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Headache is a common reason for customers to visit their pharmacy, so it’s important that staff can spot the different types and are up to date with treatment guidelines. 

Almost everyone experiences a headache at some time, with tension-type headache and migraine the most common forms. In fact, migraine is ranked the third most common cause of years lived with a disability, says the Migraine Trust. 

“The pandemic has had a significant impact on people’s migraine. Two thirds of people found their migraine worsening, with it becoming more frequent and symptoms more severe,” says Una Farrell at the Migraine Trust.

“Talk to your customers about steps they can take to reduce pain without resorting to tablets on a regular basis,” says Safi Ghauri, healthcare category manager at LloydsPharmacy.

“Your priority is the customer’s wellbeing, so understanding their requirements and helping them with a long-term plan will help build their trust and loyalty,” adds Lucy Morris, Numark patient services manager.

Market update

“Most of the pain category is doing well, especially the strong P-med category. Within this space, speed and strength are the two most important qualities in branded product choice, so it is important to call these out where possible, and point of sale material helps here. In addition, we have noticed that drug-free alternatives to medication are growing, so this is an area to watch,” says Safi Ghauri.

Numark’s Lucy Morris adds: “Total pain relief holds over a third of medicines space within pharmacy, with oral analgesics taking 86 per cent of space. Topical pain relief takes 14 per cent of space. Products dedicated to migraine hold a small proportion of space, with key players being paracetamol, codeine/co-codamol and ibuprofen.”

“Pharmacies should ensure that customers have access to the full range of headache relief products, including specialist products such as Migratain and Migraleve, as well as classic analgesics. In addition, the growth of the drug-free area which can be used alongside pain medicines or by themselves, such as Kool ’N Soothe, 4head and Tiger Balm, should be ranged together to allow customers to shop for both types of products,” says LloydsPharmacy’s Safi Ghauri.

“It’s important that pharmacy staff are on hand to point customers in the most appropriate direction as they may not understand the difference between active ingredients,” says Ms Morris. “Customers expect bold signage to help them easily locate and navigate the category. We recommend positioning beacon brands to the left of the fixture for increased visibility, followed by an own brand alternative.”

Focus on migraine

Around 10 million in the UK experience regular migraine attacks, says the Migraine Trust in its new State of the Migraine Nation report. However, it believes figures could be even higher.

Migraine is often inherited, usually begins in puberty, and peaks between age 35 and 45. Three times as many women are affected, with NICE estimating the prevalence of migraine in women in the UK is 24 per cent. 

Symptoms commonly include:

  • A unilateral, throbbing headache
  • Sensitivity to light, sounds and smells
  • Fatigue
  • Feeling or being sick.

Some sufferers experience an ‘aura’ phase before the headache. This typically includes visual disturbances, numbness or tingling sensations, muscle weakness or dizziness. Migraine symptoms can last from four hours to three days. Identifying triggers can help customers to avoid attacks. Common ones include changes to routine, stress and tension, skipping meals, hormonal changes, lack of sleep, caffeine, overuse of screens.

A headache diary can help people to understand their migraine better, from the length of attacks and symptoms to the different stages, as well as any triggers. 

“There is a lack of awareness of the range of symptoms of a migraine, which means that people might not think they are having a migraine attack and don’t see the doctor about it. There is also a lack of awareness among GPs,” says Ms Farrell. “Pharmacists can be aware of the full range of symptoms and recommend that anyone who seeks their help goes to a GP to be assessed for migraine.”

OTC analgesics such as NSAIDS and paracetamol will help some sufferers. Opioids are best avoided. Anti-sickness medication is useful for customers who experience nausea. Triptans relieve pain by narrowing blood vessels and blocking pain signals.

Preventative treatment such as beta-blockers, tricyclic antidepressants and anti-epilepsy drugs can reduce frequency and severity of attacks. Customers who experience at least four attacks a month should consider this option. 

CGRP treatment update

Calcitonin gene-related peptide antibodies (CGRP) monoclonal antibodies (mAbs) are the first preventative medicines specifically developed for migraine treatment. 

During a migraine, the cerebral nerves and blood vessels release substances including CGRP, which cause pain. The new drugs, which are given intravenously, target CGRP to prevent migraine. Currently, they are only prescribed by headache specialists or consultant neurologists. 

However, many eligible patients are unable to access CGRP mAbs, says the Migraine Trust, as their CCG refuses to pay or their GP is unable to refer them to a specialist. “We are raising this issue in the media and lobbying Government and working with the healthcare community to have this addressed,” says the Trust’s Una Farrell.

Tension-type headache

Up to 80 per cent of us experience tension-type headache, which is usually bilateral and described as a ‘tight band’ round the head, often with accompanying neck and shoulder pain. The pain is not made worse by daily activities and sufferers don’t experience nausea. Tension-type headaches can be triggered by stress, tension, anxiety and tiredness.

Simple analgesics such as NSAIDs and paracetamol are usually effective. Opioids are not recommended. Using analgesics more than twice a week can increase risk of medication overuse headache, so refer customers with frequent headaches to their GP. 

Red flags to look out for include:

  • Suspected migraine or cluster headache
  • Trauma/injury to the head or neck
  • Medication overuse is suspected
  • Trigeminal neuralgia (facial pain) may be the cause
  • There may be a cranial or cervical vascular disorder.

Cluster headache

This excruciatingly painful headache is always one-sided (although it can switch sides) and there are one or more of these symptoms: red/teary eye, runny/blocked nostril, droopy eyelid, constricted pupil, flushing/facial sweating. In most sufferers, cluster headaches occur at the same time of year. 

“Cluster headache is relatively rare and is often misdiagnosed as either migraine or a sinus headache, as symptoms including eye watering or nasal congestion sound like a sinus problem, and bouts commonly occur in Spring. Cluster headache is best managed by specialists, so all cases should be referred,” says Peter Goadsby, professor of neurology, leading cluster headache expert and patron of the charity OUCH UK (the Organisation for the Understanding of Cluster Headache).

There are two types of cluster headache: episodic and chronic. Episodic headaches (the most common type) occur over weeks and months, then disappear for a while. Chronic sufferers experience daily attacks for at least 12 months.

An attack lasts from 15 minutes to three hours. Before an attack, symptoms are similar to migraine – tiredness/yawning, and during the attack, nausea/vomiting and sensitivity to light/smells/sound. However, unlike migraine, sufferers are restless and irritable during an attack and move around to relieve the pain. Triggers include alcohol, exercise and increases in temperature.

Cluster headache is relatively rare and is often misdiagnosed as either migraine or a sinus headache

Sumatriptan injection is the most effective acute treatment, given twice daily. It can also be given via nasal spray, but this is less effective. Oxygen gives fast pain relief and should be inhaled for 15-20 minutes via a mask. Lignocaine nose drops or spray can give some relief and can be used with other drugs.

The hand-held electronic treatment device gammaCore, which delivers a low-level electric shock to block pain signals when held against the neck is now available on the NHS. Preventative drugs can also reduce frequency of attacks. The most effective are corticosteroids, used for two to three weeks at a time. For those who need longer-acting preventatives, verapamil or lithium can be prescribed.

“Medication overuse can occur in patients with cluster headache and a history of migraine. This can be avoided by using effective treatments including oxygen, sumatriptan injection, zolmitriptan nasal spray and the gammaCore device,” says Professor Goadsby.

Medication overuse headache

This is a chronic headache which results from regular overuse of analgesics for three or more months. It occurs in 1-2 per cent of people and is most common in women aged 45-plus with a history of migraine or tension headache.

Medication overuse headache is diagnosed when analgesics are used on 15+ days per month or triptans/opioids/ergotamine used on 10+ days per month. A high level of painkillers on a regular basis causes withdrawal pain as each dose wears off. People with migraine develop a dull, constant headache with migraine on top.

“It’s important to remember that those frequently buying OTC products for headaches may be treating undiagnosed migraine, and patients should be referred to their GP,” says Mathew Peters, Numark services development pharmacist.

For treatment, the medication needs to be stopped. For some, this can happen quickly, while others need to withdraw gradually. It’s common for headaches to worsen for a while before they improve. 

“Signs to watch for are frequent headaches, particularly after taking acute medication for headache and migraine. Pharmacists should advise customers to seek help from their doctor as it’s not something they can deal with themselves,” says Ms Farrell.

Views of the P3pharmacy category panel

“Headache and migraine treatments/prophylaxis have become more important as patients have found it easier to visit a pharmacy than go for an appointment. Patients typically ask if there’s anything they can take for nausea alongside pain relief, and what stimuli they should avoid. Generic co-codamol, Migraleve and Buccastem, are popular, alongside ibuprofen and paracetamol. There has also been a shift towards more natural care.”

Marisa Maciborka, Well Pharmacy, Tonteg, South Wales

“Asking the pharmacist for advice is something the public is very much at home with. Many people are comfortable self-treating, but the lockdown has brought a fresh wave of sufferers who appreciate discussions about aura and nausea. We generally opt for generic painkillers, avoiding codeine where possible due to lack of evidence of increased efficacy versus plain paracetamol. Buccastem M is the go-to when nausea requires treatment.”

Gareth Evans, Wansford Pharmacy, Peterborough

“Patients mostly know what treatment works for them when it comes to headaches, but will want to check if there is anything stronger or better than the one they have tried or selected from the shelf. I like to raise awareness of medicines overuse headache. Align the various headache treatment options together in your display, making it easier for the customer to compare and choose the best treatment for them.”

Ellis Nugent, Well Pharmacy, Llantwit Major, South Wales

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Common conditions