'High-Stakes Headaches': Why Pharmacists May be Key to Better Headache Management

Pharmacists can play a “much bigger role” in migraine care by taking the time to understand what drives their patients’ onset and symptoms and then helping those patients navigate the rapidly evolving landscape of treatment options, said Millad J. Sobhanian, PharmD, BCPS, and Olivia Morgan, PharmD, BCCCP at a presentation at the American Society of Health-System Pharmacists (ASHP) 2025 Midyear Clinical Meeting and Exhibition.¹

Headache disorders include several indications and causes, such as migraines, tension-type headaches, cluster headaches, and medication-overuse headaches. As a group, headache disorders might rank anywhere from the second to the sixth leading cause of disability globally, depending on the methodology. Migraines are an increasing burden in this space; a 2020 article in the Journal of Headache Pain found migraines alone to be the second leading cause of the world’s leading causes of disability. The burden is real, and its impacts are comprehensive: lost work, lost wages, reduced quality of life, and reduced productivity.^2-4

“I feel like sometimes folks will dismiss [migraines] in the context of other neurologic disorders or other disorders,” Sobhanian said. “When someone tells you they have a migraine, they can't go to work, they can't go to work because they can't think and function.”

Why Migraine Care Is Not ‘One-Size-Fits-All’

In their session and in a follow-up interview with Pharmacy Times, Sobhanian and Morgan urged pharmacists and other health care providers to remember that migraines rarely exist in a vacuum. Positive patient outcomes, they said, depend on identifying comorbid conditions and “secondary causes” that may trigger, worsen, or mimic migraine pain. “Some areas that we always want to highlight are … sight conditions or medication overuse headaches that could contribute to this complex migraine picture,” Sobhanian said. “Those also need to be managed in addition to the migraine to provide the best outcomes.”

This emphasis informs how Sobhanian and Morgan describe their patient visits. “Headache treatment relies heavily on initial and ongoing patient history,” Morgan said. She said she conducts extensive, “structured” patient interviews, opening with broad questions and then drilling down into details to allow patterns and triggers to emerge. “This helps us to get a good storybook picture, is what I call it, how we can best help,” Morgan said. “Sometimes I've had 30–, 45-, sometimes hour-long visits with patients, depending on the need, where all we do is talk about your migraine.”

Sobhanian and Morgan said collaborative practice agreements (CPAs) can improve efficiency for patients. Within these CPAs, Morgan said, “through our neurologists, we can see our own patients, we can prescribe within these visits, we can order labs, we write notes, and then your whole visit with us is just talking about migraine treatment.”

That intensity of follow-up can matter when a regimen requires education, patience, and iteration. “I see [some patients] a week later, two weeks later [following the original appointment] because some people need a little extra hand holding,” Morgan said. “Even if it's a 10-minute conversation like, ‘You can do this. I know you can do this. How are you doing?’”

New Therapies, Old Barriers

Sobhanian and Morgan reviewed migraine-specific therapies in their session, especially those targeting calcitonin gene-related peptide (CGRP). In the interview, the presenters described CGRP options as a turning point and possible panacea for patients with migraine, but as with many other aspects of migraine care, payers can require extensive documentation and hurdles to overcome before they will cover these medications.

“Getting these medications covered is still a bit of a challenge, and I think that's a barrier, like where we have to jump through these hoops,” Sobhanian said. The “hoops” often require patients to try certain medications first, even if they are not as aggressive or effective at combating migraines or cause adverse reactions, “just because what's on the insurance is formulary,” Sobhanian said. He used the example of topiramate: “It's effective, but sometimes the tolerability can be an issue,” he said. “Rarely are [patients] able to get to a full therapeutic dose. And even when they do, the adherence is not super great.”

The Pros and Cons of Not Letting the Perfect be the Enemy of the Good

For Morgan, the payer barrier is precisely where health systems—and pharmacists—can build better pathways. “We can run test claims,” she said. “We’re not going to say that we're perfect. I cannot just produce free medicine, but one thing we can do is start talking about maybe an agent that's non-specific to start with. Let's give you some relief. Let’s see if this works. And then let's start working at something in the background, in case it doesn't.”

Sobhanian highlighted a similar focus on systems-level learning from denials. “We're constantly reviewing our denials and things and identifying reasons [why] someone can't get these particular medications, and then updating our process and protocols,” he said, with the goal of “moving towards accessing these therapies earlier in the disease process.”

Sobhanian also said patients often get sent home with medications that, along with not being very effective, may cause adverse drug-drug interactions or be easily overused by patients, whether intentionally or not. This is especially problematic for butalbital-containing products, as are prescriber behaviors that endanger patient wellbeing.

“Some patients [are] getting set home with with medications that aren't really …abortive,” Sobhanian said. “It's a very common cause for medication overuse and dependence; patients take massive doses, and then they can't come off of it.” Both presenters returned to the idea that patient-centered outcomes matter as much as numeric thresholds—and that “wins” include improved function even without total migraine freedom.

“The general rule is about 30% to 50% reduction in monthly migraine days,” Sobhanian said. “If their symptoms are better, they can get back to work most of the month now, then they should stay on their therapy.”

Morgan framed it similarly: “The initial goal should always be fewer and less, so it should be like, less severe, less frequent [headaches]. It should last less time, or overall fewer migraine days.”

How Can Pharmacists Make a Difference?

The ultimate takeaway, Sobhanian said, is that migraine care should cross settings and practices. “[As] pharmacists,” he said, “we can play a much bigger role in this…regardless of if we're in the retail environment, [or] specialty pharmacy, or inpatient or outpatient. … We're the ones who are able to spend a lot of time with patients, [to] really sit and listen and … be that empathetic ear to get to the root of what the issue is.”

Morgan added that headache care should feel less intimidating for pharmacists, especially those who are finishing their education and entering practice for the first time. “Neuro tends to scare people a little bit,” she said. “But I think you don't have to be a neuro expert to help patients with their headache. … This is pain, and I think the best thing we can do is to help treat their pain in what ways that we know and to learn a little more to advance that care of the patient, and then to partner with neurology and to learn more.”

REFERENCES

1. Sobhanian MJ, Morgan O. “High-Stakes Headaches: Update on Headache Pharmacotherapy and Pharmacists’ Role in Management.” Presented at: American Society of Health-System Pharmacists Midyear 2025 Clinical Meeting and Exposition; December 7-10, 2025; Las Vegas, Nevada.

2. Headache disorders affect 3 billion people worldwide—nearly one in every three people, ranking sixth for health loss in 2023 | Institute for Health Metrics and Evaluation. Institute for Health Metrics and Evaluation. Published 2023. Accessed January 8, 2026. https://www.healthdata.org/news-events/newsroom/news-releases/headache-disorders-affect-3-billion-people-worldwide-nearly-one

3. World Health Organization. Headache disorders. Who.int. Published March 6, 2024. https://www.who.int/news-room/fact-sheets/detail/headache-disorders

4. Steiner TJ, Stovner LJ, Jensen R, Uluduz D, Katsarava Z. Migraine remains second among the world’s causes of disability, and first among young women: findings from GBD2019. The Journal of Headache and Pain. 2020;21(1). doi:https://doi.org/10.1186/s10194-020-01208-0

‌

‌

‌