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Headache & migraine

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Headache & migraine

With over 10 million people in the UK suffering from headache and 8 million affected by migraine, how can community pharmacists and their teams ensure that these customers are using the best treatments for their own individual needs? 

 

Learning objectives

After reading this feature you should be able to:

Recognise the different types of common headache
Identify the symptoms of migraine
Recommend the most appropriate treatments and lifestyle advice.

 

“There are a number of different types of headache that are categorised by their symptoms and frequency,” says Nitin Makadia, a pharmacist from the AAH Pharmaceuticals Careway programme.

“For example, a simple headache is often something that occurs infrequently and is self-limiting – in other words, if you do nothing it will still go away. It is often caused by lifestyle and environmental factors such as too much alcohol, dehydration, lack of sleep and tension, working shifts, eye strain, and looking at computer screens for long periods.

“Then there are cluster headaches, which can go on for several weeks and be so debilitating that sufferers sometimes call them ‘suicidal headaches’. They are characterised by extreme pain on one side of the head or behind an eye. Like migraine, they can completely disrupt a person’s life, but fortunately they are relatively rare. They are commonest in men, and eight out of 10 people who get cluster headaches are smokers.”

Migraine is another extremely debilitating condition affecting people of all ages (even very young children) and is much more than just a bad headache, says Rebekah Aitchison, Migraine Action marketing and communications officer.

Migraine is much more than just a bad headache

“There is no ‘test’ for migraine, so diagnosis can be difficult and depends on the story and pattern of attacks,” she says. “A severe headache may be common, especially in adults, but other symptoms may be more prominent; for example, nausea and/or vomiting, increased sensitivity to light, sound or smell, neurological symptoms – often referred to as the ‘aura’ – which can comprise visual disturbances, confusion, tingling or numbness in the limbs.

“For some the ‘common’ headache may not even be present. A silent migraine, for example, does not include a headache at all, and others can present as abdominal migraines, which are particularly common among children.”

Migraine attacks normally last between four and 72 hours and ‘migraineurs’ are symptom-free between attacks. On average, migraineurs experience around 13 attacks a year, but some experience up to two attacks a week and may be bedridden for much of this time.

Triggers can include hormones (this is particularly common in women); certain foods (people often refer to cheese, wine and chocolate but it can be any number of foods); dehydration; anxiety; stress (but the opposite can also be the case, with some sufferers reporting migraines on the first day of a holiday or at the weekend); tiredness; oversleeping; weather and pressure changes, to name just a few.

“We would recommend that pharmacists make patients aware of this risk, to prevent migraine sufferers having to come off all medication in the future for a period of time,” says Rebekah Aitchison.

Treatment options

To be able to recommend the most suitable pain relief, a variety of pain relief options should be stocked in a wide range of formats. For headaches, painkillers such as paracetamol, ibuprofen and aspirin can be recommended, but be careful of overuse, says a spokeswoman for Well (previously Co-op Pharmacy).

Stress reduction could also be addressed, says Emma Charlesworth, Numark’s communications manager. “You should recommend that, wherever possible, a person avoids stressful situations and tries relaxation techniques including yoga and tai chi, massage, meditation and breathing techniques. Applying a hot flannel to the neck and forehead can relax muscles and reduce tension and for sufferers of regular headaches, keeping a headache diary can help identify possible triggers.”

Although there is no cure for migraine, Dr Fayyaz Ahmed, a consultant neurologist at Hull Royal Infirmary and trustee of the Migraine Trust, says there are two ways to approach the treatment of migraines with drugs.

They are: stopping a migraine in progress, which is called ‘abortive’ or ‘acute’ treatment, and prevention. “Acute treatment uses over-the-counter pain relief drugs, such as aspirin, or NSAIDs like ibuprofen, which relieve mild migraine pain for some people if taken early enough and at the right dose. Most acute drugs for migraine work best when taken as soon as symptoms begin. For people with extreme migraine pain, a more powerful ‘rescue’ drug might also be prescribed.”

“Prevention involves some medicines used daily to help prevent attacks. Many of these drugs were designed to treat other health conditions, such as epilepsy and depression, and so may not prevent all migraines, but they can help a lot. Hormone therapy may help prevent attacks in women whose migraines seem to be linked to their menstrual cycle.”

And then there are alternative methods. “Biofeedback has been shown to help some people with migraine,” says Dr Ahmed. “It involves learning how to monitor and control your body’s responses to stress, such as lowering heart rate and easing muscle tension. Other methods, such as acupuncture and relaxation, may help relieve stress. Counselling can also help, if the patient thinks his/her migraines may be related to depression or anxiety.”

Patient education and better self-care is key to successfully managing headache and migraine

Formats and ingredients

As with many treatments, different people prefer taking their medicines in different formats, so it is worth reminding customers that there is usually a pain relief format that will suit them. “Caplets or tablets are easier to swallow for some people, and soluble tablets don’t have to dissolve in the stomach so act quicker, but are usually high in sodium – so frequent use can be an issue for those with high blood pressure,” says the Well spokeswoman.

“There’s also the option of a nasal spray or injection for migraine because, with the condition, the ability to absorb painkillers through the stomach can be impaired. There are also menthol sticks to relax and decongest.”

Serotonin and migraine

As far back as the early 1960s serotonin (also known as 5-hydroxytryptamine or 5-HT) was believed to be involved in migraine, and over the years multiple theories have been developed about its exact role. “Recent work has shown that serotonin-containing neurons in the brainstem are involved in regulating many aspects of human behaviour, including stress, appetite, mood and sleep, as well as pain,” says Dr Ahmed, “and many migraineurs will recognise disturbances of all these as characteristic of their attacks. 

The exact role of serotonin remains controversial but what is clear is that drugs that stimulate certain serotonin receptors (triptans) are effective treatments for acute attacks, while drugs that block other serotonin receptors, such as methysergide and pizotifen, are effective prophylactic agents for migraine.”

Too little training

Peter Goadsby, professor of neurology at King’s College London, who chairs the British Association for the Study of Headache and is a trustee for the Migraine Trust, says training for pharmacy teams and doctors is too minimal for what is a common complaint. “Medical students get a few hours in their course and I am not aware that headache [management] is compulsory in pharmacy training, yet it should be. Basic formal training would help a great deal in equipping pharmacy staff for this challenge.”

Fin McCaul, community pharmacist and owner of Prestwich Pharmacy in Manchester, believes pharmacy staff are not short of knowledge, but may not be equipped with the skills or confidence to share it with customers. “I think there is a mine of information out there, but the difficulty we have with the category is that patients have their own expectation of what is wrong with them and how to treat themselves – and they just keep buying the products they have always used, even if they are not the right ones for them.

“For example, about 80 per cent of the headache market is around tension headaches, yet people are taking paracetamol or co-codamol for this when the best treatment is ibuprofen, especially fast relief ibuprofen. Educating patients to take this as soon as possible, rather than waiting because they don’t like taking pain medication, is the message we need to get out there.

“Staff have the knowledge but may not have the skills to interrupt a purchase to make sure the person is doing the right thing. We have also got to understand that patients don’t always know what is best for them and staff have to believe they have the knowledge to get a better outcome for their customers, as well as the confidence to say ‘I can help you get better’.”

Lifestyle advice

Rebekah Aitchison of Migraine Action agrees that improving self-care habits can be key to reducing migraine attacks. “Many migraineurs have lived with their condition for years and easily fall into a pattern of taking medication out of habit rather than reviewing if it is still meeting their needs or if there are any better options available to them,” she says.

“Simple advice, such as taking medication as early as possible during an attack and taking tablets with fizzy water to aid absorption, can make a difference. Also advise patients to keep hydrated and maintain a regular sleep pattern even at the weekend. Dependent on the patient’s history, it may also be worth advising eating often to help keep blood sugars up, avoiding flashing lights, doing light exercise every day, and trying relaxation techniques that can help reduce stress and anxiety.

“Pharmacy staff should also be encouraging customers to seek advice from their GP if current medications do not seem to be giving enough relief or their migraines are more frequent than two to three a month as preventative medication may be required.”

Key facts

  • Migraine attacks normally last between four and 72 hours
  • Many migraineurs take their medication out of habit rather than reviewing if it still meets their needs
  • Medicines counter staff have the knowledge but may not have the confidence to check a person is doing the right thing

 

Category management

The headache and migraine category lends itself perfectly to facilitating an intervention by medicines counter assistants or pharmacists – something you just can’t get from supermarket shelves, says Numark’s Emma Charlesworth.

“Once a diagnosis is made, you should have in mind the range of options for non-drug, rescue and prevention available in-store,” says Dr Andrew Dowson, director of the NHS King’s headache service at King’s College Hospital and chairman of Migraine Action’s medical advisory board. “If there is diagnostic uncertainty, treatment failure or analgesic dependence, [staff should] feel confident suggesting a GP review, and if there is an acute or worrisome presentation suggest immediate medical input.”

Making the most of the pain management category also involves understanding how people use pharmacies generally, so that teams can respond to these customer needs and behaviours. “We believe that category display should always be clear and the pain relief category should be divided by brand and active ingredient to help customers navigate the fixture easily,” says a Solpadeine spokesperson, “with behind-the-counter brands clearly signposted and staff on hand to give pain advice and information. Relevant POS materials can also help customers make an informed choice at the point of purchase.”

If staff can handle queries about the category with confidence they will not only keep customers coming back, but may actually help them change their preferred treatment options to more successful ones, says Emma Charlesworth.

“The idea is not to sell more analgesics but to sell appropriately and capture customers who may simply go elsewhere should they not have the benefit of an interaction by a member of the pharmacy team.”

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