain killers or analgesics combined with a sedative (eg Mersyndol, Fiorinal)
Prescription medications taken to treat more severe headaches include
- Stronger NSAIDs
- Analgesics containing stronger narcotic-type analgesics
- Ergots such as ergotamine (eg Cafergot) that have a specific action against migraine
- Triptans such as sumatriptan (eg Imigran), naratriptan (eg Naramig), zolmitriptan (eg Zomig) that have a specific action against migraine
- Anti-nausea drugs such as metoclopramide (Maxolon), prochlorperazine (Stemetil) and domperidone (Motilium).
In terms of threating migraine, Joyce McSwan says non-pharmacotherapy options can be “useful and quite appropriate.”
“We can tend to think that someone else is advising on the non-pharmacotherapy aspects of preventative treatment but often it gets overlooked or the patient might just need reminding.”
Neurologist Dr Raymond Schwartz said: “Given the limited utility and not insignificant side-effects of conventional migraine-prophylactic medication, I like to recommend evidence-based natural therapies, such as feverfew, coenzyme Q10, magnesium and selected B vitamins, as first-line migraine preventative therapy or as part of a broader holistic approach.
“B group vitamins have been shown to reduce the frequency and severity of migraine, particularly menstrual associated migraine. The precise mechanism of action is not clear but they are thought to exert an effect on cell energy (mitochondrial function) and as an anti-oxidant.
“B Vitamins, for which there is evidence of utility in migraine, should be used daily as prophylaxis for those patients suffering about one or more episodes of migraine per week.
He adds, “Attention to diet, in particular amine containing foods, and exercise can be helpful too.”
McSwan says there are clear guidelines on preventative treatment for migraine and the pharmacist certainly has a role to play, but it’s also vital to ensure there’s a plan in place for acute management.
“Pharmacy can back-fill the gaps, which is valuable and appreciated by the patient and the doctor. It shows you know what you’re talking about and you’re proposing an option.”
Australian Journal of Pharmacy, 01/09/2017: Clinical tips: headache and migraine, www.ajp.com.au/education/clinical-tips/clinical-tips-headache-migraine/
Australian Journal of Pharmacy, July 2017. Taking care of your headache
Headache Australia, Migraine advice sheet http://headacheaustralia.org.au/migraine/ (accessed 15/05/2018)
Headache Australia, Headache advice sheet http://headacheaustralia.org.au/what-is-headache/ (accessed 14/05/18)
O’Sullivan EM et al, ‘Headache Management in Community Pharmacies’ , Ir Med J. 2016 Mar 10;109(3):373.