Management of migraines in community pharmacy

Clinical
By
Tara de Koning
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Pharmacists play a vital role in supporting patients with migraines.

People with headaches are one of the most common presentations to community pharmacies and pharmacists play a pivotal role in identifying people with migraine and providing education.1

Pharmacists are frequently the first port of call for people who have headaches. This provides an opportunity to provide initial assessment, management and education about headaches.1

Pharmacists are also important intermediaries for undiagnosed or misdiagnosed people with headaches.2

Headaches are broadly classified into primary and secondary headaches. Secondary headaches can indicate serious health concerns. Urgent referrals for further investigation should be considered for any of the following3:

  • Thunderclap onset
  • Fever and meningismus
  • Papilledema with focal signs or reduced level of consciousness
  • Acute glaucoma
  • Temporal arteritis
  • Relevant systemic illness
  • In elderly patients, new headache with cognitive change.

Migraines are considered a primary headache disorder, which are due to a primary neurologic process without an underlying cause.1 Migraines are diagnosed based on the person’s history as there are no specific diagnostic tests.4

Tension headaches tend to be bilateral and constant, while migraines are usually unilateral and throbbing.2,4 With migraines, pain is aggravated by routine activities such as walking, climbing stairs or bending over.2,4 Migraines were found to be the sixth highest cause worldwide of years lost due to disability, affecting home life, employment, school and social activities.2,4,5

Population-based studies report that 45% of people with migraines say they are forced to miss family social and leisure activities, and 32% avoid making plans for fear of cancellation due to headaches.6

Migraines also significantly impact mental health with anxiety and depression significantly more common in people with migraine than in healthy individuals.7

Community pharmacist’s role

Management of migraines should be individualised for each person.4 Successful management includes appropriate use of medications, elimination of triggers or precipitating factors, routine monitoring and follow-up, and education.2,4

Triggers and/or precipitating factors include caffeine (and caffeine withdrawal), hormonal changes, stress, smoking, lack of sleep, certain foods, strenuous exercise, weather changes, fumes and vapours, bright light, noise and foods.4

It is helpful for the person to keep a diary to record episodes including frequency, duration and severity of attacks. This will help their doctor diagnose their condition and help identify triggers. An example of a diary is available at www.headaches.org.2,4

Non-pharmacological therapies can be a helpful adjunctive treatment to pharmacological options. These include behavioral therapy and psychosocial interventions, including relaxation therapy, biofeedback, and stress management, all of which may be effective in some populations.8

Over-the-counter medicines

The pharmacist is often first-line when a person is asking for advice on the use of over the counter (OTC) medicines. This places pharmacists in a position to provide information on migraine and the appropriate use of OTC medicines.1

Pain intensity for people with migraines are classified as mild, moderate or severe.1 OTC analgesics may be appropriate in people who experience mild-to-moderate migraines 2 to 4 times a year or <1 or 2 attacks per month.2

Ask

A simple set of questions can help determine the true nature of a person’s headache and whether they need to see their doctor. These include2:

  • Medical and headache history
  • Effect on ability to function
  • Number of no-headache days a month
  • Symptoms beyond headache pain
  • Previous response to over-the-counter medications
  • Contraindications to OTC medicines.

Advise

Patients should take OTC medicines as soon as the headache starts.2 Taking OTC medicines as soon as the headache starts is important for efficacy; however, be mindful that overuse increases the risk of medication overuse headaches (MOH). This is characterised by an almost daily incidence of headache. The main treatment is to discontinue the medicine causing the MOH.2

OTC medicines should not be taken more than 2–3 times a week.2,5

The role of ibuprofen in the management of migraines

Non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen may be good first-line agents in people with mild-to-moderate migraine.9

NSAIDs function through their inhibition of prostaglandins, which may interfere with the neurogenic inflammation associated with vasoactive peptide release during migraine.9

Controlled trials of ibuprofen in doses ranging from 200 to 1200 mg reported improvements in pain response, intensity, pain-free status, and the sensory and gastrointestinal symptoms of migraine compared to placebo.9

For stronger pain relief, Nuromol is an ibuprofen/paracetamol combination containing 200mg ibuprofen and 500mg paracetamol, for the temporary relief of acute pain and/or inflammation, from the makers of Nurofen. More patients achieved relief with Nuromol than some other OTC NSAIDs.10

Nuromol is more effective pain relief than paracetamol/codeine 1000/30 mg and one tablet last for up to 8 hours, giving long-lasting relief while reducing tablet burden.10

References

  1. Giaccone M, Baratta F, Allais G, et al. Prevention, education and information: the role of the community pharmacist in the management of headaches. Neurol Sci. 2014 May;35 Suppl 1:1-4. At: https://www.ncbi.nlm.nih.gov/pubmed/24867826
  2. Wenzel R. Understanding migraines. 2019. At: medscape.org/viewarticle/545807
  3. Becker WJ, Findlay T, Moga C, et al. Guideline for primary care management of headache in adults. Can Fam Physician. 2015 Aug; 61(8): 670–679. At: https://www.ncbi.nlm.nih.gov/pubmed/26273080
  4. Radia C, Rawlens E, Jones S. Migraine management. At: www.pharmaceutical-journal.com/acutepain/migraine-management/20069252.article
  5. World Health Organisation. Headache disorders. 2016. At: who.int/news-room/fact-sheets/detail/headache-disorders
  6. Lipton RB, Diamond S, Reed M, et al. Migraine diagnosis and treatment: results from the American Migraine Study II. Headache. 2001;41:638–645. At: https://www.ncbi.nlm.nih.gov/pubmed/11554951
  7. Wenzel RG, Lipton RB, Diamond ML, et al. Migraine therapy: a survey of pharmacists’ knowledge, attitudes and practice patterns. Headache. 2005;45:47–52. At: https://www.ncbi.nlm.nih.gov/pubmed/15663613
  8. Puledda F, Shields K. Non-Pharmacological Approaches for Migraine. Neurotherapeutics. 2018 Apr; 15(2):336– 345. At: https://www.ncbi.nlm.nih.gov/pubmed/29616493
  9. Pardutz A, Schoenen J. NSAIDs in the Acute Treatment of Migraine: A Review of Clinical and Experimental Data. Pharmaceuticals (Basel). 2010 Jun; 3(6):1966–1987. At: https://www.ncbi.nlm.nih.gov/pubmed/27713337
  10. Nuromol Product Information, 2016. At: https://www.nps.org.au/medicine-finder/nuromol-tablets