Handling Headache: Types, Treatments, and Counseling Pearls

Headaches are complex. They can have a spectrum of causes and some may require urgent medical attention. Thus it is important for pharmacists to ask patients the right questions, understand what’s happening, and discuss the best treatment.

Pharmacists can be a quick means of helping patients understand how to optimize their current medications and prevent potential adverse drug events through counseling. They can also serve as an advocate for patients through close contact with the patient’s prescriber office. Some type of education and counseling, as well as asking how patients are managing their headaches and how effective their medication treatments are at resolving or preventing them, should occur at every clinic appointment.

“There is a lot of counseling needed for patients to understand what constitutes a headache that can be treated at home and a headache that requires urgent medical attention,” said Adrienne DeBerry, PharmD, a clinical pharmacist consultant for Real Talk Health Pro. “Counseling includes making sure patients know these alarm symptoms and how to properly use treatment medications to remedy the headache.”

Shari N. Allen, PharmD, BCPP, an associate professor in the Department of Pharmacy Practice at Philadelphia College of Osteopathic Medicine in Georgia, added that counseling on headache and its pharmacologic treatment should generally take place when a patient receives a new diagnosis. Patients should also receive counseling when a medication is going to be initiated or a dose changed.

“From there, counseling [can be] patient specific when they need it, if they have questions, if they are experiencing an increase in headache frequency, to assess whether the medication is working, [and so on],” she said. “It is dependent on the particular patient. For example, if I am treating a patient for migraine and they are on a stable regimen that is working well, I won’t need to counsel them on the medications every time unless something has changed. However, I will briefly assess headaches at each visit—which in my case is usually every 3 months for stable patients.”

Discussion Points

As it is important for pharmacists to know the type of headaches their patients are dealing with, the consultation conversation should not be quick and general.

Allen uses the time to assess the patient’s symptoms, as these will determine the type of treatment to be used. “When and how to administer the medication is also important,” she said. “Discussions should include the use of OTC and prescription abortive medications [for a migraine attack] and [education on medication]…overuse headaches.”

Brian Caswell, RPh, owner of Wolkar Drug in Baxter Springs, Kansas, noted that sometimes, headache comes up in the course of other counseling conversations as just one of several issues a patient is experiencing. Many times, those issues are stress related. At Wolkar Drug, headache conversations occur approximately 2 to 3 times a week.

“A lot of times, [a patient] may be coming in picking up medication or buying an OTC medication, and they just bring up casually that they are experiencing headaches,” he said. Once Caswell determines the type of headache the patient is having, he will ask about frequency, how the patient is treating it, and how successful or not successful that treatment has been.

“I usually ask them how debilitating the headache is,” he said. He wants to know to what extent the headache is interfering with their life. “If we see the frequency is up, or that things are getting worse, we may [refer] them back to their physician or a specialist in the area.”

Drug interactions are always an important counseling point, especially for headaches, as many migraine treatments can interact with mental health medications. Those discussions, DeBerry noted, should include ensuring that patients understand alarm symptoms that warrant urgent medical attention, such as headache accompanied by a fever or stiff neck, or thunderclap headache and other “red flags.”

“Knowing when to take acute headache treatments and the frequency of use…can limit the likelihood of a patient experiencing a medication overuse headache,” she said. “If a patient is using headache medications more than 2 to 3 days a week, the patient needs to contact their prescriber. It is also important to make sure the patient understands the [adverse] effects of their headache medications, as some may cause drowsiness or should not be used before operating heavy machinery.”

Exploring Treatment Options

Knowing the symptoms of a headache helps determine the type of medications that can be used to treat it. Understanding other symptoms, such as nausea or vomiting, is also helpful in determining the appropriate formulation of the medication.

For acute treatment, options include nonsteroidal anti-inflammatory drugs (NSAIDS), triptans, ditans, select calcitonin gene-related peptide (cGRP) agents, ergotamine, butalbital and caffeine combination analgesics, antinausea medications, and corticosteroids. These abortive medications should be taken at the onset of symptoms to enable them to work best, Allen explained. For preventive treatment, solutions include beta blockers, antiepileptics, tricyclic antidepressants, and cGRP agents.

Great options are available to treat headaches, Caswell added, so patients shouldn’t be shy about coming in for help. “If they are debilitating, we can help fix that,” he said. “We want to instill hope within those people. For a lot of migraineurs, it’s sometimes difficult to get it treated properly and they can become very depressed. We tell them we will find an answer, but the road might be a little longer than they expect. [But] there is a road to recovery.”

Common Questions

Whether treating patients with migraine, cluster, tension, or even medication overuse headaches, pharmacists will often hear the same type of questions.

“Most of the time, we get questions about how quickly the medication will work to resolve the headache and whether they will have to keep taking this medication forever,” DeBerry said. “How quickly typically varies by treatment. Acute treatments such as triptans can work as quickly as within the hour, while some take longer to kick in. For preventive therapies, some cGRP injectable agents, [such as erenumab-aooe (Aimovig), fremanezumab-vfrm (Ajovy), or galcanezumab-gnlm (Emgality)], can take 2 to 3 months to [achieve] maximum benefit in headache prevention.”

Regarding how long a medication may have to be taken, DeBerry noted that sometimes, depending on their cause, headaches can get better over time and the patient can try reducing their preventive treatment. Although some patients may be able to eventually decrease the use of headache medications over time, this is not a guarantee. “Each patient’s headache syndrome can respond differently—or not respond—to certain medications,” DeBerry said.

In Allen’s experience, common patient questions focus on trying to find a treatment that works, so she often talks about which medications are used to treat the applicable headache type and how best to receive the drugs’ benefits. “I always try to stress the difference between abortive medications and prophylaxis,” she said. “If a patient is taking too many abortive doses, it may be appropriate to start a prophylaxis agent. Recognizing this is important for care.”

Additionally, educating patients on medication overuse headaches—caused by the very medications that should alleviate the headaches—is important. Allen tries to define what that amount is or how many days of use would increase the risk for medication overuse.

“Pharmacists in the community setting and in clinics are the most accessible health professionals and we can act as patient advocates if we are not managing the headaches ourselves,” Allen said. “Pharmacists have the knowledge to be able to assess headache type, determine when certain medications (abortive or prophylaxis) are needed, and how much is too much.”