Some 80 per cent of adults have episodic tension headache and 15 per cent have migraine. Research by Nurofen Express found that 40 per cent of us experience headache at least once a week and 67 per cent once a month or more. Migraine causes 190,000 attacks a day in the UK, says the Migraine Trust, making it more prevalent than diabetes, epilepsy and asthma combined. Yet less than 50 per cent of sufferers consult a doctor for diagnosis or advice.
Some 45 per cent of pharmacists surveyed by Nurofen Express believes patients are mistreating their headaches.
Research by the All-Party Parliamentary Group on Primary Headache disorders has found the number of A&E admissions for headache has increased by 12 per cent in the past three years, making it the most common neurological reason for attendance. ‘The evidence examined by the inquiry revealed that poorly informed and unsupported headache patients are misusing NHS services as they seek a firm diagnosis, appropriate treatment and support,’ says the report. It’s clearly an area where pharmacy staff could play a more active role.
Many headache and migraine patients won’t see their GP, but rely on OTC remedies from pharmacies, so you’re in a good position to spot chronic headache and migraine sufferers and ensure they get the correct advice and treatment.
‘First and worst headaches seen in the pharmacy need medical input. If the pattern is progressive, it’s best to refer to their GP, but if it’s stable then a coherent strategy by pharmacy could be very successful,’ says Dr Andrew Dowson, director of headache services at Kings College hospital, and chair of the Migraine in Primary Care Advisors (MIPCA) group and spokesperson for Migraine Action. ‘The most common type of headache in the community is low-impact, tension-type headache and these respond well to OTC analgesia if given early. Most data points to NSAIDs rather than paracetamol. Migraine is next most common and many will respond to OTC remedies, too, but up to 50 per cent might benefit from specific migraine treatments, such as sumatriptan 50mg,’ says Dr Dowson. ‘If pharmacists are confident identifying these headaches their management can defuse patient problems and reduce inappropriate self-referral to A&E. Other unusual types of headache are best referred to the GP.’
MIPCA has produced updated guidelines on headache management for pharmacists (www.mipca.org.uk/pdf/newsletters/ NL21_Pharmacist.pdf) on how to handle headaches for pharmacists. These include:
‘A pharmacist should first establish whether the headache is something more significant by asking a series of questions such as what type of pain is present, whether there are other symptoms and what medication has already been taken. By effective use of questions and establishing a rapport with the customer, you can guide the customer to the most suitable product,’ says Gill Stone, NHS standards pharmacist at the Co-Operative Pharmacy.
Nurofen marketing director Craig Shaw believes pharmacists are in a unique position ‘as the only professionals with evidence-based clinical knowledge combined with information on cutting-edge formulations. By working in partnership with patients to understand their needs, pharmacists can make a real difference to life pain management. Techniques such as motivational interviewing can be used to work with patients to understand the psychological impact of pain. This individualised approach puts the pharmacist at the centre of the conversation. Asking open-ended questions and using listening skills, rather than relying on WWHAM-style questions and answers, followed by a product sale, will result in a more satisfying outcome.’
At Numark, Emma Charlesworth says: ‘A patient’s lifestyle can be a contributing factor to recurring or sudden onset of headaches. As well as recommending an analgesic, pharmacists should try to understand if there are any underlying factors causing the headaches. Pharmacists can play an important role in helping customers better manage their pain by recognising repeat purchasers and approaching them to discuss whether their treatment is appropriate.’
A spokesperson from Solpadeine at Omega Pharma comments: ‘It can be difficult to selfdiagnose the type of headache or migraine and therefore difficult to identify the most suitable pain relief, leaving customers overwhelmed. Pharmacists can support customers to make an informed choice, ensuring the right pain relief is recommended.’
Here are some of the most common headache types:
Tension type headache
Usually caused by stress, depression, lack of sleep, anxiety or muscle tension.
Symptoms: Feeling of tightness and pressure around head (both sides).
Pain relief: Ibuprofen and paracetamol both recommended, though some research shows faster relief with ibuprofen.
Attacks last an average four to 72 hours, with an average of 13 attacks a year (Migraine Action). Triggered by factors including hormonal changes, tiredness, skipping meals and certain foods/drinks.
Symptoms: A one-sided moderate-severe headache and at least one other symptom including nausea, vomiting, sensitivity to light/noise/smells, visual disturbances, tingling/numbness in limbs.
Pain relief: Some cases can be managed with simple analgesics (soluble works faster) or in combination with codeine or caffeine. Anti-emetic medication combined with a simple analgesic may suffice. Patients with severe migraines are treated with triptans, which give faster, longer-lasting relief. Refer those with frequent attacks to GP as they may need preventive drugs.
May be caused by a disorder of the nervous system and patients need to see GP for diagnosis. There are around 200,000 sufferers in the UK, says OUCH (Organisation for the Understanding of Cluster Headache), but only 20 per cent are correctly diagnosed.
Symptoms: Excruciating pain, centred around one eye, which may droop and be watery, usually blocked nose. Attacks last 15 minutes to one hour, up to eight times a day. Clusters last six to eight weeks with
periods of remission.
Pain relief: Nasal sumatriptan; vagal nerve stimulation; oxygen therapy.
Caused by the chemicals in alcohol and dehydrating effect of alcohol, you’ll see more of these in the party season.
Symptoms: Headache, dizziness, dehydration, dry mouth, nausea, vomiting.
Pain relief: Soluble analgesic is gentler on stomach. An antacid will settle nausea.
Medication over-use headache
Taking analgesics too frequently for headaches can cause a tolerance that lowers pain threshold, resulting in daily headache. Any analgesic can cause it, but combination painkillers are more likely to.
Symptoms: Headache often occurs in morning on waking after analgesia has worn off overnight. Mild-moderate pain.
Relief: Usually done under supervision of GP, involves gradual withdrawal of analgesia. May need amitriptyline during this stage.
Stocking well-known brands that deliver fast, effective results is key, as is correct understanding and diagnosis by the pharmacist,’ says Mr Shaw. A pain management module can be found at the www.RBforhealth.com portal.
‘Pharmacy teams can look at the category layout to help drive sales, ensuring the fixture is in a prominent position. Pain relief options should be divided by brand and segmented by active ingredient,’ says a spokesperson for Solpadeine. Consider introducing relevant POS to help customers make informed choice at point of purchase and make the most of link sale opportunities by positioning other relevant categories next to pain relief.
‘By improving knowledge of the products available you can confidently recommend the most suitable product,’ says Ms Stone.
‘Stock brand leaders which cover a range of pain relief options and also an own label representation of each of the drug types where relevant. GSL lines should be on open display to facilitate self selection. Merchandise the pain category by brand and format with pack sizes merchandising left to right and from large to small,’ advises Ms Charlesworth at Numark.
Nurofen Express targets headache faster than paracetamol or ibuprofen. It will be backed by Nurofen’s biggest campaign next year (worth £4 million), which will focus on educating consumers on the causes of headaches. According to a survey by Nurofen Express, 53 per cent of consumers would be happy for a member of the pharmacy team to approach them with advice and support on managing headaches.
Numark has developed a Counter Excellence training module, which covers common headache types.
Omega Pharma has updated its interactive online training portal www.omegapharmatraining. co.uk to better support pharmacy.
A new device to prevent migraine has been approved for sale by the FDA. Called Cefaly, it uses TENS to help reduce frequency and duration of attacks.
Reena Barai, SG Barai Pharmacy, Sutton ‘This is an area where it is important to ask the right questions and offer support with advice around lifestyle interventions. If it’s a migraine problem, for example, we help customers to identify triggers. If it could be a tension headache, we’ll ask if they have been under a lot of stress recently – we’ll give them support to reduce the stress as I feel that the role of pharmacist isn’t just about offering pharmaceutical advice. We use PAGB leaflets in the pharmacy about the dangers of overusing painkiller medication and we use those to kick-start that conversation with patients if we feel that they might be relying on their medication too much. This comes in very useful, as we often find that just telling people that using painkillers too often can cause headaches is a real eyeopener to people.’
Alan Bradley, Cornwell’s Chemist, Newcastle-under-Lyme ‘Headache and migraine is one of the most common conditions we treat in pharmacy and for this reason our healthcare assistants are confident suggesting products and offering advice for dealing with this condition. There is a broad range of analgesics to use to treat these issues, depending on their comorbidities and current medication. We are quite strict in the pharmacy with the length of time a patient can use a painkiller for, as well as the quantities we will supply to a patient on a repeated basis to try and discourage them overusing the products and becoming dependent on them.’
Bipin Patel, Broadway Pharmacy, Bexleyheath ‘For this category it is important to establish what would be the best form of treatment for each patient, although some patients who have suffered from headaches and migraines for a long time are not willing to listen to new advice or try out new things. When recommending products, the cost needs to be considered, as not all patients will be able to afford them. On the other hand, if a patient has severe symptoms, they might want to try a more expensive product if it is more likely to reduce the pain. This is a category that has a lot of repeat custom – if someone finds a product that works for them they will come back for it again. If a customer’s symptoms do not improve, and they keep trying to repeat purchase for example, signpost them to another health professional.’