Taking the Pain out of Making Choices for Treating Headaches and Migraines

Yvette C. Terrie, RPh
Published Online: Wednesday, October 1, 2003

    Whenever individuals experience a headache, it is very easy to take a dose of aspirin (acetylsalicylic acid; ASA) or acetaminophen (APAP). If the pain returns, they may take another dose. The majority of consumers who experience any type of headache tend to manage them with the use of OTC pain relievers. The primary reasons for choosing to self-medicate include convenience, low cost, and avoiding a doctor?s visit.

    Although these products are easily accessible, many consumers are not aware of the adverse effects associated with chronic long-term use of these products?in particular ?rebound? headaches. According to the National Headache Foundation (www.headaches.org), the use of 3 or more doses of analgesics per day for 5 or more days can sometimes trigger rebound headaches. Because of the potential for this problem, the pharmacist serves as an essential source of information for consumers attempting to select OTC pain relievers.

    Headaches are the most common form of pain. Although there are many types of headaches, tension and migraine headaches are the most prevalent. According to the American Council for Headache Education (www.achenet.org), 75% of all people suffer from tension headaches. Migraine headaches, which affect approximately 25 million people annually in the United States, are more common in women, with 18% experiencing migraines, compared with 6% of men.

    Today, there are a variety of OTC medications available for treating all types of headaches. Because various types of headaches are treated by different medications, it is imperative for pharmacists to determine the type of headache a patient may have. Understanding the mechanism of action of these pain relievers is crucial in making appropriate recommendations to customers, due to the potential for drug?drug interactions and contraindications regarding various conditions. A majority of all patients will never seek medical consultation for their headaches; thus their sole relief depends on using OTC painrelief medications.

Types of Headaches

    Before recommending any type of pain relief, the pharmacist must evaluate the characteristics of the patient?s headache (Table 1).

    Tension headaches are sometimes referred to as muscle contraction headaches. The pain is often described as a tight feeling across the entire front region of the head. Migraines are considered the most painful and debilitating type of headache and will not always respond to OTC pain relievers. They tend to produce moderate-tosevere pounding or throbbing pain, usually on 1 side of the head. Migraine pain commonly produces sensitivity to light and/or sounds, nausea, vomiting, and dizziness. Rebound headaches may occur due to the overuse of analgesics. Sinus headaches are often confused with actual migraines or tension headaches.

Causes of Headaches and Migraines

    Although researchers do not know the exact causes of headaches or migraines, there are certain factors that may stimulate the potential for one. They include but are not limited to the following:

? Eating habits

? Stress/sleep patterns

? Hormonal changes

? Certain foods (alcohol?especially red wine; food additives such as nitrates and chocolate)

? Changes in altitude or air pressure

    Available Products

    Patients with mild migraines generally respond to treatment with OTC medications, especially if they are taken at the initial sign of a migraine. In 1998, the FDA approved Excedrin Migraine, the first nonprescription drug exclusively for the self-treatment of migraine. The product contains exactly the same ingredients as Excedrin Excedrin Extra Strength (250 mg ASA, 250 mg APAP, and 65 mg caffeine), with the recommended dose of 2 tablets at the first sign of a migraine. This product contains as much caffeine as a cup of coffee. Adding caffeine to ASA and ASA/APAP drug-combination products has been found to potentiate the effectiveness of these ingredients to treat migraines. By the addition of caffeine, the absorption of these ingredients is increased. Also, caffeine has other effects on the nervous system. Excessive usage of these products containing caffeine can cause rebound headaches, however. In 2000, Advil Migraine and Motrin Migraine were marketed.

    Nonsteroidal anti-inflammatory drugs are the first drugs of choice in treating headaches. The number of OTC pain relievers continues to increase and can be both overwhelming and confusing to many patients. Not only are there different brands, but there are different dosage forms as well. Today there are a variety of products containing ASA or APAP alone, in combination with one another, or in combination with antihistamines, decongestants, and caffeine (Tables 2 and 3).

Miscellaneous Pain-Relief Aids

    In conjunction with the use of systemic analgesics, some patients may benefit from the use of topical agents such as Migraine Ice or TheraPatch Headache Cool Gel Patch. These products serve primarily as auxiliary comfort aids for individuals with headaches and are drug-free. These agents use a pad that contains a gel that cools the skin for approximately 4 hours on contact and can be applied to the head or neck region.

Patient Counseling

    Headaches of all types can sometimes be almost insufferable at times, but with early intervention OTC medications can be very beneficial and effective in treating mild headaches and migraines, if used properly. Although no single product has been proven more effective than another, patients should be advised not to overuse these agents and to seek medical attention if pain relief is not achieved after trying 2 OTC medications. Pharmacists should stress that, for severe headaches and migraines, OTC medications have limitations, and these headaches may only respond to the numerous prescription products available.

     The appropriate selection of an analgesic requires careful consideration of the patient?s condition. It is essential for the pharmacist to consider the type of headaches being treated and patients? medical history, including allergies and medical conditions?especially those with hepatic, renal, or clotting disorders. Pharmacists should stress the importance of not overusing analgesics because of the potential for rebound headaches. Many consumers are unaware of the potential for renal and hepatic damage due to the overuse of analgesics. The pharmacist also should encourage the patient to seek medical attention if the headache is not resolved after a few days, in order to address the potential for an underlying cause for the headache (Table 4).



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