Migraine Headache: Help Is Possible

It's easy to spot headache sufferers—they wander in the OTC aisle examining labels, looking distraught and fatigued. The National Institute of Neurological Disorders and Stroke (NINDS) indicates that migraine patients usually don't seek medical care from a healthcare provider until OTC products fail to help. Then, they appear in the clinic, asking for pain relief.¹Although acute pain relief is certainly necessary, other steps are, too.

Migraine: The Most Frequent Type of Headache

Headaches are exhausting and interfere with the sufferer's ability to function. Roughly 50% of American adults have a headache at least once a year.²In fact, NINDS indicates headache is the most common pain Americans experience, and often leads to missed school or work.¹

Healthcare professionals often struggle to help patients who experience agonizing headache. With no tests that clearly identify and classify headache by type, retail healthcare providers must rely on the patient's ability to describe his or her problem's history and symptoms.³Experts indicate there are at least 14 distinct types of common headache, and more than 100 additional rarer types.³Retail healthcare providers are infrequently trained to differentiate among them, and may diagnose garden-variety headache, rather than a more specific (and treatable) diagnosis.⁴An important point to consider is this: 1 in 7 Americans (14%) experience migraine headache, making it the most common type of headache.^2,5,6

Patients will describe migraine headaches as pounding, throbbing pain. Migraines last 4 hours to 3 days, and occur repeatedly, usually 1 to 4 times per month. Patients may also report sensitivity to light, noise, or smells; nausea or vomiting; anorexia; and upset stomach. Most patients will talk about a feeling that develops before the headache occurs—called anaura—and may describe visual disturbances.³Women are more than twice as likely as men to report migraine.⁷

What's the Goal?

Treatment goals for migraine are to alleviate acute pain, restore normal functioning, prevent relapse, and do so with the fewest medication side effects possible. Patients who experience migraine (calledmigraineurs) need 4 clinical interventions:

• Enhanced drug selection and relief of headache pain and associated symptoms
• Better monitoring for adverse effects
• Attention to patient satisfaction, and/or
• Consideration of treatment costs

Ask the Right Questions

Retail healthcare providers in community settings can use the4-Question Assessment Tool for Patients with Headacheto direct their history-taking and pinpoint the headache type.⁸These questions include the following:

a. Prohibit you from performing normal work, school, or household activities?

b. Are accompanied by vomiting?

1. What percentage of your headaches:2. How many days/month are you completely headache free?

3. What symptoms accompany your headaches?

4. What OTC products have you tried?

A simple paradigm for diagnosing migraine is this: migraine is highly likely if patients report headache with nausea, or if they experience 2 of 3 symptoms from either of these symptom triads:

• nausea, photophobia, or pulsating pain
• nausea, photophobia, or a headache that worsens with exertion^9-12

Retail health clinicians need to be aware that migraine's clinical picture can change over a series of attacks, especially in patients who have other types of headaches or comorbid conditions. For example, migraine and tension headache have common risk factors (stress, mental tension, failure to eat, fatigue, and lack of sleep). They also share triggers (physical activity, light, and noise, alcohol consumption, weather changes, and menstruation).¹³

When differencing between types of headache, retail health clinicians need to consider self-treatment exclusions (eg, severe pain, headaches persisting for 10 or more days, last trimester of pregnancy, age younger than 8 years, history of liver disease, heavy alcohol consumption, underlying pathology). These patients are likely to have more complex clinical concerns and may need referral.³

Tailoring Treatment

OTC products can provide adequate relief for some patients. Pharmacists and retail health clinicians can help patients navigate the OTC aisle and select products (or combinations of products) that are most likely to lead to relief. A full range of medications is available to treat migraine^9-12:

• Patients need to take abortive therapy as soon as they realize a migraine is starting.
• Many OTC medications are effective:Combination analgesics containing aspirin, caffeine, and acetaminophen are effective first-line abortive treatments.Ibuprofen at manufacturer-recommended doses is effective for many migraineurs' acute migraine pain

If OTC medications fail to meet treatment goals, prescription drugs can help. Triptans are effective and safe for treatment of acute migraine, and are available in oral, transdermal, intranasal, and injectable dosage forms.

Migraineurs who self-treat usually employ acute analgesics and either ignore or are unaware of preventive treatments.¹⁴Approximately 38% of migraineurs need preventive therapy based on headache days per month and the level of attack-related impairment caused by the headaches; however, only 3% to 13% currently use it.¹⁵Retail healthcare providers can help migraineurs by recommending prevention, including the following:

• Valproate (Depacon) and topiramate (Topamax) reduce migraine attack rates by at least 50%.
• Propranolol has been found to reduce the migraine frequency, but its effectiveness for chronic migraine is unclear.
• Tizanidine (Zanaflex) may reduce the frequency, severity, and duration of chronic migraine.

Caution in Certain Situations

In addition, pharmacists and retail health clinicians need to know the evidence-based recommendations that urge caution^9-12:

• Prescribers should avoid routine use of opiates and barbiturate-containing compounds as abortive treatments.
• All patients with chronic daily headache should be aware of and avoid medication overuse, which can complicate the course of the headache.
• Patients with incapacitating symptoms need referral to an emergency department.

Track Adherence, Follow-up

Choosing the best medication for migraineurs is a good start, but medication adherence, switching, and re-initiation in patients with chronic migraine are additional issues. Migraineurs' adherence is notoriously poor. It falls to 50% between 1 and 2 months, 25% at 6 months, and just 14% at 12 months. Twenty-three percent of patients who discontinued their migraine medication switched to another prophylactic. When patients switch to alternative prescription medications, they repeated the tendency to nonadherence; adherence rates of between 4% and 13% at 12 months have been reported.¹⁶Clearly, encouragement and frequent counseling are needed to improve adherence and ensure migraineurs benefit from treatment.

References

1. National Institute of Neurological Disease and Stroke (NINDS). Headache: Hope Through Research. 2012. ninds.nih.gov/disorders/headache/detail_headache.htm. November 28, 2016.

2. World Health Organization. Headache disorders fact sheet. April 2016. who.int/mediacentre/factsheets/fs277/en/. November 28, 2016.

3. Headache Classification Committee of the International Headache Society. The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia. 2013;33(9):629-808.

4. Smith TR. Pitfalls in migraine diagnosis and management. Clin Cornerstone. 2001;4(3):3.

5. Lipton RB, Stewart WF, Diamond S, et al. Prevalence and burden of migraine in the United States: data from the American Migraine study II. Headache. 2001;41(7):646-657.

6. Burch RC, Loder S, Loder E, Smitherman TA. The prevalence and burden of migraine and severe headache in the United States: updated statistics from government health surveillance studies. Headache. Jan 2015;55(1):21-34.

7. Pleis JR, Ward BW, Lucas JW. Summary health statistics for U.S. adults: National Health Interview Survey, 2009. Vital and health statistics. Series 10, Data from the National Health Survey. 2010(249):1-207.

8. Wenzel RG, Sarvis CA, Krause ML. Over-the-counter drugs for acute migraine attacks: literature review and recommendations. Pharmacother. 2003;23(4):494-505.

9. Hainer BL, Matheson EM. Approach to acute headache in adults. Amer Fam Phys. 2013;87(10):682-687.

10. Yancey JR, Sheridan R, Koren KG. Chronic daily headache: diagnosis and management. Mmer Fam Phys. 2014;89(8):642-648.

11. Gilmore B, Michael M. Treatment of acute migraine headache. Amer Fam Phys. 2011;83(3):271-280.

12. Weaver-Agostoni J. Cluster headache. Amer Fam Phys. 2013;88(2):122-128.

13. Cady R, Garas SY, Patel K, Peterson A, Wenzel R. Symptomatic Overlap and

Therapeutic Opportunities in Primary Headache. J Pharm Pract. 2015;28(4):413-8.

14. Giaccone M, Baratta F, Allais G, Brusa P. Prevention, education and information: the role of the community pharmacist in the management of headaches. Neurol Sci. 2014;35 Suppl 1:1-4.

15. Lipton RB, Bigal ME, Diamond M, Freitag F, Reed ML, Stewart WF. The American Migraine Prevalence and Prevention Advisory Group. Migraine prevalence, disease burden, and the need for preventive therapy. Neurology 2007;68:343-349.

16. Hepp Z, Dodick DW, Varon SFet al. Persistence and switching patterns of oral migraine prophylactic medications among patients with chronic migraine: A retrospective claims analysis.

Cephalalgia. 2016 Nov 10. pii: 0333102416678382. [Epub ahead of print]