A Pharmacist's Guide to OTC Therapy: Migraines

As many as 28 million Americans (~10% -12% of the population) suffer from migraine headaches??a common, debilitating condition that tends to disrupt work and social activities. The condition is more prevalent among women, with an onset usually in adolescence and incidence declining over time. Triggers may include stress, hormone levels, magnesium levels, and certain foods (Table 1).

Acute Medical Treatments

According to the US Headache Consortium guidelines, the treatment goals for migraines are as follows:

• Treating the attacks immediately and avoiding recurrence
• Restoring a patient's ability to function
• Reducing the use of "rescue"medications
• Cost-effectiveness for overall management
• Achieving self-care
• Minimizing adverse effects

Analgesic Agents

OTC analgesics such as aspirin, acetaminophen, and nonsteroidal anti-inflammatory drugs (NSAIDs) are the first-line agents for mild-to-moderate attacks (Table 2). Drug therapy should be initiated immediately at the onset of an attack for optimal results, and patients should seek medical help if their pain does not subside within 48 hours.

Patients should be counseled about possible adverse effects of analgesics. Although acetaminophen is well tolerated, it should be used with caution by those who consume excessive alcohol or have liver problems. NSAIDs can cause abdominal discomfort and nausea and should be used with caution in patients who have kidney disease or a history of gastric ulcers.

Supplements and Herbs

Feverfew (Tanacetum parthenium) is the most frequently used herbal supplement for the prevention of migraines. It is available in leaf form and also in capsules. Although some studies of feverfew have reported a reduction in the severity and duration of migraine headaches, its effect remains inconclusive, and results may not be seen for several weeks. Feverfew should not be used by pregnant women. Possible drug interactions with serotonin agents remain unproven.

Magnesium has been evaluated in migraines. People with migraines have been shown to have lower levels of magnesium before and after an attack. Supplementing with magnesium (usually 200 mg per day) may reduce the frequency of migraines.

Vitamin B₂(riboflavin) has been studied as a possible supplement for the reduction of migraines. Results have been evident after several months of therapy.

Patient Counseling Tips

Pharmacists can indeed play a critical role by helping patients understand their illness and aiding in the selection and dosing of the various OTC preparations. Here are some tips:

• Counsel patients on the medication and its drug interactions, its side effects, and the possibility of rebound headaches due to overmedicating
• Advise patients to keep a headache diary, noting frequency, intensity, and duration, as well as possible triggers
• Educate patients on possible triggers, such as aged cheeses, chocolate, caffeine, and red wine
• Refer to a physician any patient who has ??2 headaches that last ??3 days each month, those who must take medication more than twice a week, and those whose headaches become debilitating

For More Information

National Headache Foundation: 888-643-5552, www.headaches.org

American Council for Headache Education: 856-423-0258, www.achenet.org

Dr. Pelegrin is the pharmacy manager of a Publix Pharmacy in Miami, Fla.