Most of us have, at some point in our lives, experienced a headache. Unfortunately, some people experience more headaches than others. These headaches may also be more severe and intolerable, which, in most cases, leads the headache sufferer to the pharmacy. It is this first visit which may be the start of a journey to a headache nightmare. The focus in this article will be on the more common headache types that the pharmacist is likely to encounter, and what role the pharmacist can play to ensure that the headache sufferer is offered the best advice for the management of their headache type(s).

Most of us have, at some point in our lives, experienced a headache. Unfortunately, some people experience more headaches than others. These headaches may also be more severe and intolerable, which, in most cases, leads the headache sufferer to the pharmacy. It is this first visit which may be the start of a journey to a headache nightmare. The focus in this article will be on the more common headache types that the pharmacist is likely to encounter, and what role the pharmacist can play to ensure that the headache sufferer is offered the best advice for the management of their headache type(s).

The three headache types and their treatment which will be discussed are:

• Tension-type headache
• Migraine headache
• Medication overuse headache

TENSION-TYPE HEADACHE
This is a common headache and it is the most frequent of all types of headache. Tension-type headache can be divided into episodic and chronic forms. The chronic type is worse than the episodic or intermittent type, and is often associated with more pain, more accompanying symptoms and more medication overuse. It is not usually precipitated by or influenced by daily hassles and stress. In the chronic form, the headache can occur daily and be almost constant. The intermittent form occurs about 6 times per month. The headache usually lasts between 4 and 13 hours, but can be as short as 30 minutes and as long as 7 days. The headache is usually described as “dull” and “non-pulsating”. Many patients describe a “tight band” around the head or pressure on the head. One of the features that differentiate tension-type headache from migraine is the “pressing” quality as opposed to the pulsating throbbing headache of migraine. Migraine is also aggravated by movement, whereas tension-type headache is generally not¹. Refer to Table 1 for the main differentiating features of the tension-type headache and migraine. Tension-type headache and migraine may also co-exist.

Treatment of tension-type headache Treatment begins with the elimination of physical triggers of muscle spasm such as working conditions in which the neck or limbs are in an uncomfortable position, carrying a heavy handbag over one shoulder, carrying of heavy books or a lap top computer in one hand, etc. Stress factors can also precipitate tension-type headache, however not necessarily¹.

Non-pharmacological treatment
Non-pharmacological treatment consists mainly of physical therapy such as physiotherapy, relaxation and exercise programs, improvement of posture, adequate sleep, and hot and cold packs¹. Treatment of the acute headache Simple analgesics such as aspirin or paracetamol, NSAIDs and muscle relaxants will often break the acute headache fairly rapidly. Frequent use of combination OTC drugs should be avoided as they can cause drug-induced headache and convert episodic tension-type headache or infrequent migraine headache into drug-induced or rebound headache1. Some tension-type headache sufferers may require pharmacological prophylaxis. Tricyclic anti-depressants (e.g. amitriptyline) have been extensively and successfully used^1,2.

MIGRAINE HEADACHE
Migraine headache is a common episodic headache characterised by various combinations of neurological, gastrointestinal, and autonomic changes. It has been ranked by the WHO to be among the world’s most disabling medical illnesses. Migraine headache affects patients’ quality of life and impairs work, social activities, and family life³. Migraine is usually inherited from either parent and occurs more frequently in women than in men. There are two major categories of migraine, viz. migraine without aura (previously called common migraine) and migraine with aura (previously called classic migraine)¹. Only about 20% of migraineurs have the visual aura associated with their migraines. The pathophysiology of migraine is complicated and goes beyond simple vasodilatation of the meningeal blood vessels. Non-pharmacological treatment The treatment of migraine headache is a holistic approach and requires nonpharmacological treatment together with pharmacological treatment. Non-pharmacological treatment encompasses keeping a headache diary to determine the potential trigger factors that may precipitate an attack and to avoid these, exercising, developing techniques to reduce stress (e.g. relaxation training, hobbies, biofeedback), a regular sleep routine and eating meals on a regular schedule. There is an endless list of migraine triggers which have been implicated, however the ones which are worth mentioning are hormonal (e.g. menstrually associated migraines in women), nutritional (e.g. monosodium glutamate found in bagged crisps, nitrites, nitrates, caffeine, aspartame), and environmental factors such as changes in altitude¹. It is important that the migraineur identifies her/his potential triggers because what may be a trigger for one migraineur may not be a trigger for another.

Pharmacological treatment of migraine headache
The pharmacological treatment of migraine can be divided into two entities: the treatment of the acute attack and prophylactic treatment.

Treatment of the acute migraine attack
Acute treatment should be initiated early when the pain is mild during a migraine attack. Acute treatment can be specific (ergots and triptans), or non-specific (simple analgesics and NSAIDs). Nonspecific treatment such as aspirin and paracetamol combined with an antiemetic can be used to treat mild migraine attacks. Efficacy is best if taken as early as possible in the attack in adequate dosages². The recommended aspirin dose is 900-1200 mg taken at once or 1000 mg of paracetamol taken at once4. Naproxen may be effective for moderate episodes. Narcotics such as codeine, pethidine, butalbital and morphine should be avoided in the treatment of migraine. These drugs are relatively short acting which can cause a return of the headache after treatment. They can aggravate nausea and vomiting and carry the risk of causing dependency. The frequent use of drugs containing codeine or caffeine also has the risk of causing rebound headaches⁵. Specific anti-migraine treatment is aimed specifically at stopping the acute attack of migraine. There are two broad classes: ergotamine and its related compounds, and the triptans (5-HT1b/1d receptor agonists). The triptans have revolutionised the treatment of migraine and have become the drugs of choice for moderate to severe migraine attacks^2,5. Ergotamine is not used as much because of the potential side effects such as retroperitoneal fibrosis.

Prophylactic treatment of migraine Prophylaxis means prevention. It is not every migraineur who requires prophylactic treatment. Prophylaxis should be instituted when:

1. Migraine has a substantial impact on a patient’s life, despite the use of acute medications.
2. If acute medication fails to provide relief
3. High attack frequency.
4. Where there are contra-indications, negatively affecting the use of successful acute medication.
5. Where there is overuse of acute medication⁵.

Not all agents used for prophylaxis are formally indicated for such use; clinical experience and observation have driven the use of many of these agents. It is important to highlight that clonidine, which is frequently added to the “migraine cocktail” that many pharmacists recommend to migraine sufferers, plays no role whatsoever in the acute treatment of migraine. It is actually contra-indicated for the acute treatment of migraine⁶.

Preventative medication does not stop all migraine attacks; acute therapy is therefore used in addition to preventative medication for breakthrough attacks. There are several drugs which are used for prophylaxis and the choice of agent is tailored to the needs of the specific patient⁵. (Table 2.) It is important to highlight that clonidine, which is frequently added to the “migraine cocktail” that many pharmacists recommend to migraine sufferers, plays no role whatsoever in the acute treatment of migraine. It is actually contra-indicated for the acute treatment of migraine⁶. To be effective as a prophylactic agent, it needs to be taken on a daily basis. Clonidine has a lot of side effects, such as sedation, dry mouth, dizziness etc.

MEDICATION OVERUSE HEADACHE (MOH) (analgesic rebound headache)
Medication overuse headache, or analgesic rebound headache as it is sometimes known, is often secondary to a primary headache, most commonly migraine followed by tension-type headache. Frequent, near-daily or daily use of simple analgesics (aspirin or paracetamol), combination analgesics (containing caffeine, codeine or barbiturates), opioids, ergotamine, or triptans “transforms” the headache into one that occurs daily⁷. Headache secondary to overuse of medication became more apparent in patients using ergotamine for migraine. Ergot is very slowly eliminated from the body, so is readily accumulated if taken three times a week or more frequently, and produces a rebound headache as a result of the drug withdrawal. The patient, however, might reasonably mistake this for recurrent migraine. Continued use leads to ever shortening periods between headache recurrence and medication intake until both are daily. The patient claims (rightly) that only further doses of ergotamine bring relief⁸.

According to a survey conducted in the USA, it was found that MOH was more common among women, and was most likely to occur in patients aged 31 to 40 years. No one analgesic was consisconsistently identified as causative, although paracetamol, butalbital + aspirin + caffeine, and aspirin were commonly used by patients. Depression and physical conditions (especially GIT symptoms) were commonly observed⁹. Characteristic features of MOH include the following:

• The frequency of the headaches increases insidiously over time.
• Patients often awake in the early morning with headache (even though this was not a feature of their original headache), usually because of the medication wearing off.
• A proportion of individual headache attacks may become nondescript (losing their characteristic migrainous or anatomic features and phenotypically resembling tensiontype headache);
• The threshold for stress or exertion to precipitate headaches is frequently lowered.
• Escalating doses of symptomatic medications are required, and
• Headaches occur within a predictable period after the last consumption of symptomatic medication, usually with reduced efficacy (related to rebound or withdrawal phenomenon)^7.

Treatment of Medication Overuse Headache
The medication overuse headache sufferer needs to be referred to a neurologist for a withdrawal programme. Sometimes these patients may even require hospitalisation. Once the analgesics have been withdrawn, the nature of the original headache that caused the problem may be revealed. The headache can then be appropriately treated.

The role of the pharmacist in advising the headache sufferer As mentioned, the pharmacy is often the first port of call for many headache sufferers. In order to avoid the headache nightmares discussed, the pharmacist can play a pivotal role in the following ways:

Tension-type headaches

1. Educate the patient with regards to elimination of physical triggers of muscle spasm.
2. Discuss the non-pharmacological treatment such as physiotherapy, relaxation, exercise programmes, etc.
3. Offer episodic tension-type headache sufferers simple analgesics such as aspirin, paracetamol, NSAIDs and muscle relaxants for the acute headache.
4. Warn patients about the dangers of overusing analgesics.
5. Refer chronic tension-type headache sufferers to their doctor for prophylactic treatment.

Migraine

1. Educate migraineurs about the nonpharmacological treatment discussed such as keeping a headache diary to determine potential triggers (and to avoid these), exercising, eating meals on a regular schedule, etc.
2. Offer aspirin (900 – 1200 mg), or gram paracetamol, or a NSAID such as naproxen plus an anti-emetic to be taken at once as soon as the symptoms begin for mild migraine attacks.
3. Avoid combination analgesics especially those containing caffeine which has greater risks of MOH.
4. Inform migraineurs of migraine-specific medications (triptans) which are effective for moderate to severe migraine attacks and are available on prescription from their doctor.
5. Warn patients about the dangers of overusing analgesics.

Medication overuse headache

1. Educate the patient by giving a careful explanation of the problem. The headache often gets worse before gets better during with-drawal. Inform these patients that after the medication is successfully withdrawn they will feel better, sleep better, Headache and the Pharmacist better, will be less depressed and will worry less about getting headaches. Remember that co-morbid depression and/or anxiety may be present.
2. Refer the patient to the neurologist and offer much needed support while on a withdrawal programme.
3. Keep a close eye on headache patients’ medication history. If it is noticed, for example, that a migraine patient is on a triptan plus one or more combination analgesic (on script or OTC), investigate and advise appropriately. This may even mean contacting the patient’s doctor.
4. For this type of headache, prevention is better than cure. Educate front shop assistants, as more often than not, the pharmacist is not included in the transaction process at all.

Because of the nature of the problem of medication overuse headache, and the headache sufferers themselves, many pharmacists tend to bury their heads in the sand and don’t believe that they are able to make a difference. However, as has been discussed, the pharmacist can play a significant role in the headache sufferer’s pathway to successful headache management. As someone once said, “Most people are more comfortable with old problems than with new solutions”, but remember that each grain of sea sand contributes to making up a beach.

REFERENCES

1. Fritz V. Know Your Brain: Headaches. Ranburg: KYB, 2001
2. Kernick D. Management of headache. Update, Jul 2004: 48-30.
3. Silberstein SD. Migraine. Lancet 2004; 363:381-391
4. Elrington G. Migraine: Diagnosis and Management. J Neurology Neurosurgery Psychiatry 2002; 72 (Suppl 2): ii10-ii15
5. Smuts JA. Migraine: Diagnosis and current management options. SA Fam Pract 2003; 45(8):32-38.
6. Clonidine package insert. MIMS Desk Reference 2004, Vol.38:423-424
7. Gladstone J, Eross E, Dodick D. Chronic Daily Headache: A Rational Approach to a Challenging Problem. Seminars in Neurology, Vol. 23, No. 3, 2003.
8. Steiner TJ, MacGregor EA, Davies PTG. Guidelines for all doctors in the diagnosis and management of migraine and tension-type headache. British Association for the Study of Headache. 2nd Edition, 2000.
9. Rapoport A et al. Analgesic Rebound Headache in clinical practice: Data from a physician survey. Headache 1996; 36(1):14-9.