Case scenario

Chau, a 23-year-old female, requests ‘something strong for migraine’. She tells you she is developing a headache, has sensitivity to light and awful nausea. Chau has been experiencing migraines twice a month since they were originally diagnosed by her doctor 6 months ago. Despite trying paracetamol, ibuprofen and paracetamol/metoclopramide on different occasions, she hasn’t found something that effectively resolves her symptoms. Chau confirms she has no other medical conditions, takes no regular medicines and is not pregnant or breastfeeding.

Learning objectives

After reading this article, pharmacists should be able to:

  • Describe the clinical features of tension-type headache and migraine
  • Discuss the pathophysiology and risk factors of tension-type headache and migraine
  • Discuss acute and preventive management options for tension-type headache and migraine
  • Explain the use of triptans for migraine headache

Competency (2016) standards addressed: 1.1, 1.4, 1.5, 1.6, 2.1, 3.2, 3.5

Accreditation expiry: 31/01/2027

Accreditation number: CAP2402OTCJJ

Already read the CPD in the journal? Scroll to the bottom to SUBMIT ANSWERS.

Introduction 

Migraine and tension-type headache are the most prevalent of all neurological disorders, affecting a significant portion of the Australian population.1 It has been found that a large number of these people will not seek medical attention.2

Pharmacists play a vital role in screening for ‘red flags’ in these patients, recommending referral when it is required, and supporting the selection of appropriate treatment options. 

Epidemiology

In Australia, it is estimated that 4.9 million people (almost 20% of the population) experience migraine, with women being approximately three times more likely to experience migraine than men.3 Tension-type headache is even more prevalent, reported to affect almost 90% of the population at some point in their lives.4

Migraine and tension-type headache can significantly impact quality of life, leading to decreased productivity, absenteeism, and increased healthcare utilisation. Nearly all individuals with migraine and 60% of those with tension-type headache experience reductions in social activities and work capacity.

Aetiology, pathophysiology and risk factors 

Migraine is a complex neurovascular disorder that involves both genetic and environmental factors.6 The underlying mechanisms of migraine are thought to involve altered neuronal processing and dysregulation of the trigeminovascular system.7 

While the exact cause of migraine is not fully understood, there are several known risk factors for developing the condition. These include a family history, female sex and hormonal changes..8 Fluctuations in oestrogen are a particularly potent trigger, with many experiencing migraine just prior to and/or during menstruation.7

Lifestyle and environmental factors, such as stress, lack of sleep, weather changes, dietary triggers, caffeine (consumption or withdrawal), red wine or general alcohol consumption, can also trigger attacks and exacerbate symptoms in some individuals.7,9,10

The pathogenesis of tension-type headache involves both central and peripheral factors, and is associated with muscle tension and contraction in the head, neck and shoulders.11 It can be triggered by many of the same factors as migraine.10 Other potential risk factors for tension-type headache include a history of anxiety or depression, as well as poor sleep quality and inadequate physical activity.4 

Clinical features and diagnosis 

Accurate diagnosis of headache disorders is crucial in reducing stigma and ensuring patients receive appropriate treatment. 

Migraine and tension-type headache can occur in both episodic and chronic forms, with the chronic form diagnosed when the patient experiences headaches for ≥15 days per month for at least 3 months.12 

Migraine and tension-type headache are diagnosed primarily through patient-reported history, using the criteria outlined in the 3rd edition of the International Classification of Headache Disorders.12 As such, keeping a headache diary to record the frequency, duration and characteristics of headaches and associated symptoms can be useful. 

Occasionally, when red flags are present, imaging investigations may be required to rule out alternative diagnoses. Initial diagnosis, and recognition of headache type in the pharmacy, can be complicated, as many patients will experience both migraines and tension-type headache.12 

The ID Migraine tool is a quick and simple screening tool, consisting of three yes/no questions that can assist pharmacists in identifying patients who may have migraine. If a patient answers yes to two of the following three questions, it is reasonable to conclude the patient is experiencing migraine, as the tool has a 93% positive predictive value.13 

Questions:

1) Has a headache limited your activities for a day or more in the last 3 months? 

2) Are you nauseated or sick to your stomach with a headache? 

3) Does light bother you when you have a headache? 

Migraine headache 

Migraine typically occurs in four phases: the premonitory phase, aura phase, headache phase and postdrome phase.7,14 

The premonitory phase can start hours or days before the headache and is characterised by subtle changes in mood or energy levels.14 

The aura phase affects up to a third of people who experience migraines and typically lasts less than an hour. An aura is a neurological phenomenon involving changes in sensory perception. It most commonly manifests as visual symptoms such as seeing flashing lights, zigzag lines and blind spots. As the aura resolves, the headache phase sets in.7,14 

Migraine headache typically presents as a unilateral, pulsating headache with moderate to severe intensity, lasting 4–72 hours, accompanied by nausea, vomiting, photophobia, phonophobia and sometimes osmophobia.12 

The postdrome phase occurs after the headache and can cause feelings of fatigue, irritability and difficulty concentrating. It is important to note that not all patients experience each phase, and the presenting symptoms within phases can vary between individuals and between attacks.14 

Tension-type headache 

In contrast, tension-type headaches are characterised by a bilateral, aching, pressing or tightening ‘vice-like’ headache of mild to moderate intensity, often associated with neck pain and muscle tension. They can vary in duration, lasting from 30 minutes to 7 days. 

Tension-type headache can also be differentiated from migraine as it is not aggravated by routine physical activity such as walking or climbing stairs and is not accompanied by nausea or aura.15 

Referral points 

Pharmacists must be aware of ‘red flags’ that require referral for medical review and further investigation. 

Important referral points for medical review include16: 

  • a new or different type of headache
  • presence of speech difficulties, confusion, memory problems, balance problems, drowsiness or seizures
  • presence of ocular symptoms
  • neck stiffness, fever or vomiting
  • recent head or neck trauma
  • a headache that wakes the patient
  • recent-onset headache triggered by coughing, sneezing, straining, bending over, exertion or sexual activity
  • headaches with rapidly escalating frequency or severity
  • a suspected drug reaction
  • headache not responding to treatment migraine symptoms increasing in frequency or occurring on >2 days a month. 

The SNNOOP10 mnemonic, see Table 1, provides a comprehensive list of red flags and can be used to prompt questioning when screening.17 

Treatment options Pharmacists should take a patient-centred approach to treatment, considering individual needs and preferences to optimise outcomes. 

In migraine and tension-type headache, the goals of treatment are to alleviate symptoms and reduce the frequency and severity of headache attacks to ultimately improve quality of life. 

Nonopioid analgesics, including aspirin, non-steroidal anti-inflammatory drugs (NSAIDs) and paracetamol, are first-line treatments for both conditions.18,19 

In migraine, these can be used alone or in combination with triptans and/or antiemetics as needed, depending on the patient’s clinical profile, to provide additive benefits.18

Studies directly comparing efficacy of various NSAIDs in headache and migraine are lacking. If one NSAID is ineffective, a different NSAID can be considered.21 

Opioid analgesics (including codeine) should only be used for headache under expert advice when other options are contraindicated or not tolerated, as evidence of benefit is limited. 

They can aggravate gastrointestinal symptoms in migraine and are the medication class most likely to cause medication overuse headache (see below).18,20

Migraine specifics 

In migraine, an appropriate nonopioid analgesic should be taken early during the headache phase, within 30 minutes of symptom onset to optimise efficacy.20 

Single larger doses tend to be more effective than repeated smaller doses.21 For example, suitable oral doses for migraine include aspirin 900–1,000 mg, repeated after 4–6 hours if needed (maximum 4 g/24 hours), or ibuprofen 400–600 mg, repeated after 4–6 hours if needed (maximum 2.4 g/24 hours)18. 

Metoclopramide and prochlorperazine can be recommended over the counter to manage the gastrointestinal symptoms of migraine and improve analgesia.18,20,22 Sedating antihistamines such as diphenhydramine, can also relieve nausea and may be beneficial in promoting sleep, which can terminate headache.20,23

Triptans 

For migraine, all triptans are effective and well-tolerated. While triptans can be effective at any time during the headache phase, they are most effective when taken early in the attack while the headache is still mild.24 Triptans are not effective when taken during the aura phase before the headache begins.25,26 

Although some evidence suggests eletriptan may have the greatest efficacy,27,28 individual responses to different triptans vary considerably.20 Minor pharmacokinetic differences in onset and duration exist between triptans and formulations, and different triptans are subject to different drug interactions, of which pharmacists should be aware.26 

Response to one triptan does not predict response to another, thus if a particular triptan is ineffective, an alternative triptan can be trialled during a subsequent attack.20,24 

For patients who initially respond to an oral triptan and find their headache comes back, the triptan dose can be repeated after at least 2 hours (4 hours for naratriptan).18 However, if there was no response to the first dose, redosing within the same attack is unlikely to provide a benefit and is not recommended.18

A number of triptans are now available as Pharmacist Only medicines for patients with migraine diagnosed by a doctor, and who present with a stable and well-established pattern of symptoms.29 A patient’s medical history must be reviewed, as triptans are contraindicated in uncontrolled hypertension, peripheral vascular disease, history of stroke or transient ischaemic attack, and ischaemic heart disease, due to their vasoconstrictive properties. Potential for drug interactions with concurrent medications must also be considered.30

Medication overuse headache 

Headache treatments should be used judiciously. Frequent use has the potential to cause medication overuse headache, a secondary headache disorder characterised by increased headache frequency due to the regular use of certain medications, such as opioids and triptans (on 10 or more days per month)12, and, less commonly, nonopioid analgesics (on 15 or more days per month). Interestingly, medication overuse headache only occurs in those with a pre-existing headache disorder. It does not develop in those using the same medicines frequently for other conditions such as arthritis. 

Patients who are not getting relief with usual doses of medicines, and those who require acute treatments frequently should be referred to their doctor for review. 

Treatment of medication overuse headache includes gradual withdrawal of the causative agent under medical supervision, potential bridging therapy with modified-release naproxen or prednisolone, and often addition of an agent for headache prophylaxis.31 

Preventive treatment 

Many patients are unaware that preventive medicines are available to help prevent migraine or tension-type headache. Pharmacist referral to a patient’s doctor to discuss prophylaxis where appropriate has the potential to significantly improve patient outcomes. 

Prophylaxis for migraine and tension-type headache is indicated for patients who experience 2 or more severe attacks per month that significantly impair their quality of life and who do not respond well to acute treatment taken at the onset of attacks.18,30

Due to the lack of direct comparisons between prophylactic drugs and the variability in individual responses, selection of a prophylactic medicine depends on the patient’s comorbidities, concurrent medications, and the potential adverse effects associated with each drug.18

For migraine, first-line choices include amitriptyline, candesartan, nortriptyline, pizotifen, propranolol, topiramate, valproate and verapamil.18 Botulinum toxin and calcitonin gene-related peptide antagonists can be used in complex/ refractory cases.20 Some evidence also exists for magnesium, riboflavin and ubidecarenone supplementation in preventing migraine.18

For tension-type headache, first-line choices include amitriptyline or nortriptyline, followed by mirtazapine or venlafaxine.19

Non-pharmacological management

Non-pharmacological self-care for migraine and tension-type headache includes lifestyle modifications such as stress reduction, obtaining adequate sleep, regular exercise, and a healthy diet.20,22 For acute relief a cold pack on the forehead or back of the skull, a hot pack on the neck/shoulders, neck stretches and resting in a quiet, dark room is recommended.18

Additionally, behavioural therapies such as cognitive-behavioural therapy, biofeedback and relaxation techniques can be effective in managing symptoms.18

While evidence for these treatments varies, a multimodal approach that combines non-pharmacological and pharmacological interventions can be effective for many patients. 

Knowledge to practice 

Patients often present to community pharmacy seeking treatment for migraines and tension-type headaches. Pharmacists can assist by screening for red flags which suggest medical review and/or further investigations are required, and by recommending appropriate pharmacological and non-pharmacological management when appropriate. 

Pharmacists should take a headache history to differentiate between headache types, identify the most bothersome symptoms, and explore past treatments trialled. 

This information, along with the patient’s medical and medication history, can be used to guide tailored over-the-counter treatment recommendations and, where necessary, referral to discuss prescription management options, including prophylactic medicines.

Case scenario continued

As Chau has been diagnosed with migraine; has a stable, well-established pattern of symptoms; is presenting with typical migraine symptoms; has found simple analgesics insufficient for previous headaches; and has no contraindications, you recommend eletriptan 40 mg as an initial dose. You counsel to ensure effective use, discuss using a headache diary, and refer Chau to her GP to discuss ongoing management, including possible prophylaxis. 

Chau returns 2 weeks later and reports the eletriptan worked well. Her GP agreed a trial of a preventive agent was warranted given the frequency and impact of her migraines, and she hands you a prescription for candesartan. She says she will continue using the headache diary to identify triggers and track the effect of her new medicine.

Case scenario continued

As Chau has been diagnosed with migraine; has a stable, well-established pattern of symptoms; is presenting with typical migraine symptoms; has found simple analgesics insufficient for previous headaches; and has no contraindications, you recommend eletriptan 40 mg as an initial dose. You counsel to ensure effective use, discuss using a headache diary, and refer Chau to her GP to discuss ongoing management, including possible prophylaxis. 

Chau returns 2 weeks later and reports the eletriptan worked well. Her GP agreed a trial of a preventive agent was warranted given the frequency and impact of her migraines, and she hands you a prescription for candesartan. She says she will continue using the headache diary to identify triggers and track the effect of her new medicine.

This article is accredited for group 2 CPD credits. Click submit answers to complete the quiz and automatically record CPD against your record.

SUBMIT ANSWERS

If you do get an enrolment error, please click here

Key points

  • Migraine and tension-type headaches are prevalent in Australia and have a significant impact on a patient’s quality of life.
  • Pharmacists play an important role in screening for headache red flags which suggest medical review and/ or further investigations is required.
  • Pharmacological treatments can be recommended over the counter where appropriate, along with non-pharmacological management strategies.

Further resources

  • Migraine and Headache Australia is a division of the Brain Foundation that provides support, resources and education for people who experience migraine and other headache disorders.At:https://headacheaustralia.org.au
  • Migraine Australia is a patient organisation that supports people with migraine and includes helpful information about the condition. At:www.migraine.org.au
  • APF’s non-prescription medicine guide ‘Headache and Migraine

References

  1. Deuschl G, Beghi E, Fazekas F, et al. The burden of neurological diseases in Europe: an analysis for the Global Burden of Disease Study 2017. Lancet Public Health. 2020;5(10):e551-e67.
  2. Pfizer Australia. Headache and Migraine. 2005.
  3. Deloitte Access Economics Report. Migraine in Australia whitepaper: Measuring the impact. 2018.
  4. Ashina S, Mitsikostas DD, Lee MJ, et al. Tension-type headache. Nat Rev Dis Primers 2021;7(1):24.
  5. Leonardi M, Steiner TJ, Scher AT, et al. The global burden of migraine: measuring disability in headache disorders with WHO’s Classification of Functioning, Disability and Health (ICF). J Headache Pai 2005;6(6):429–40.
  6. Ebahimzadeh K, Gholipour M, Samadian M, et al. A comprehensive review on the role of genetic factors in the pathogenesis of migraine. J Mol Neurosci 2021;71(10):1987–2006.
  7. Silberstein S. Migraine. MSD Manual 2022. At: msdmanuals.com/en-au/professional/neurologic-disorders/headache/migraine#v7528174
  8. Charles A. Vasodilation out of the picture as a cause of migraine headache. Lancet Neurol 2013;12(5):419–20.
  9. Amiri P, Kazeminasab S, Nejadghaderi SA, et al. Migraine: A review on its history, global epidemiology, risk factors, and comorbidities. Front Neurol 2021;12:800605.
  10. Wober C, Wober-Bingol C. Triggers of migraine and tension-type headache. Handb Clin Neurol 2010;97:161–72.
  11. Steel SJ, Robertson CE, Whealy MA. Current understanding of the pathophysiology and approach to tension-type headache. Curr Neurol Neurosci Rep 2021;21(10):56.
  12. Classification Committee of The International Headache Society. International Classification of Headache Disorders, 3rd Edition ‘ICHD-3’: International Headache Society; 2018. At: https://ichd-3.org/classification-outline/.
  13. Karli N, Ertas M, Baykan B, et al. The validation of ID Migraine screener in neurology outpatient clinics in Turkey. J Headache Pain 2007;8(4):217–23.
  14. The timeline of a migraine attack. American Migraine Foundation. 2018. At: https://americanmigrainefoundation.org/resource-library/timeline-migraine-attack/
  15. Silberstein S. Tension-type headache. 2023. At: www.msdmanuals.com/en-au/professional/neurologic-disorders/headache/tension-type-headache
  16. Sansom LN, ed. Headache and migraine. Australian pharmaceutical formulary and handbook; [updated 2023 Sept 28]. At: https://apf.psa.org.au/non-prescription-medicine-guides/headache-and-migraine
  17. Do TP, la Cour Karottki NF, Ashina M. Updates in the diagnostic approach of headache. Curr Pain Headache Rep 2021;25(12):80
  18. Therapeutic guidelines; [updated 2019 Jan]. At:https://tgldcdp.tg.org.au/viewTopic?etgAccess=true&guidelinePage=Neurology&topicfile=migraine
  19. Tension-type headache. Therapeutic guidelines; [updated 2017 Nov]. At: https://tgldcdp.tg.org.au/viewTopic?etgAccess=true&guidelinePage=Neurology&topicfile=tension-type-headache
  20. Rossi S, ed. Australian medicines handbook; [updated 2023 July]. At: https://amhonline.amh.net.au/chapters/neurological-drugs/drugs-migraine/migraine
  21. Pardutz A, Schoenen J. NSAIDs in the acute treatment of migraine: a review of clinical and experimental data. Pharmaceuticals (Basel) 2010;3(6):1966–87.
  22. Mayans L, Walling A. Acute migraine headache: treatment strategies. Ame Fam Physician 2018;97(4):243–51.
  23. Bigal ME, Hargreaves RJ. Why does sleep stop migraine? Curr Pain Headache Rep 2013;17(10):369
  24. Ashina M. Migraine. N Engl J Med 2020;383(19):1866–76.
  25. Bates D, Ashford E, Dawson R, et al. Subcutaneous sumatriptan during the migraine aura. Sumatriptan Aura Study Group. Neurology. 1994;44(9):1587-92.
  26. Olesen J, Diener H, Schoenen J, Hettiarachchi J. No effect of eletriptan administration during the aura phase of migraine. Eur J Neurol 2004;11(10):671–7.
  27. Thorlund K, Mills EJ, Wu P, et al. Comparative efficacy of triptans for the abortive treatment of migraine: a multiple treatment comparison meta-analysis. Cephalalgia 2014;34(4):258–67.
  28. Hou M, Liu H, Li Y, et al. Efficacy of triptans for the treatment of acute migraines: a quantitative comparison based on the dose-effect and time-course characteristics. Eur J Clin Pharmacol 2019;75(10):1369–78.
  29. Australian Government. Therapeutic Good (Poisons Standard – February 2023) Instrument 2023: Federal Register of Legislation; 2023. At: legislation.gov.au/Details/F2023L00067
  30. Rossi S, ed. Australian medicines handbook; [updated 2023 July]. At: https://amhonline.amh.net.au/chapters/neurological-drugs/drugs-migraine/triptans?menu=vertical
  31. Medication overuse headache. Therapeutic guidelines; [updated 2017 Nov]. At: https://tgldcdp.tg.org.au/viewTopic?etgAccess=true&guidelinePage=Neurology&topicfile=medication-overuse-headache&guidelinename=Neurology&sectionId=toc_d1e467#toc_d1e467
  32. Pharmaceutical Society of Australia. Headache Self Care Fact Card. In: Pharmaceutical Society of Australia, editor. [Online]. V5.0 ed. Canberra: Pharmaceutical Society of Australia Ltd

Our author

DR JACINTA JOHNSON (she/her) BPharm(Hons), PhD, AdvPracPham, GAICD, FPS, MSHP is a credentialled Advanced Practice Pharmacist, Senior Lecturer in Pharmacy at the University of South Australia, and Senior Pharmacist for Research within SA Pharmacy. Her clinical area of expertise is pain medicine.

OUR REVIEWER

MORNA FALKLAND BPharm is a retired Hospital and Medicines Information Pharmacist.

CONFLICT OF INTEREST DECLARATION

Dr Johnson has received payment for consultant work preparing educational material regarding triptan medications from Aspen Pharmacare Australia Pty Ltd and Viatris Pty Ltd (2021–2023). She has also volunteered with Headache Australia/Brain Foundation (unpaid)