Making headway: A pharmacist's guide to headaches
Headache is the umbrella term used for a number of different conditions that can be difficult for pharmacists to differentiate and therefore manage appropriately
After reading this feature you should be able to:
- Identify the different types of headache from the symptoms patients describe
- Explain the treatment options available
- Recommend the right OTC products and lifestyle measures for the various headache types
A 2014 study conducted in 10 European countries found the annual prevalence of headache to be 78.6 per cent and the lifetime prevalence 91.3 per cent – so it is a rare individual who won’t suffer from the condition at some point.
Headache is a common reason for seeking a GP appointment – a 2006 analysis of practice records found that around four per cent of adults had seen their family doctor for a headache, while many more opt for self-management. It is important that pharmacy teams have a sound grasp of the different types of headache and the current evidence base regarding treatment options.
For all headache disorders, it is worth considering the use of a diary to record the frequency, duration and severity of the condition, as well as the effectiveness of any treatments used. Journals also form a useful basis for discussing the impact of headaches on an individual. Providing information and support can be of value, NICE says, in its guidance on headaches in over-12s.
- Around four per cent of adults see their GP about headache
- One study estimates that each person with migraine loses nearly 20 working days a year to the condition
- Sufferers of cluster headache may fear the underlying cause is extremely serious
Presentation: Generalised (but occasionally unilateral) episodic pain described as tightness or pressure around the head and neck, which may be tender when massaged and lasts anything from minutes to days. Women are slightly more likely to experience the condition than men, with prevalence peaking between 20 and 39 years of age.
Sub-types and impact: According to the International Headache Society (IHS), nearly everyone will suffer from episodic tension-type headaches on an infrequent basis. More concerning is the group that experiences the condition more frequently – defined as at least 10 episodes per month for more than three months – as this can cause considerable disability. A further group exists in the form of those who go on to have chronic tension headaches (i.e. 15 or more days of headache a month for three months or longer), which can have a significant impact on quality of life and lead to high levels of disability.
Management: Infrequent episodic tension headaches are selflimiting, but simple analgesia is an option if the patient feels the need. Cochrane reviews have shown paracetamol 1,000mg or ibuprofen 400mg to be of some benefit, but highlight issues with how headache studies are conducted in terms of patients chosen and outcomes reported, which limit the usefulness of results.
Opioids are not recommended due to a lack of evidence of effectiveness and the risk of side effects. Relaxation techniques such as yoga, exercise and massage may prove helpful.
Prevention: Addressing triggers can help reduce the incidence of tension headaches. A diary can help to pinpoint factors such as dehydration, missing meals (the commonest causes of tension headaches in children), noise, poor posture, stress, anxiety and tiredness. Acupuncture has been shown to be beneficial to people who suffer from frequent tension headaches, according to a Cochrane review, with NICE recommending a course of up to 10 sessions over five to eight weeks for chronic cases.
There is limited evidence supporting the use of low dose amitriptyline for reducing tension headache frequency, but this is not supported by NICE. The use of other antidepressant types is also not supported.
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Children may experience migraine, although it often presents differently in terms of symptoms
Presentation: Unilateral (but sometimes generalised) severe pain often described as throbbing and accompanied by other symptoms such as photophobia, phonophobia, nausea and vomiting. The condition appears to be three times more common in women than men with the first attack usually experienced during a person’s teenage years.
Children may also experience migraine, although it is worth noting that it often presents differently – bilateral pain, cyclical vomiting, abdominal migraine and dizziness are all more common in the under- 18s. Frequency varies from occasional to several times a year, with attacks lasting anything from one hour to three days.
Sub-types and impact: The two commonest forms of the condition are migraine without aura (experienced by 70-90 per cent of sufferers, according to the Migraine Trust) and migraine with aura.
The term “aura” refers to neurological symptoms that usually precede the headache, which can include visual disturbances (e.g. seeing coloured or blind spots, sparkles, stars, flashing lights or zigzag lines, or experiencing tunnel vision or temporary blindness), or other issues such as numbness, tingling, weakness on one side of the body, dizziness, impaired speech or hearing, memory changes, confusion, partial paralysis, fainting or seizures.
Symptoms can be aggravated by everyday activities, so sufferers tend to withdraw from or avoid work during attacks, which leads to reduced productivity. One study estimates that each person with migraine loses nearly 20 working days a year to the condition (comprising more than eight days taken off sick and over 11 more lost in reduced output).
Migraine has also been associated with an increased risk of mental health disorders including depression, panic attacks and anxiety, and both ischaemic and haemorrhagic stroke. The condition is considered chronic if the patient experiences migraine on 15 or more days a month. An attack that lasts more than 72 hours is termed status migrainous.
Management: Once migraine has been diagnosed, the usual treatment is an oral triptan plus a NSAID or paracetamol. If vomiting is an issue, a non-oral triptan formulation such as a nasal spray or subcutaneous injection should be considered. It should be noted that ‘melt’ products are absorbed after swallowing, so are classified as oral preparations. An antiemetic may be beneficial for some, even if nausea and/or vomiting is not present, but opioids and ergots should not be used.
A young person with migraine can take paracetamol or ibuprofen. Oral triptans are not licensed for patients under the age of 18 years but nasal sumatriptan alongside simple analgesia is an option for 12-17-year-olds. Non-oral forms of the antiemetics prochlorperazine and metoclopramide are licensed for over-12s, so can be used if needed.
Prevention: Several factors predispose to migraine, ranging from stress, depression and anxiety to hormonal changes such as menstruation and the menopause. There are also many possible triggers, including altered sleep patterns, bright lights, strong smells, dehydration, missed meals, jet lag, strenuous exercise and several foods, particularly chocolate, cheese, caffeine and alcohol.
Keeping a diary can help, but it is sensible to counsel that there may not be an obvious cause – or that conversely, there may be multiple triggers and it may be counterproductive to try and identify them. Similarly, balance is required in avoiding triggers as compromising quality of life in such a way may not always translate into a reduction in the frequency or severity of attacks.
Preventative treatment should be considered for anyone experiencing migraine frequently (usually regarded as being more than twice a month) as these individuals are at risk of disability and medication overuse. The patient must be involved in the decision to pursue this path and understand that while the aim is to reduce the frequency, severity and duration of attacks, they may still require acute treatment from time to time.
First-line treatment should be propranolol or topiramate, says NICE, as both are supported by a decent amount of evidence. The latter requires a conversation about the need for effective contraception as it can cause foetal abnormalities as well as impairing the effectiveness of hormonal contraceptives. If both drugs prove ineffective, or are unsuitable, a course of acupuncture or amitriptyline may be offered.
There is some evidence supporting use of the food supplement riboflavin, says NICE, but it does not advocate the use of valproate, although a Cochrane review described it as effective and reasonably well-tolerated. NICE says that women experiencing predictable menstrual migraine who do not respond to standard acute treatment may try frovatriptan or zolmitriptan on the day they expect a headache. All patients on migraine prophylaxis should be reviewed after six months.
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Red flag symptoms
NICE lists the following as features of headache that warrant further investigation and/or referral:
- Worsening headache with fever
- Sudden onset headache that reaches maximum intensity within five minutes
- New-onset neurological or cognitive deficit
- Personality changes
- Impaired consciousness; recent head trauma
- Headache triggered by coughing, sneezing or trying to breathe out with mouth and nose blocked
- Headache triggered by exercise or change in posture
- Painful red eye
- Significant changes in the nature of the headache
- Compromised immunity
- Age under 20 years with a history of malignancy
- History of cancer that is known to metastasise to the brain
- Vomiting without an obvious cause.
Other reasons for referral include:
- Usual treatment options appear ineffective
- Preventative treatment is not working
- Diagnosis is uncertain
- Chronic headache disorders
- Exposure to or withdrawal from substances such as alcohol, cocaine or painkillers.
Medication overuse headache
Presentation: Chronic head pain resulting from and perpetuated by overuse of medication to relieve headache symptoms (e.g. paracetamol, NSAIDs, opioids, triptans). Symptoms usually resolve when the overused drug is stopped, although withdrawal can initially cause the condition to worsen. According to the IHS, medication overuse headache can be diagnosed if the headache occurs on half or more days per month for more than three months as a result of regular overuse of headache medication. Overuse is defined as a minimum of 10 days per month for triptans, opioids, ergots and combination analgesics, and 15 or more days per month for simple analgesics.
Risk factors and impact: There are several factors that are believed to contribute to the development of medication overuse headache, including concurrent mental health conditions, dependence-related behaviours, family history and a pre-existing diagnosis of migraine or tension headache. It is rare in individuals who take analgesics for another reason such as arthritis. Peak incidence is in women aged 40-45 years who have been diagnosed with migraine, tension headaches or both.
Management: Treatment hinges on withdrawing the overused medication. According to NICE, this should be done abruptly, rather than gradually, and the patient should abstain for at least one month. Symptoms can worsen before they improve (for triptans and ergots, this can take seven to 10 days, while simple analgesics can take two to three weeks), so close monitoring and support should be in place. Withdrawal under hospital supervision may be appropriate if the overused medication is strong opioids, the patient has failed on previous attempts to stop the relevant drug, or has relevant comorbidities.
Prevention: The estimated relapse rate within five years is 40 per cent, with the risk highest in the first year following withdrawal of the overused drug. Providing information on the condition and counselling on appropriate use of medication forms the basis of prevention strategies.
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“Symptoms of medication overuse headache usually resolve when the overused drug is stopped, although withdrawal can initially cause the condition to worsen”
Presentation: Unilateral pain around the eye or temple, lasting between 15 minutes and three hours, and occurring episodically from as infrequently as every other day to as much as several times in the course of a single day. Often the patient experiences the pain at the same time of day for the duration of the cluster period, with first thing upon waking particularly common.
The pain, which is usually described as agonising or excruciating, is accompanied by nasal and ocular symptoms, such as rhinorrhoea, congestion, eyelid oedema, ptosis (drooping of the upper eye lid), conjunctival redness and lacrimation, plus sometimes facial sweating and flushing.
Sub-types and impact: Cluster headaches are generally sporadic with cluster periods of weeks or months separated by remission periods that usually last months or years. The attack frequency determines whether the condition is regarded as:
- Episodic: headaches occur in periods lasting from a week to a year with gaps of at least one month in between (this is the case for around 80 per cent of sufferers)
- Chronic: attacks occur for more than a year with remission periods of less than a month or none at all.
The condition is relatively rare, affecting about one to two people in every 1,000, according to the Migraine Trust, and there seems to be a genetic link. It is more common in men than women, and in heavy smokers, with typical onset between 20-40 years of age.
It tends to be a lifelong disorder, although periods of remission often lengthen with age, and the severity of the symptoms mean that most sufferers need to restrict their daily activities during attacks and experience considerable morbidity.
Management: Acute bouts are managed using subcutaneous or nasal triptans (for individuals aged over 18 years) and/or short burst oxygen therapy, according to NICE. A Cochrane review regards subcutaneous sumatriptan as superior to intranasal zolmitriptan, but says that this is based on limited data.
A second Cochrane review concludes that normal pressure oxygen therapy delivered via a mask at home or in a clinic is effective in cluster headaches. Paracetamol, NSAIDs, opioids, ergots and oral triptans should not be used, but NICE is supportive of the use of transcutaneous vagus nerve stimulation (TVNS), which uses low voltage electrical currents delivered from a patient-administered handheld device to stimulate the cervical branch of the vagus nerve to relieve pain.
Prevention: Cluster headaches can be precipitated or exacerbated by triggers, most commonly alcohol, smoking and strong smelling substances such as paint, petrol, bleach, perfume and solvents – so avoidance, particularly during an episode, can help. Verapamil has a place in prevention during bouts, according to NICE, as has TVNS, which can help reduce the frequency of attacks. NICE also supports the use of sphenopalatine ganglion stimulation devices, which may be implanted for up to two months for patients with chronic cluster headache.
Of all the conditions mentioned in this article, cluster headache is probably the one that requires the most careful counselling because it is so painful. Sufferers may fear there is something extremely serious going on, so providing information on the condition as well as signposting to support organisations is particularly valuable.
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