Migraines: Responding to the Pain

Patients require careful assessment before OTC analgesics for migraines can be recommended.

Migraine headaches affect an estimated 36 million individuals in the United States.

Migraines are often characterized by pain that is typically unilateral and described as intense and throbbing. Migraines can negatively impact a patient’s quality of life; as a result, some patients experience depression, anxiety, and sleep disorders.^1-5 A study published in 2013 suggests that there may be a link between the number and the severity of migraines in individuals with a history of allergies and hay fever.⁶

Migraines can be classified into 2 subtypes: migraines with aura, and migraines without aura.^7,8 The pain associated with migraines may sometimes be preceded by an aura, the onset of which is described as abrupt; however, some patients do not experience an aura. An estimated 20% of patients who get migraines experience an aura.⁹ Some patients may report sensitivity to light, noise, or odors; some degree of nausea; and vomiting.^1,4-7 The duration of migraines may range from a few hours to 3 days.^1,4-7 Migraines may also be associated with sinus pain, neck pain, anxiety, mood changes, and difficulty concentrating.¹ See Table 1 for more facts about migraines.

Migraine Triggers

Many females experience migraines during the premenstrual part of the menstrual cycle, but migraines may also occur during and after the menstrual cycle.^7,9,10 Additionally, some women may experience migraines during perimenopause and menopause, suggesting that hormone fluctuations may be a precipitating factor.^7,9,10 While the etiology of migraines is not known, several potential triggers for migraines have been recognized (Online Table 2).

Nonprescription Therapies

The nonprescription products currently marketed for the treatment and management of mild to moderate migraines contain analgesics such as acetaminophen, ibuprofen, or aspirin. The available combination formulations contain caffeine and an analgesic; for example, Excedrin Migraine contains acetaminophen, aspirin, and caffeine. Several alternative/natural medications are marketed for the relief and management of migraine symptoms; these products include Hyland’s Migraine Headache Relief Tablets and topical formulations such as WellPatch Migraine Cooling Pad (The Mentholatum Company) and Migraine Kool ‘n’ Soothe (Kobayashi). Other products marketed for migraines include Sinol All-Natural Nasal Spray Fast Headache Relief (Sinol USA), which contains the active ingredient capsaicin.

Table 2: Potential Triggers for Migraine Attacks^5,7-11

• Changes in weather, altitude, and/or barometric pressure
• Hormonal changes during menstrual cycle or pregnancy
• Environmental factors, including noise, bright lights, or certain odors
• Vasoactive substances in certain foods: nitrates, tyramine (in aged cheese and red wine), monosodium glutamate
• Alcohol
• Chocolate
• Stress or fatigue
• Anxiety
• Use of certain pharmacologic agents (ie, nitrates, oral contraceptives, nifedipine, postmenopausal hormones)
• Disruptions or changes in sleep or eating patterns

The Role of the Pharmacist

Before a pharmacist recommends self-treatment of migraines to patients, it is imperative that patients exhibiting signs of an undiagnosed migraine be referred for medical evaluation to confirm a diagnosis and exclude other possible issues. To screen patients for allergies, contraindications, and drug interactions, pharmacists should carefully assess patients’ medical, medication, and allergy histories before recommending OTC analgesics for mild to moderate migraines.

Table 3: Examples of Key Patient Counseling Tips Regarding Safe Use of OTC Analgesics and Migraines⁹

• If the onset of migraines is predictable, take medication to prevent the migraine. For example, if you are susceptible to menstrual migraines, take an analgesic 2 days prior to the anticipated onset of the headache.

• Try to halt a migraine by taking medication as soon as the symptoms begin.
• If possible, apply an icepack or cool compress to your forehead or temples during acute migraine attacks.

• Do not take aspirin or NSAIDs if you are allergic to aspirin or have asthma or nasal polyps; take acetaminophen if there are no contraindications to taking it.

• Do not take NSAIDs if you are at high risk for cardiovascular disease or stroke unless you take them under the supervision of a physician.

• Do not take aspirin or NSAIDs if you have a history of gastrointestinal disorders, ulcers, liver or kidney disease, or heart failure.

• To avoid possible hepatic damage, limit acetaminophen use to no more than 4 g a day.

• Do not take aspirin if you are currently taking medications for diabetes mellitus, gout, or arthritis, unless directed by your primary health care provider.

• Individuals with a history of hepatic disease should avoid the use of acetaminophen.

• Do not use salicylates or NSAIDs if you are taking anticoagulants.

• Do not administer aspirin or other salicylates to children younger than 15 years who are recovering from chickenpox or symptoms of influenza.

Pharmacists can suggest implementing various nonpharmacologic measures that may help alleviate or prevent migraine headaches, such as relaxation techniques, avoiding stress, eating a balanced diet, and getting an adequate amount of sleep (Online Tables 3 and 4). Pharmacists should advise patients to always read product labels carefully prior to use, especially when using multi-ingredient products, in order to avoid potential toxicities, unnecessary drug use, or therapeutic duplications. Analgesics are often also found in cough, cold, and flu products as well as some allergy medications. Patients should be counseled on the proper use, recommended duration of use, and potential adverse effects of these products and be advised to take them with food or milk if stomach upset occurs.

Table 4: Patient Resources on Migraines

• The National Headache Foundation website: www.headaches.org
• The American Headache Society website: www.achenet.org
• The American Pain Society website: www.ampainsoc.org
• Migraines in children. Migraine Research Foundation website: www.migraineresearchfoundation.org/Migraine%20in%20Children.html
• American Migraine Foundation website: www.americanmigrainefoundation.org

Fortunately, most mild to moderate migraines last only a few hours and can be effectively managed through self-treatment. However, patients should be encouraged to seek medical care if they do not experience adequate relief after using OTC products, if they experience chronic migraines, or if migraines worsen or increase in intensity or frequency. In these cases, patients should be encouraged to discuss with their primary health care provider the various prescription options for preventive therapy. Parents and caregivers should be directed to have children with migraine symptoms evaluated by their primary health care provider to ascertain the most effective and safest treatment option.

Ms. Terrie is a clinical pharmacy writer based in Haymarket, Virginia.

References

• Migraine fact sheet. Migraine Research Foundation website. www.migraineresearchfoundation.org/fact-sheet.html. Accessed January 29, 2014.
• Facts about migraine. American Migraine Foundation website. www.americanmigrainefoundation.org/support-the-foundation/facts-about-migraine/. Accessed January 29, 2014.
• Reddy D. The pathophysiological and pharmacological basis of current drug treatment of migraine headache. Expert Rev Clin Pharmacol. 2013;6(3):271-288.
• Stovner LJ, Hagen K. Prevalence, burden, and cost of headache disorders. Curr Opin Neurol. 2006;19(3):281-285.
• Migraine headaches. American Headache Society website. www.achenet.org/resources/types_of_headaches/#migraine. Accessed January 29, 2014.
• Martin T, Fanning KM, Serrano D, et al. Chronic rhinitis and its association with headache frequency and disability in persons with migraine: results of the American Migraine Prevalence and Prevention (AMPP) Study. Cephalalgia. November 2013.
• Headache: hope through research. National Institute of Neurological Disorders and Stroke website. www.ninds.nih.gov/disorders/headache/detail_headache.htm. Accessed January 29, 2014.
• Migraine. National Headache Foundation website. www.headaches.org/educational_modules/completeguide/migraine2.html. Accessed January 29, 2014.
• Aura. National Headache Foundation website. www.headaches.org/education/Headache_Topic_Sheets/Aura. Accessed January 29, 2014.
• Wilkinson J, Remington T. Headache. In: Krinsky D, Berardi R, Ferreri S, et al, eds. Handbook of Nonprescription Drugs. 17th ed. Washington, DC: American Pharmacists Association; 2012.
• Migraine: precipitating factors. National Headache Foundation website. www.headaches.org/educational_modules/completeguide/migraine3.html. Accessed January 29, 2014.