Headache is the most common form of pain and a significant opportunity for pharmacists to offer advice and guidance for improved health outcomes. By Leanne Philpott
According to the World Health Organisation, approximately half of the adult population has had at least one headache in the last year and yet it states that headaches remain ‘underestimated, under-recognised and under-treated throughout the world.’
It’s estimated that 50% of people with headache self-treat without any professional consultation. This creates huge opportunity for the pharmacy to support self-care, resulting in more informed treatment decisions, better symptom control and ultimately improved health outcomes for the patient.
Is it really migraine?
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 by any means.
Pharmacist and director of PainWise Joyce McSwan tells The AJP, “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.”
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 as follows:
- 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
McSwan says the worry is when patients pull out 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.”
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
“Looking at the non-pharmacotherapy options can be useful and quite appropriate in managing migraines,” says McSwan.
“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 says migraine is like a bushfire with anxiety and stress acting like strong southerly winds.
“These exacerbate the symptoms of migraine, so to successfully manage migraine you need to help patients manage their anxiety and stress.
“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.
“As pharmacists, if we see a script for Inderal 10mg and we know it’s for a migraine we need to be asking if the patient has an acute plan. At that point you can talk about caffeine and aspirin and put some thought and time into it. Write up an acute plan and see if it’s acceptable in the eyes of the patient’s GP. The doctor might be focused on prevention, but what happens when a migraine comes?
“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.”
Dr Schwartz advises, “Acute attacks are best managed by taking the most effective tryptan that suits the patient immediately, at the onset of the attack. A simple mindfulness breathing technique may also be helpful at this stage. If the headache progresses you need to take the strongest and most effective simple analgesic (an anti-emetic if necessary) in a trial and error way.
Yet McSwan says pharmacists shouldn’t be giving too much in the way of major treatment options. “We can, if not contra-indicated, give ibuprofen but that’s about as far it is goes without a true diagnosis.”
Talking tension headache
Despite all the attention given to migraine, tension-type headache accounts for the majority of headaches with many people relying on self-care for treatment.
Chiropractor and editor of headache.com.au Dr Jerome Dixon says, “Tension headache is often over-applied as a category. It’s a broad umbrella term used for people with headache developing over a period of time. You can have tension headache caused by clenching and grinding the jaw or as a result of eyestrain from sitting at a computer for too long.
McSwan says, “The International Headache Society now uses tension-type headache as the accepted classification for headaches presenting with mild-to-moderate bilateral pain of pressing or tightening (non-pulsating) quality.
“The source of tension headaches is the overuse of the muscles in the neck and head, most commonly in response to stress. While the causative factors in tension headaches are now widely accepted to be excessive contraction of the neck and head muscles, evidence for this is only now being fully understood.
“Overuse produces strain at key trigger points in the muscles, causing the production of inflammatory modulators such as prostaglandins and bradykinin. These inflammatory modulators activate nerves associated with muscles, producing pain signals.
“Ensuring pharmacists have up-to-date knowledge of tension-type headache pathophysiology can encourage greater involvement in the optimal management of patients, and prevention of progression to a chronic condition.”
“Some people have their own way of dealing with tension headaches, like lying in a dark room, or if they recognise that their headache only comes on through fatigue they might just ‘put up’ with it. Generally patients will present when their symptoms become worse or they progress,” says Dr Dixon.
“However, intensity of pain is not a good indictor of how serious the problem is. Headaches that progressively get worse and are persistent are the types of headaches that need to get diagnosed. Even a mild ‘muzziness’ can be an indictor of something more serious.
“Often the pharmacist is the first point of contact for someone with headache or migraine, so the advice they get is really important. Certain headache medications, such as ibuprofen or sumatriptan, used in conjunction with other medications can have interactions. It’s vital that pharmacists are diligent and ask people buying an OTC medicine what it’s for.”
He says it’s also worthwhile asking if their condition has been diagnosed. “A lot of people think I’m feeling tense or I’m stressed so I’ve got a stress or tension-related headache. They’re not necessarily diagnosed correctly, if at all.
“History is really important in head pain. In 95% of cases it gives the diagnosis to the practitioner. Pharmacists can ask how long the patient has had the pain and whether it’s progressing or persistent. If it’s getting worse or unrelenting, they need to see a healthcare specialist such as GP, chiropractor or physiotherapist.
“In cases where the patient has had the pain on and off for years and it hasn’t really progressed, the pharmacist is well positioned to advise them.”
McSwan says first-line treatment would be an anti-inflammatory plus non-pharmacotherapy stress reduction activities and therapies.
“Early, effective dosing of topical or oral nonsteroidal anti-inflammatory drugs (NSAIDs) can be used for a period of time but with tension-type headaches it’s about managing the causes.”
Dr Dixon recommends asking a few leading questions that might give some indication as to the cause of the headache such as: do you eat regularly or do you skip meals? Do you drink a lot of coffee? Do you drink plenty of water? Have you seen an optometrist? Do you spend a lot of time using computers?
“It doesn’t hurt for the pharmacist to be the gatekeeper and advise the patient to go see their GP, especially if the symptoms are progressive or neurological in the quality of the pain, for example a numbness or progressive worsening of the symptoms or a loss of vision. These are red flags that warrant referral.”
“Pharmacists must create the opportunity to engage with patients seeking advice on headache treatments to ensure that the pharmacy is the place where treatment is optimised, not just a place in which patients buy medicines,” advises McSwan.
The go-to for total pain relief
According to research conducted by GSK, stocking the right pain relief brands is vital. 95% of shoppers plan which brand they will buy before visiting a pharmacy and if they can’t find their intended product in store, more than a third will walk away.
While Panadol remains the most trusted pain relief brand in Australia, reflected in its category value leading growth (+6.2% YA), S3 pain relief products, such as Voltaren Rapid 25, are expected to drive the segment forward in the future.
To capitalise on S3 products it’s important to encourage conversations, understand the individual’s pain and discuss the options with them. The recent regulatory changes to codeine-containing analgesics could help drive more meaningful discussions in this area.
Companion sales are also a big opportunity in the pain category. Effective pain management strategies involve more than just systemic pain relief. Anti-inflammatory topicals, cold packs and appropriate diet and exercise all need to be considered as part of a pain management plan. In addition to increased basket size, this gives pharmacy the ability to get more involved and showcase their expertise.
Ultimately, the ability to offer the right solution will help position pharmacies as ‘the destination’ for pain suffers.