Case 1—Migraine Headache Relief
NJ is a 34-year-old woman with chronic migraine headaches. She has tried numerous OTC products for symptom relief and is looking for something she can use on a consistent basis to prevent her headaches from occurring in the first place. She has done extensive research on prescription products for headache relief and is scared by their potential side effects. NJ would like to try something herbal before moving on to a prescription product. She reports no known allergies and that she takes an oral contraceptive daily. Are there any herbal alternatives that you can recommend for migraine relief?
Migraine headaches account for a significant burden on sufferers due to lost productivity, impaired quality of life, and increased health care expenses. Migraines are estimated to affect nearly 18% of women and 6% of men in the united States.1 Foods, medications, stress, and hormonal fluctuations around the time of menstruation are all possible triggers for migraine symptoms in women.
Several herbal products, including butterbur, feverfew, coenzyme Q10, and magnesium, have been tried for migraine prevention. According to the 2012 update to the migraine prevention guidelines from the American Academy of Neurology and the American Headache Society, all of these agents provide some benefit in migraine prevention.2 Of these agents, butterbur has the most clinical support for its efficacy in reducing the frequency and severity of migraines and could be recommended for NJ. Butterbur contains 2 pharmacologically active compounds: petasin, which is thought to inhibit leukotrienes and reduce smooth muscle spasms, and isopetasin, which is thought to decrease prostaglandin synthesis and inflammation.1 In clinical trials, 50 to 75 mg of butterbur administered twice daily was shown to be effective in reducing the frequency of migraine attacks, with higher dosages having a greater effect.1,2 Butterbur is a known substrate of CYP3A4 and use should be avoided with concomitant inducers or inhibitors of this isoenzyme. Additionally, safety with use longer than 16 weeks has not been established; for chronic symptoms, refer NJ to her physician to discuss prescription-only options.3
Case 2—Memory Loss
MK is a 67-year-old woman who reports forgetting little things: she sometimes forgets to feed her dogs, she’s been late with paying some bills, and she can never seem to find her keys. She inquires about a natural product to boost her memory. She takes aspirin 81 mg daily, metoprolol 25 mg twice daily, lisinopril 20 mg daily, and atorvastatin 40 mg daily for hypertension and dyslipidemia. She reports no known allergies. What is the evidence for the herbal agents touted for memory enhancement? Is MK a candidate for self-treatment?
Natural medicines that may improve memory include huperzine, ginkgo, lecithin, choline, and dimethylaminoethanol (DMAE). Memory loss—specifically that associated with Alzheimer’s disease—is thought to be related to deficiency in acetylcholine (ACh), and many of these agents are thought to increase levels of ACh in the central nervous system. Specifically, huperzine, an alkaloid from Chinese club moss, is thought to increase levels of ACh in the brain by inhibiting the enzyme acetylcholinesterase.4 Clinical trials of huperzine have generally included small sample sizes and been of short duration; little is known about its long-term safety and efficacy. Further, huperzine is considered to have a side-effect profile similar to the prescription-only ACh inhibitors, including nausea, vomiting, diarrhea, cramps, and increased urination frequency. in addition, increased cholinergic toxicity could occur if this agent were used in combination with a prescription ACh inhibitor.4 Among other agents increasing or mimicking increased ACh levels, acetyl-L-carnitine is the most promising memory booster, particularly when used in patients younger than 66 years with an early onset and rapidly progressing disease.4 Finally, ginkgo has been long theorized to have anti-inflammatory and antioxidant properties that may reduce inflammation and improve cerebral circulation; study results, however, have been inconsistent. In the case of MK, physician referral in lieu of an herbal remedy is likely the best option; ginkgo may interact with her aspirin therapy and increase her risk of bleeding.
Case 3—Eczema in Children
BK comes to the pharmacy with her 8-month old daughter, who has patchy, chapped skin on her cheeks and forehead and on the inner aspect of her elbows. BK says she has not recently changed detergents or introduced new foods into her child’s diet. She reports the child has no known allergies to foods or medications and that she takes a daily vitamin D liquid supplement since she is still being breastfed. BK says she first noticed the lesions a month or so ago, but they seem to have gotten worse despite use of a topical colloidal oatmeal lotion. What can you recommend for BK’s daughter?
BK’s daughter may be experiencing the skin disorder known as atopic dermatitis, a chronic and recurrent immune-mediated disorder of the skin that often presents in infancy and may affect 10% to 20% of children.5,6 The condition usually affects the cheeks, face, and extremities.6 Flares of this condition can be triggered by exposure to allergens, including certain soaps or detergents, animal dander, and cigarette smoke. To minimize the potential for irritation due to allergens, remind BK to wash the child’s clothing with unscented detergent and to avoid use of fabric softeners. BK should also continue to use a gentle soap indicated for infant skin when bathing her daughter, and should consider bathing the child every other day to minimize the effects of bathing on over-drying the child’s skin. Treatment of atopic dermatitis usually consists of use of topical products to promote hydration of the skin and to reduce itching; emollient creams or lotions can help rehydrate the skin and minimize the appearance of dryness.5 These topical products work best when applied immediately after a bath. Hydrocortisone is the nonprescription product of choice used to treat this inflammatory condition. However, given the daughter’s age, BK should not be counseled to use topical hydrocortisone at this time.5
Case 4—Allergic Conjunctivitis
CK is a 42-year-old man who reports experiencing bad seasonal allergies during the spring, including symptoms of red, itchy, watery eyes and nasal congestion. His physician prescribed an ocular antihistamine product for him, but he reports that it is too expensive for him; if possible, he would like to try something OTC before using this type of medication. He has no known allergies and takes rosuvastatin 10 mg daily, methylphenidate 36 mg daily, and cetirizine 10 mg daily as needed. What type of product can CK use for self-treatment?
CK’s symptoms and presentation are consistent with allergic conjunctivitis, a common ocular complaint that often occurs concomitantly with seasonal allergic rhinitis. Allergic conjunctivitis is usually triggered by exposure to allergens, such as pollen or animal dander, and can be associated with the use and local application of ophthalmic products to the eye. Symptoms of allergic conjunctivitis often include itchy, red, or bloodshot eyes and are often accompanied by a watery discharge that may cause blurring of the individual’s vision.7
In terms of nonpharmacologic interventions, recommend CK avoid exposure to known allergens, including monitoring pollen counts and avoiding spending time outdoors when counts are high, closing windows, and using air filters to help mitigate symptoms. For very irritated eyes, tell him to apply cold compresses to relieve itching and redness.7 As an alternative to the histamine antagonist/mast cell-stabilizing agent his physician prescribed, consider recommending an OTC topical eye drop containing ketotifen fumarate (Alaway or Zaditor). Instruct CK that the selected product should be instilled twice daily into both eyes and can be used concomitantly with the oral antihistamine product, cetirizine, that he is currently taking. Other less expensive nonprescription alternative antihistamine/decongestant combination products also are available. However, these products need to be administered 3 to 4 times per day. Further, the long-term use of ocular decongestants may result in rebound vasodilation and worsening redness of the eye and should be avoided.
Case 5—Heartburn and Calcium Supplementation
ML is a 54-year-old woman who comes to the pharmacy with a prescription for Nexium 40 mg. She says she has had heartburn for years despite significantly modifying her diet and that Nexium really helps to control it. She is also looking for an OTC product to prevent osteoporosis. Her girlfriend was just diagnosed with it and had to start prescription medication. ML says her mother also has osteoporosis and broke her hip last year, leading to a painful recovery that required multiple surgeries. ML’s bone mineral density is normal, but seeing her mom suffer has made her worry about what will happen to her as she gets older. Her doctor has advised her to take calcium daily, but she was overwhelmed by the range of supplement choices at the pharmacy and has been lazy about calling her doctor to ask which she should take. What would you recommend to ML regarding her choice of calcium supplement?
The recommended daily allowance for women 50 years and older is 1200 mg of calcium and 800 to 1000 IU of vitamin D.8 Available supplements contain 2 forms of calcium: calcium carbonate or calcium citrate. Either is recommended, but patients who are taking medications for heartburn that reduce levels of stomach acid can absorb calcium citrate more easily. Since ML is taking Nexium, she should take calcium citrate. She should also be counseled to take her daily dose in 2 separate portions. The percentage of calcium absorbed depends on how much is ingested at 1 time, and absorption is highest in doses <500 mg.9 Therefore she can take a supplement with calcium citrate 600 mg twice daily, with or without food. Patients who take calcium carbonate should take it with food to help aid absorption. it is also important to assess a patient’s calcium intake from other food sources, such as yogurt and milk, to ensure that they do not get too much.
Case 6—Vaginal Infection
GR is a 36-year-old woman who comes to the pharmacy looking for something to treat an infection. Upon questioning, she says her vaginal discharge is thick and white. She says it looks like cottage cheese, but has no odor. She says it appeared the previous day and now she is very itchy. She works for an advertising company and has been extremely busy for the past few weeks working 14-hour days to launch a new product, so she needs something quick and hassle-free. She says she has no medical conditions, is not on any medications, and has no fever or pain. What would you recommend for GR?
GR appears to have vulvovaginal candidiasis. The goal of therapy is typically to provide symptom relief and eliminate the infection. Since GR does not have any exclusion to self-treatment (eg, pregnancy, age under 12 years, or fever or pain in the lower abdomen, back, or shoulders) and she doesn’t have any medical disorders and is not taking medications, she is a candidate for self-treatment. A nonprescription FDA-approved imidazole product is the recommended initial therapy for uncomplicated vulvovaginal candidiasis and relief of external vulvar itching and irritation associated with the infection. These drugs include butoconazole, clotrimazole, miconazole, or tioconazole.10 Since GR is extremely busy, it might be appropriate to start her on the Monistat 1 Combination Pack. She should apply the cream to her vulva twice daily as needed for itching and insert the suppository into her vagina at bedtime, leaving it in for 1 day. Comparisons of miconazole single-dose and 7-day treatments have found similar overall cure rates, with significantly faster rates of symptom relief by day 3 in the single-dose group.11 In addition, GR might benefit from consuming yogurt containing live cultures. Yogurt can help decrease vulvovaginal candidiasis, particularly in women who experience recurrent infections. She might also benefit from decreasing her intake of sugar.
1. Wilkinson JJ. Headache. In: Krinsky DL, Berardi RR, Ferreri SP, et al, eds. Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care. 17th ed. Washington, DC: American Pharmacists Association; 2012:67-86.
2. Holland S, Silberstein SD, Freitag F, et al. Evidence-based guideline update: NSAIDs and other complementary treatments for episodic migraine prevention in adults: report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society. Neurology. 2012;78:1346.
3. Natural medicines in the clinical management of headache. In: Natural Medicines Comprehensive Database [Internet]. www.therapeuticresearch.net. Stockton, CA: Therapeutic Research Faculty. Published c 1995-2013. Accessed February 21, 2013.
4. Natural medicines in the clinical management of Alzheimer’s Disease. In: Natural Medicines Comprehensive Database [Internet]. www.therapeuticresearch.net. Stockton, CA: Therapeutic Research Faculty. Published c 1995-2013. Accessed February 21, 2013.
5. Scott SA. Atopic dermatitis and dry skin. In: Krinsky DL, Berardi RR, Ferreri SP, et al, eds. Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care. 17th ed. Washington, DC: American Pharmacists Association; 2012:615-630.
6. Pediatric atopic dermatitis. Medscape website. http://emedicine.medscape.com/article/911574-overview. Accessed April 1, 2013.
7. Fiscella RG, Jensen MK. Ophthalmic disorders. In: Krinsky DL, Berardi RR, Ferreri SP, et al, eds. Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care. 17th ed. Washington, DC: American Pharmacists Association; 2012:509-530.
8. National Osteoporosis Foundation. www.nof.org/aboutosteoporosis/prevention/calcium. Accessed May 5, 2013.
9. National Institute of Health: Office of Dietary Supplements. http://ods.od.nih.gov/factsheets/calcium Accessed May 5, 2013.
10. Vaginal and vulvovaginal disorders. In: Krinsky DL, Berardi RR, Ferreri SP, et al, eds. Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care. 17th ed. Washington, DC: American Pharmacists Association; 2011:124.
11. Upmalis D, Cone FL, Lamia CA, et al. Single dose miconazole nitrate vaginal ovule in the treatment of vulvovaginal candidiasis: two single blind, controlled studies versus miconazole nitrate 100mg cream for 7 days. J Womens Health Gend Based Med. 2000;9:421-429.
About the Authors
Dr. Mansukhani is a clinical pharmacist in South Plainfield, New Jersey, and clinical assistant professor, Ernest Mario School of Pharmacy, Rutgers University.
Dr. Bridgeman is an internal medicine clinical pharmacist in New Brunswick, New Jersey, and clinical assistant professor, Ernest Mario School of Pharmacy, Rutgers University.