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Migraine is the third most common health condition in the world. Victoria Goldman explores pharmacy’s role in diagnosis, its symptoms and the best strategies for pain relief

In September 2025, for Migraine Awareness Week, the National Migraine Centre surveyed 300 people across the UK to understand how the public perceives migraine. The results revealed widespread misconceptions about this serious neurological condition and highlighted a pressing need for further education. Seventy-one percent of respondents wrongly characterised migraine as merely a “bad headache”, and 88 per cent believed that a headache is always present during an attack, despite many people experiencing migraine without head pain. In addition, 96 per cent of respondents didn’t know that abdominal pain or stomach upset can be a migraine symptom. 

“Neck and shoulder pain is very commonly the first sign of a migraine attack,” says Dr Katy Munro, senior GP headache specialist at the National Migraine Centre and author of Managing Your Migraine (Penguin Life, 2021). “Jaw pain can be associated with migraine too, and even dental pain. In fact, any pain in the face or above the neck could be due to migraine. A tension headache can also be a mild migraine, especially if someone also feels sick.”

In a survey by The Migraine Trust in January 2022, pharmacists were identified as the number one place where patients wanted to receive advice about migraine management. Yet there is still no formal migraine treatment pathway in community pharmacy. 

Although migraine is the third most common health condition in the world, it is often under-recognised and inappropriately managed, and research has shown that migraine-specific medicines, such as triptans, are underused. 

“Pharmacy plays a key role in supporting people with migraine,” wrote Rob Music, chief executive of The Migraine Trust, on the charity’s website in April 2025. “This includes those who are undiagnosed and seek over-the-counter treatments, and people who are diagnosed and seeking support in managing their condition. We would like to see this role strengthened with additional training for pharmacists to enable them to take a more proactive role in supporting people with migraine to access the right treatments, avoid medication overuse headache, and recommend referral to their GP based on their symptoms.”

Expanding the pharmacy role

In a January 2025 report, the Company Chemists’ Association stated that including migraine as a Pharmacy First condition could allow up to 2.5 million migraine sufferers to access treatment in pharmacies. 

Professor Claire Anderson, Royal Pharmaceutical Society president, says the introduction of dedicated migraine pathways would enable community pharmacists to deliver even more structured, evidence-based care: “This would give pharmacy teams the tools to improve diagnosis, strengthen self-management support and reduce pressure on GP services.”

“A commissioned migraine service would further enhance this. Patients would gain consistent, accessible care close to home, while pharmacists would have additional resources and training to enhance the services they already deliver. Such a service would also help to reduce health inequalities and improve outcomes for people living with migraine.”

Lucy Morris, patient services manager at Numark, says that since pharmacy is not yet being used for routine migraine care, many patients are still relying on GPs, or even A&E. 

“Inclusion as a Pharmacy First pathway or a dedicated commissioned pathway would likely benefit both patients and pharmacists, provided it is implemented with proper training, funding and clear referral pathways,” she argues. 

“Benefits would include faster access to appropriate acute treatment, earlier identification of those needing specialist input, consistent messaging across services, and reduction in unnecessary GP/A&E visits.”

Abigail Duthie, community pharmacist in NHS Grampian, Scotland, says her pharmacy has already added a migraine-specific section to their Pharmacy First consultation form. “It helps counter staff recognise when a patient may be suffering from migraine and prompts them to involve a pharmacist early to support diagnosis and management,” she says. “A commissioned migraine service would definitely benefit patients in terms of faster access to treatment and reducing the need for GP appointments, but it would need to be designed realistically. Acute management sits well in pharmacy, but long-term prophylaxis would still need GP or practice pharmacist involvement to make sure patients are monitored safely.”

Appropriate training

According to Munro, there is now a great push for people to consult their community pharmacist first for common conditions such as headache or migraine, but what is lacking is pharmacy training. 

“If migraine attacks aren’t very frequent or severe, patients should go to a pharmacist,” she says. “The vast majority of people with a headache will have migraine, and pharmacists should be trained to identify migraine based on clinical history. When healthcare professionals haven’t had much training in headache and migraine, they worry about missing secondary headaches. But with the appropriate training, they become much more confident to diagnose appropriately.”

Over the last two years, The Migraine Trust has been piloting a new approach to improve access to migraine support and treatment from community pharmacy teams in Scotland: initially in Grampian, and then rolling out the project to NHS Highland, NHS Lanarkshire, NHS Lothian, NHS Orkney, NHS Shetland, and NHS Tayside. 

“The project has two main focuses,” says Katy Styles, lead for realistic medicine at NHS Grampian. “Firstly, increasing the awareness, knowledge and confidence of pharmacy teams in recognising and helping patients to manage migraine. And secondly, to raise public awareness of migraine and its impact, as well as knowledge and resources to improve its management.”

The project initially gathered feedback using focus groups containing pharmacists and people living with migraine. Then, pharmacy colleagues and migraine experts developed eLearning modules, live training and resources for pharmacy teams, along with public awareness resources and campaign materials, including a public information webinar. 

Following the project, according to Rob Music, there was a 71 per cent increase in pharmacists who felt confident in assessing whether a person is presenting with migraine, and a 56.5 per cent increase in pharmacists who felt confident in supplying migraine medicines. After attending the public “manage your migraine” patient webinar, 91 per cent of the attendees felt that attending the event improved their understanding; 76 per cent said the event helped with their concerns and anxieties; and 91 per cent indicated they would now discuss migraine with a pharmacist.

“We know that around a third of community pharmacists in Grampian attended the training in the first year of the project, and pharmacists have continued to engage with the online training since then,” says Styles. “Pharmacists who have engaged in the training have reported increased understanding of migraine and increased confidence in supporting patients to manage migraine. 

“Patients have reported feeling much more knowledgeable about their condition and understanding how to get the best out of the treatment options, including how to effectively combine medications.”

Duthie says that her experience of taking part in the project has been a positive one. “Where pharmacists have been equipped to manage migraines more proactively, the benefit has been mutual,” she says. “Patients get supported faster and feel genuinely cared for, and pharmacists feel like they’re practising at the level they trained for, rather than just selling painkillers.”

Differential diagnosis

According to the National Health and Care Excellence (NICE) guidance on migraine, filling in a headache diary for a minimum of eight weeks can help patients and healthcare professionals establish the cause of head pain and identify any triggers. Headache diaries are available to download from The Migraine Trust website. 

Red flag symptoms that need urgent referral to a GP include: a worsening headache with fever; a suddenonset headache reaching maximum intensity within five minutes; newonset neurological, cognitive or personality changes; recent (typically within the past three months) head trauma; a headache triggered by coughing; Valsalva maneuvers (trying to breathe out with the nose and the mouth blocked); sneezing; exercise or change in posture. 

“Headache isn’t a diagnosis,” says Munro. “It’s a symptom of another condition. One key question to ask people is what they do when they have a headache. If they want to lie down in a dark room, this could be migraine. If they want to pace around, this could be cluster headache. Cluster headache is the easiest to identify from its symptoms, but is much rarer and should be referred to primary care. Then there are the secondary headaches, caused by serious conditions such as brain tumours.”

Duthie says that it’s usually not too difficult to assess if a headache is likely to be migraine, once pharmacy teams ask the right questions. “The main things we ask are: ‘Does the headache limit your ability to do normal activities?’; ‘Do you feel nauseated or sick to your stomach with it?’; and ‘Does light or sound bother you when it happens?’” she says. “If those line up, it points strongly towards migraine, which helps us decide whether a triptan is more appropriate than standard painkillers.”

Styles says that after taking part in the NHS Grampian project, patients have been much more able to live with migraine, since their treatment has been changed during the project, including receiving a diagnosis of migraine where their symptoms were previously misdiagnosed as chronic sinusitis.

According to Munro, a headache/migraine pathway would fit in well with the existing Pharmacy First sinusitis pathway. “Chronic sinusitis symptoms are often due to migraine,” she says. “There is a big overlap of symptoms, and most people are unaware of how common migraine is. If people have recurrent sinusitis, they are given antibiotics, and this seems to help their symptoms within two or three days. However, if their sinusitis is caused by migraine, this is when their symptoms are likely to improve anyway. Many patients with what seems to be sinus pain would benefit from trying a triptan before antibiotics.”

Migraine management

According to an analysis of randomised controlled trials, published in the British Medical Journal in 2024, triptans (such as sumatriptan) are more effective for acute migraine attacks than other medicines. Non-steroidal anti-inflammatories (NSAIDs such as diclofenac potassium or ibuprofen) were the next most effective group, followed by newer migraine-specific medicines such as rimegepant (an oral calcitonin gene-related peptide inhibitor). All active medicines were more effective than placebo. 

“Pharmacists should recommend triptans as a first-line rather than conventional painkillers,” says Munro. “A lot of painkillers marketed for migraine contain codeine, which isn’t even suitable for migraine. Sumatriptan has been OTC for many years, but it can make people quite sleepy. However, if the pharmacist is recommending a triptan and it’s helping with the pain but causing side-effects, patients should be referred to their GP to try one of the other triptans available on prescription.”

Duthie says that her pharmacy’s customers experiencing acute migraine attacks usually want pain relief first, but many also ask about triggers, lifestyle changes, sleep, stress, hydration, and hormonal links. “Some have done a lot of Googling and are actively trying to manage it,” she says. “Others just want whatever will stop the pain quickly. By helping them optimise treatment – correct use of triptans, combination therapy, managing triggers, avoiding medication overuse, timing of doses, and signposting when prophylaxis might be appropriate – pharmacists are well placed to reinforce long-term self-management.”

Preventative approach

NICE guidance highlights the importance of explaining the risk of medication overuse headache to people who are using acute migraine treatments regularly. These ‘rebound headaches’ develop in people with migraine (and other types of headaches) if they are using paracetamol or NSAIDs on 15 or more days a month or using triptans, ergotamine, codeine-based medicines and combination painkillers on 10 or more days per month. Rimegepant, taken for acute migraine attacks and the prevention of episodic migraine, doesn’t cause medication overuse headache.

“We usually pick up medication overuse headache by spotting patterns,” says Duthie. “If someone is using painkillers most days, regularly buying combination analgesics, or saying the medication ‘takes the edge off’ but the headaches are getting more frequent, that’s a red flag. A quick, supportive chat about how often they’re taking analgesia normally confirms it – but it can be a hard conversation to have. Once they understand the link though, most are relieved to finally have an explanation.”

If a patient with migraine is having more than four migraine attacks a month, they should be encouraged to take a preventative migraine medicine. Currently, prophylactic migraine treatments need to be initiated by a patient’s GP or in secondary care. 

“From the pharmacy side, we’re limited to acute options – aspirin, ibuprofen, triptans and prochlorperazine via OTC, Pharmacy First or Pharmacy First Plus,” says Duthie. “However, we can still support patients by advising on the available prophylactic options and when they might be appropriate.”

Acupuncture or some dietary supplements such as riboflavin may also help to prevent migraine attacks, and may be preferred by customers who don’t wish to take regular medication. “There is evidence that certain supplements can help to prevent migraine,” says Munro. “These include magnesium, vitamin B2 and coenzyme Q10. There are also neuromodulator devices that pharmacies could stock, such as Cephaly and Nerivio.”