Headaches: Wise Use of OTC Analgesics for Prevention and Management

Everyone experiences occasional headaches, but some individuals are more susceptible to them. Many individuals elect to self-treat headaches using OTC analgesics. In fact, it is estimated that more than two-thirds of OTC analgesics are used for headache pain relief.¹ The types of headache that are most amenable to self-treatment with OTC analgesics include tension headaches (also known as stress headaches), diagnosed migraines, and sinus headaches.¹

Selecting an appropriate analgesic may be an overwhelming experience for some consumers, especially those who have pre-existing medical conditions or are taking other medications. Pharmacists are in an ideal position to guide patients on the proper selection and use of analgesics and can encourage patients to seek further medical care if self-treatment is not appropriate. Additionally, pharmacists can screen for possible contraindications, drug—drug interactions, and therapeutic duplications. By reviewing patients’ medication profiles, pharmacists can identify medications that may be causing headaches, can make clinical recommendations, and can encourage patients to see their primary health care provider.

Types of Headaches

Headaches are commonly categorized as primary or secondary.^1-3 Primary account for an estimated 90% of headaches and are not related to an underlying illness.^1-3 Examples include tension headaches, cluster headaches, migraines, and medication overuse headaches (also known as rebound headaches) (Table 1^1,4,5).^1-3

Secondary headaches result from an underlying medical condition.^1-3 Examples of conditions that may these headaches include sinusitis, severe hypertension, head trauma, hematomas, temporomandibular joint dysfunction, metabolic disorders, substance abuse or withdrawal, stroke, cerebral hemorrhage, and meningitis or other bacterial or viral infections.^1-3 Patients experiencing secondary headaches should always be referred to their primary health care provider for medical evaluation and treatment.

OTC Therapies

OTC analgesics for treating and managing headaches include acetaminophen, nonsteroidal anti-inflammatory drugs (eg, ibuprofen, naproxen), and salicylates (eg, aspirin, magnesium salicylate, sodium salicylate) (Table 2).^1,4 These products are available as single-entity or combination products (eg, tablets, capsules, gel capsules, liquid gels, enteric-coated tablets, extended- or sustained-release forms, liquids, suspensions, effervescent tablets, rapid-release gel capsules, powders, chewable tablets) (Tables 3 and 4). Formulations are also marketed for sinus headaches, tension headaches, and migraines, and contain different combinations of ingredients to provide pain relief. For example, some medications for sinus headaches may contain an analgesic and a decongestant. Patients should be advised to always read product labels carefully, especially when using multi-ingredient products, to avoid unnecessary drug use or therapeutic duplications.^1,4

Table 3. Combination Product OTC Analgesics for Headaches

Active Ingredients

Brand Name

Acetaminophen, phenylephrine

• Excedrin Aspirin Free Sinus Headache
• Sudafed PE Maximum Strength Sinus Headache

Naproxen sodium and pseudoephedrine

• Aleve D Sinus and Cold

Acetaminophen, aspirin, caffeine

• Excedrin Migraine
• Excedrin ES
• Goody's Extra Strength Headache Powder
• Goody's Cool Orange ES Headache Powder
• Vanquish Extra Strength
• Good Sense Added Strength Headache Relief

Aluminum hydroxide, aspirin calcium Carbonate, magnesium hydroxide

• Ascriptin Maximum Strength

Acetaminophen and caffeine

• Excedrin Tension Headache
• Goody's Headache Relief Shot

Aspirin and caffeine

• Anacin Fast Pain Relief

Ibuprofen and pseudoephedrine

• Advil Cold and Sinus

Naproxen and pseudoephedrine

• Aleve D Sinus and Headache

Aspirin, caffeine, salicylamide

• BC Headache Powder

Table 4. Topical OTC Analgesics for Headaches

• Well Patch Migraine Cooling Headache Pads
• Sinol Headache Relief Spray

The Pharmacist’s Role

Prior to recommending any OTC analgesic, pharmacists should always screen patients for potential allergies, contraindications, and drug—drug interactions. Patients should be reminded about the proper use of analgesics, including duration of use; be advised to take these products with food or milk if gastrointestinal upset occurs (Tables 5^1,4 and 6^1,4); and be warned about potential adverse effects associated with the use of these products. Patients with pre-existing medical conditions or who take prescription medications should discuss the use of OTC analgesics with their primary health care provider to ascertain appropriateness.

Table 5. Patient Counseling Tips Regarding Headaches and OTC Analgesics

• Patients who are pregnant, breast-feeding, or taking any other medications or have a pre-existing medical condition should be encouraged to consult their primary health care provider prior to using any of these products.

• Restrict the use of nonprescription analgesics to treat headaches to 3 days per week to avoid medication overuse headaches.

• Do NOT use nonprescription analgesics for more than 10 days unless directed by a physician, and do not exceed the recommended dosages.

• Do NOT use naproxen in children younger than 12 years.

• Do NOT take ASA or NSAIDs if you are allergic to ASA or have asthma or nasal polyps; take APAP, if appropriate.

• Do NOT take NSAIDs if at high risk for cardiovascular disease or stroke, unless under the supervision of a physician.

• Do NOT take ASA or NSAIDS if there is a history of GI disorders, ulcers, liver or kidney disease, or heart failure.

• To avoid possible liver damage, limit dosage of APAP to no more than 4 g/day.

• Do NOT take ASA if currently taking medications for diabetes, gout, or arthritis, unless directed by your primary health care provider.

• Individuals with a history of hepatic disease should avoid APAP.

• Do NOT use salicylates or NSAIDs if taking anticoagulants.

• Children younger than 15 years who are recovering from chickenpox or symptoms of influenza should not take ASA or other salicylates.
• Do NOT use OTC analgesics if consuming 3 or more alcoholic drinks per day.

• Do NOT take products containing magnesium salicylate if you have renal disease.

• Do NOT drink alcohol while using these products.
• To avoid GI upset, take NSAIDs and salicylates with food or milk.

• If appropriate, patients with a migraine diagnosis who can predict the onset may benefit from taking an analgesic before known triggers.

^{APAP = acetaminophen; ASA = aspirin; GI = gastrointestinal; NSAID = nonsteroidal anti-inflammatory drug.Adapted from references 1 and 4.}

Although most mild headaches can be easily managed and only last a few hours, patients should be encouraged to seek further medical care if they do not obtain relief from using OTC analgesics, if they experience chronic headaches, or if their headaches increase in intensity or frequency.^1,4 Patients should also be reminded that excessive use of these products may lead to rebound headaches or medication overuse headaches.^1,4

Table 6. Exclusions for Self-Treatment of Headaches

• Severe headaches
• Recent head trauma
• A history of hepatic disease or consumption of 3 or more alcoholic drinks daily
• Headaches lasting longer than 10 days with or without treatment
• Secondary headaches
• Younger than 8 years
• Symptoms of migraines without a diagnosis
• Patients in the last trimester of pregnancy
• Headaches with high fever and/or signs of infection
• Headaches accompanied by vomiting

^{Adapted from references 1 and 4.}

Pharmacists should remind patients to incorporate various nonpharmacologic measures to reduce or prevent headaches, such as relaxation techniques, stretching exercises for the neck, getting enough sleep, maintaining a balanced diet, and incorporating stress management and exercise into their daily routine.¹ Patients with migraines should be reminded to avoid known triggers, when possible, and to apply cold packs to the forehead or temples to reduce the pain associated with migraines.^1,4

Ms. Terrie is a clinical pharmacist and medical writer based in Haymarket, Virginia.

References

• Wilkinson J. Headache. In: Krinsky D, Berardi R, Ferreri S, et al, eds. Handbook of Nonprescription Drugs. 18th ed. Washington, DC: American Pharmacists Association; 2015.
• Silberstein SD. Approach to the patient with a headache. Merck Manual: Professional Version website. merckmanuals.com/professional/neurologic-disorders/headache/approach-to-the-patient-with-headache. Accessed January 28, 2017.
• Headache. John Hopkins Medicine website. hopkinsmedicine.org/healthlibrary/conditions/adult/nervous_system_disorders/headache_85,p00784/. Accessed January 28, 2017.
• Dlugosz C. Headaches. The Practitioner's Quick Reference to Nonprescription Drugs Washington, DC: American Pharmacists Association; 2012.
• Hutchinson S. Sinus headaches. American Migraine Foundation website. americanmigrainefoundation.org/living-with-migraines/types-of-headachemigraine/sinus-headaches. Accessed January 28, 2017.