Most people will experience headache symptoms at some point – recent figures indicate lifetime prevalence of headaches is 91.3 per cent; in a year 78.6 per cent of people report an episode.
The most common types of primary headache are tension-type (TTH, 40 per cent) and migraine (10 per cent). Less common is cluster headache (1 per cent). Statistics from Nurofen suggest that whilst headaches are among the most likely types of pains to be treated, as many as one in five headache occasions are simply endured.
While most headache sufferers say they experience frequent headaches, most appear to be of mild severity. Commonly reported triggers include a lack of or disturbed sleep (headache 34 per cent, migraine 33 per cent) and dehydration (headache and migraine, both 19 per cent)
Surveys and research
A recent survey by Nurofen, looking into the impact of lockdown, revealed that 34 per cent of people claimed to have experienced more headaches during lockdown than they had done prior to it. This increase was more marked in females (up 39 per cent) than males (up 28 per cent) and most prominent in the 25-34 and 35-44 age groups (both up 42 per cent). While headaches are also known to be a very common symptom of viral infections, surprisingly, early Chinese studies reported a relatively low prevalence (12-15 per cent) of headaches associated with Covid-191.
Experts from Nurofen have also underlined the importance of proper diagnosis when treating headaches. Researchers analysed patient-reported symptoms of migraine from over 2,000 sufferers and were able to demonstrate that automated classification of headache disorders could be helpful. The study2, which used a machine-learning approach to attempt to classify major headache disorders, using questionnaires completed by patients, concluded the results “might be used to inform or assist physicians by pre-screening”.
Headache red flags
NHS guidance recommends investigation by a GP if:
- The headache keeps returning
- Painkillers don’t relieve the headache and/or it worsens
- Severe throbbing pain at the front or side of the head is present
- There is sickness or vomiting and the patient finds light or noise painful
- There is weakness or numbness in the arms or legs.
Other reasons for referral include:
- Usual treatment options are not working
- Preventative treatment stops working
- The diagnosis is unknown
- Chronic headache
- Exposure to or withdrawal from alcohol, cocaine or OTC painkillers.
Different types of headache
Tension-type headache (TTH) is experienced by up to 78 per cent of people. It’s characterised by intermittent pain and tightness or pressure around the head and neck. It may last for a few minutes but can last for a few days. Tension headache is more prevalent in women, and in the 20-39-year age group.
Most people manage the condition themselves and simple OTC painkillers such as paracetamol or ibuprofen are the preferred option if pain relief is necessary. If alternatives are sought, relaxation techniques, massage or exercise are recommended to help relieve a mild headache.
Tension headache can be triggered by poor posture, stress and anxiety in addition to dehydration and skipping meals. Frequent sufferers may be advised to keep records of frequency, duration and severity, along with treatments used and whether they have been effective, to help identify potential triggers.
With an estimated global prevalence of 14.7 per cent, migraine is the third most common disease in the world, behind dental caries and tension headaches. According to the Migraine Trust, migraine affects three times as many women as men, and research has suggested that around 190,000 migraine attacks happen every day in the UK. Migraine can affect children, but it usually starts during puberty and is most prevalent in the 35 to 45 age group.
The two commonest types are classic migraine and migraine with aura - associated neurological symptoms such as blind spots, flashing lights and zigzags, even temporary blindness or tunnel vision, which precede the migraine headache. Non sight-related aura symptoms include numbness, tingling, weakness on one side of the body, dizziness, speech or hearing problems, confusion, partial paralysis, fainting and seizures.
The perception from patients is that there is room for improvement in healthcare professional knowledge around migraine
Once migraine has been diagnosed, the usual treatment is an oral triptan plus an NSAID or paracetamol. A young person with migraine can take paracetamol or ibuprofen. Oral triptans are not licensed for patients under the age of 18 years; nasal sumatriptan is an option for 12-17 year olds.
A recent survey revealed that 90 per cent of migraine sufferers believed migraine had a negative impact on their quality of life. Almost 42 per cent also complained of dissatisfaction with their prescribed migraine treatment. Teva, who carried out the survey along with the European Migraine and Headache Alliance (EMHA), has called for more proactive support from health professionals, along with improvements in diagnosis and treatment. Some 30 per cent felt their doctor was not sufficiently informed on the latest migraine treatments. “The perception from patients is that there is room for improvement in healthcare professional knowledge around migraine,” says Elena Ruiz de la Torre, executive director at the European Migraine and Headache Alliance (EMHA).
The National Institute for Health and Care Excellence (NICE) published guidance on fremanezumab in June 2020, a decision described by the Migraine Trust as being “an important step towards its availability”. The drug will be available for people who are diagnosed with chronic migraine, defined as experiencing symptoms on fifteen or more days per month, including having a migraine on eight or more of those days.
MEDICATION OVERUSE HEADACHE
Many headache and migraine triggers have been exacerbated by Covid-19; according to a study carried out in India3, migraine patients in particular have seen a spike in attacks during lockdown. As people worldwide continue to be advised to avoid troubling their GP for minor ailments, they may be tempted to overuse OTC medications, leading to an increase in the prevalence of chronic headache.
NICE estimates that 1-2 per cent of the general population worldwide may experience medication overuse headache, for which the diagnostic criteria include: headaches which occur on 15 or more days per month in someone with a pre-existing headache disorder, and regular overuse for more than three months of one or more drugs - nonsteroidal anti-inflammatories (including aspirin) or paracetamol - that may be used for acute and/or symptomatic treatment of headaches.
If the patient is using ergotamine, triptans, opioids or combination analgesics, they only need to be using them on 10 days or more per month for their intake to be considered overuse.
Cluster headache (CH) is one of a group of headaches known as trigeminal autonomic cephalalgias, causing severe, debilitating pain. CH usually affects one side of the head, although it can change sides, sometimes mid-attack. The pain tends to be focused around the eye socket and temple, sometimes spreading to the ear, jaw, forehead and neck.
- Reddening and watering of the eye
- Runny or blocked nostril
- Drooping and/or swollen eyelid
- Constriction of the pupil
- Flushing and facial sweating
- Restlessness/rocking/pacing up and down/extreme agitation.
Studies have reported a prevalence which ranges from 56 – 401 per 100,000 population, suggesting that there are at least 84,000 sufferers in the UK. Diagnosis is made entirely on the basis of the symptoms presented by the patient – there is no diagnostic test currently available.
Episodic CH attacks usually occur on a daily basis over a period of weeks or months and then stop for weeks, months or even years. In chronic CH however, which affects 10-20 per cent of sufferers, attacks occur regularly with less than four weeks of pain-free remission in any twelve-month period.
In episodic CH, headaches often start at the same time of year and occur at the same time during the day or night. Each attack typically lasts between 15 minutes and 3 hours (although they can be longer) and sufferers can have up to eight attacks in a day. Advising sufferers to sleep the pain off is not recommended – attacks are common within 30-90 minutes of falling asleep.
There is currently no effective over the counter medication, according to Val Hobbs, trustee of cluster headache charity OUCH, who explains, “A sufferer will need to see their GP to have sumatriptan injections or nasal spray prescribed and high flow oxygen. We also recommend referral to a headache neurologist. Misdiagnosis is very frequent in CH, particularly if a female sufferer presents. It is automatically assumed to be a migrainous condition.”
OUCH operates a free 24-hour, five days per week advice line for sufferers (0800 669 682).
Views from the P3pharmacy category panel
“This is a really important category for our pharmacy, and we are now the first port of call for all types of headache. Queries tend to be mostly about tension headaches and those related to colds and flu, but also from customers who have a history of migraine to find out what they can take for it. Nurofen is still our best seller. Cuprofen is also popular as it’s cheaper. Migraleve is very popular as customers like the different tablets for different stages of migraine. Solpadeine does well for us, mainly with older customers. Syndol is popular for sinus headaches.”
Lila Thakerar, Shaftesbury Pharmacy, Harrow
“This area accounts for most of our analgesic sales. Customers are looking for a ‘magic’ cure for their headaches and migraines, and it is essential to tailor advice and products to each patient in order for it to be effective. During the pandemic, more customers have complained of headaches, often associated with increased screen time as many people are working from home. Migraleve and Co-codamol sell extremely well. Many products in this category have sale restrictions and can get hidden behind the pharmacy counter, so it is imperative to ensure display units are visible to all customers at eye level.”
Selina Gill, locum pharmacist, West Midlands
“This is the most common ailment that I see in our pharmacy. Customers often come to us before seeing their GP or any other healthcare professional. Therefore, giving the right advice and treatment is very important as most want a solution that is effective and works fast. Typical queries include customers mistaking a headache for a migraine and wanting to treat it with the strongest OTC product available. The most popular products for our pharmacy are Nurofen, 4head, generic paracetamol and ibuprofen. As this is an everyday query, it is best to stock a comprehensive range of pain management products.”
Yasmeen Afsar, Well Pharmacy, Hartlepool
1. Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020; 395: 497â€‘506. https://pubmed.ncbi.nlm.nih.gov/31986264/
2. Kwon, J., Lee, H., Cho, S. et al. Machine learning-based automated classification of headache disorders using patient-reported questionnaires. Sci Rep 10, 14062 (2020) https://www.ajmc.com/view/machine-learning-may-facilitate-headache-disorder-diagnoses
3. Managing migraine in the times of Covid-19 pandemic https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7213033/
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