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Headache & migraine

Your customers may not realise that there are many different types of headache and as a result could be missing out on the correct treatment.

Learning objectives

After reading this feature you should be able to:

  • Diagnose what type of headache customers have from the symptoms described
  • Recognise when it is appropriate to refer patients for medical advice
  • Recommend the right OTC products and lifestyle measures for the various headache types.

 

Pretty much everyone experiences a headache from time to time, which they often dismiss as a mere annoyance. Treating headaches in this way downplays both the level of debilitation that many people experience and the cost to society, which is significant.

The NHS spends an estimated £250m on all headache disorders each year and the annual financial burden to the UK economy is put at £5-7bn when healthcare costs, lost productivity and disability are taken into consideration. In this feature, we look at a series of scenarios with the aim of improving the advice and recommendations made to customers seeking help in pharmacies for headaches.

Worn down and worn out...

Joanna Statham says that she has been suffering from constant headaches for the past few days. She describes the pain as tightness on both sides of her head, and says that while she is managing to go about her day-to-day business, she is finding life tiring and uncomfortable. She has been going to bed early each night as a way of coping, but wonders if there is anything she could buy that would help or if she should see her doctor.

Joanna seems to be suffering from tension headache, the commonest form of headache, and one that more frequently afflicts women rather than men. The precise cause of tension headaches isn’t clear, but they are often brought on by a trigger.

Triggers can range from stress and anxiety to dehydration and missing meals, but some sufferers find their tension headaches are prompted by something very specific, such as sudden bright sunlight or certain smells. What is clear is that the condition is primary in nature and not caused by an underlying condition. Management is two-pronged:

  • A simple analgesic, such as paracetamol or a non-steroidal antiinflammatory drug (NSAID), is usually enough to relieve the pain
  • Identifying and resolving the trigger to prevent a recurrence (e.g. someone skipping meals could try to eat more regularly).

In other cases, some lateral thinking may be required. For instance, someone who thinks that their work is precipitating the headaches may be understandably reluctant to leave their job. In this case, the individual in question may benefit from learning some relaxation techniques or taking regular exercise.

Those who suffer from tension headaches on more than 15 days a month for more than three months may benefit from a course of acupuncture, according to NICE guidance on the topic.

One of the most important things someone with tension headaches can do is find a way of coping with stress, but this is not always easy.

Struck by lightning

John McCartney looks severely under the weather. He tells you he has an excruciating headache around his left eye and describes the feeling as being “hit by lightning.” When you look closely, you notice that the pupil of that eye is slightly smaller, and that the eye itself is red and watery. John says his headache started very suddenly about an hour or so ago, and is identical to the symptoms he has experienced almost every day – and at the same time of day – for the past week or so. He says that while the pain only lasts a couple of hours, he finds it extremely debilitating.

John may be experiencing the relatively unusual phenomenon of cluster headaches, which are estimated to affect around one in every 500 to 1,000 people, and men more frequently than women. Symptoms include severe pain on one side of the head, plus at least one of the following: a red and watery eye; unilateral eyelid drooping and swelling; a constricted pupil in one eye; sweating; a blocked or runny nostril; or a single hot, red ear. Symptoms start abruptly and last between 15 minutes and three hours, and typically recur between one and eight times a day for several weeks or months before subsiding.

The cause of cluster headaches is unclear but is thought to be due to overactivity in the hypothalamus of the brain. There appears to be a familial link, and smoking increases the risk of the condition developing. Some individuals notice that certain things trigger the headaches; for example, a strong smell, exercise, a change in the weather or drinking alcohol. Cluster headaches that have periods of remission of less than one month between bouts are considered chronic, which is the case for some 10-20 per cent of patients.

John needs to see his GP, who may refer him to a neurologist for tests to exclude other conditions. If the diagnosis of cluster headaches is confirmed, he may be offered a subcutaneous or nasal triptan or oxygen for acute treatment. OTC treatments – including paracetamol, NSAIDs, opioids and oral triptans – are not effective and should not be offered.

During a bout of cluster headaches, prophylactic therapy in the form of verapamil may be tried. If this does not work, alternative treatments such as corticosteroids, lithium, occipital nerve blocks or external vagal nerve stimulation may be tried, but only under specialist supervision. If John is a smoker he should be told of the link between smoking and cluster headaches with a view to encouraging him to quit.

Individuals suffering from cluster headaches can find the condition very distressing and feel incredibly isolated. Support can make a significant difference and is available from the Organisation for the Understanding of Cluster Headache website.

What does NICE say about headache?

NICE guidance on the diagnosis and management of headaches in the over-12s was updated at the end of 2015, and contains useful information on red flags that indicate a medical referral is in order.

The red flags include: headache triggered by pressure changes such as bending down or coughing or by exercise; varying symptoms; recent head trauma; worsening headache accompanied by a fever; new cognitive or neurological symptoms such as slurred speech or confusion; impaired consciousness; personality changes; vomiting; and immunocompromised patients.

More information at the NICE website.

Monthly misery

Carol Todd says that for the past few months, she has been suffering from one-sided “splitting” headaches. The pain is sufficiently intense that she finds concentrating difficult and feels nauseous to the point that she has occasionally been sick. She says that afterwards she always thinks that she should have known it was going to happen because she remembers feeling dizzy beforehand, and looking back through her diary, it always seems to coincide with the start of her period. Painkillers don’t seem to have much of an effect – instead she prefers to shut herself away in her bedroom so she can’t hear anything and with the curtains closed so no light gets in. She finds that she is often very tired for a couple of days after the pain has subsided.

This appears to be a classic case of migraine with aura. The aura can involve visual disturbances, such as seeing flashing lights or coloured spots, memory changes, numbness, paraesthesia, unilateral weakness, vertigo, feelings of fear or confusion, or may affect speech and hearing. Occasionally, sufferers may faint or experience partial paralysis. These symptoms develop quickly and usually last no longer than an hour, when they are succeeded by an intense headache, usually frontal or unilateral in location, and often worse on movement.

Other symptoms can include nausea, vomiting, sweating, abdominal pain, diarrhoea and increased sensitivity to light and sound, with the experience lasting anything from a few hours to several days, and often leaving fatigue in its wake.

Migraine is thought to stem from abnormal brain activity that alters nerve signals, chemical levels and blood flow, and has a strong hormonal element. Not only are women much more likely to suffer from migraine than men, menstrual migraine is considered a condition in its own right.

Other common triggers are stress, anxiety, excitement, fatigue, poor posture, hypoglycaemia, dehydration, alcohol, caffeine, smoky environments, loud noises, changes in climate, strong smells, bright lights and flickering screens.

Carol has been very sensible to note down when her headaches occur and link them to her menstrual cycle, as it makes diagnosis much easier. If she is able to identify the warning signs, she could try taking OTC painkillers straightaway, as they are more likely to be absorbed before the headache starts (soluble variants will further speed this process).

Carol may be a suitable candidate for triptan therapy on the day she anticipates getting a migraine, although this will only work if her menstrual cycle is predictable. Otherwise, she may be prescribed prophylactic treatment in the form of topiramate – although this drug is associated with foetal malformations, so Carol will need to be on appropriate contraception – or propranolol or amitriptyline.

If these options are unsuitable or ineffective, a course of acupuncture may be beneficial. There is some evidence that taking riboflavin 400mg once daily can be effective at reducing migraine frequency and intensity, so this may be something Carol wishes to try. She should not, however, use combined hormonal contraceptives as these have been linked to an increased risk of stroke in women who suffer from migraines accompanied by aura symptoms.

Keeping a headache diary for at least eight weeks is recommended by NICE as a way of aiding diagnosis and gauging how successful any treatments have been. The diary should record details such as how often the headache occurs and how long it lasts, any suspected triggers, the symptoms including the severity of the pain, and any medicines or treatments tried. A template is available from the Migraine Trust here.

Headache can cause untold misery for sufferers unless managed effectively

Pain that goes on and on...

Martina Craw is at the end of her tether. She has been suffering from constant headaches and it doesn’t matter what she takes or what she does, they don’t seem to stop. She says the pain is “dull” compared to the migraines she has suffered from in the past, but is worse in the morning, and persists pretty much all day, every day. What are the very strongest painkillers she can buy, she asks, that will relieve the headache once and for all?

This appears to be a classic case of medication overuse headache, sometimes referred to as “painkiller” or “rebound” headache. The condition occurs because frequent use of analgesics (a minimum of 10-15 days per month for at least three months) causes the receptors that inhibit pain to become down-regulated. It isn’t just paracetamol, NSAIDs and opioids that contribute to the problem; triptans and ergot alkaloids used in the management of migraine may also be responsible, as may caffeine, which is often present in combination OTC analgesic preparations.

A vicious cycle is created, in which the sufferer – more frequently a woman rather than a man – continues to take painkilling medication in order to bring the condition under control, but finds that the symptoms gradually worsen as a result. This can lead to the individual seeking out stronger or alternative medicines, which continue to exacerbate the problem.

The only way of getting a handle on medication overuse headache is to stop taking painkillers. It is generally recommended that this is done gradually rather than abruptly, but with the ultimate aim of achieving at least one month free of the medicines that have been contributing to the issue.

Withdrawal symptoms may occur, such as nausea, agitation and disturbed sleep, and the headaches may worsen before they improve, during which time (anything between seven days and up to three weeks), a considerable amount of support, encouragement and willpower will be needed. Staying well hydrated during this time can make a difference, as will choosing a time when stress levels are not at their peak (e.g. avoiding the run-up to a wedding or when starting a new job).

Certain patient groups require close monitoring and increased levels of support before and while embarking on the medication withdrawal process (e.g. those who have been on strong opioids, individuals with mental health issues or underlying conditions such as arthritis that require analgesic treatment, older patients who are particularly frail, and pregnant women). Anyone who has tried and failed several times to withdraw from overused medication also falls into this category.

It is worth noting that a history of medication overuse headache is not, in itself, a reason to avoid all painkillers forever. Once the habit has been broken, most individuals are able to return to normal analgesic usage, as long as they obey the usual recommendation to the take the lowest possible dose for the shortest amount of time. An information leaflet is available from Lifting The Burden, a UK charity.

Keeping a headache diary for at least eight weeks is recommended by NICE as a way of aiding diagnosis and gauging treatment success

What else could it be?

This feature runs through some of the commonest reasons why someone experiences a headache, but there are many reasons why symptoms can occur:

  • Dehydration, either because of not drinking enough fluid (this is particularly common in children) or because of drinking too much alcohol
  • Cold, flu, sinusitis or toothache
  • A temporomandibular disorder
  • Carbon monoxide poisoning
  • Sleep apnoea
  • Changes in altitude
  • Stroke
  • Meningitis
  • Brain tumour.

The presentation for each condition is different, and all symptoms, signs and other relevant features should be taken into consideration.

 

Key facts

  • Women are more likely to suffer migraine while cluster headaches affect more men
  • Frequent use of analgesics cause the receptors that inhibit pain to become down-regulated
  • OTC treatments – including paracetamol, NSAIDs, opioids and oral triptans – are not effective in cluster headaches

 

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