US Pharm. 2014;39(3):6-11.
One of the most common disorders for which patients request assistance from pharmacists is headache.1 It is critical for pharmacists to have a thorough understanding of which types of headache can be safely self-treated and which headaches must be referred to a physician for further evaluation.
Prevalence of Headache
Headache is not a reportable disease, so it is likely that the available prevalence data underestimate its true occurrence. The National Institute of Neurological Disorders and Stroke (NINDS) estimates that fully 90% of adults will experience one or more headaches during their life, and an appreciable number of these patients will experience more than one type of headache.2 About two-thirds of children have had a headache of one type or another by the time they reach the age of 15 years.2
Etiology of Headache Pain
Humans have 12 cranial nerves originating at the base of the brain.2 One is the trigeminal nerve, with three branches that innervate the scalp, intracranial/extracranial vasculature, meninges, face, neck, ears, eyes, and throat.2 The brain itself is unable to feel pain, as it lacks pain receptors. However, pain-sensitive nerve endings (nociceptors) are able to carry pain messages via the trigeminal nerve to the thalamus in reaction to pain-inducing stimuli. These triggers include stress, foods, odors, and medications. The thalamus transmits the pain signals to the brain. When they reach it, the patient perceives a headache.
Headache Classification
Headache has a very complicated differential diagnosis, because there are at least 150 different types.2 Experts attempt to simplify the diagnostic process by creating various classification schemes and taxonomies. The NINDS, for instance, assigns headaches to one of only four broad categories: 1) vascular headache (e.g., migraine, cluster headache, toxic headache induced by fever, headache caused by hypertension); 2) tension (muscle contraction) headache; 3) traction headache; and 4) inflammatory headache.3 The agency explained that the latter two headache types are usually caused by a more serious underlying disorder, as in the case where meningitis causes inflammation.
Primary Versus Secondary Headaches
A useful classification for pharmacist consultation is one that uses just two categories: primary and secondary headaches. Primary (or benign) headaches are those that are not caused by any serious underlying disorder, as opposed to the rare secondary headaches induced by an organic pathology.2 Fortunately, 99% of headaches are primary in origin.4,5 Most primary headaches can be self-treated, while secondary headaches should be referred.
Migraine Headache
Approximately 12% of Americans experience migraine headaches.2 The usual age of onset is 10 to 45 years, and migraine is more common in females.2,6 The causes of migraine pain are not fully elucidated, but the source is hypothesized to be within the brain, specifically via activation of nerve fibers located within the walls of certain blood vessels within the brain that perfuse the meninges. The first physiological abnormality is thought to be temporary narrowing of some blood vessels, decreasing the brain’s supply of blood and oxygen. This event is followed by a compensatory enlargement of other vessels in an attempt to normalize the brain’s oxygenation.2
Patients may be able to identify factors that trigger their migraines. Triggers are highly individual, and reportedly include changes in sleep patterns, missed meals (perhaps resulting in hypoglycemia), physical stress or exercise, abrupt changes in the weather or environment, strong odors or chemical fumes, smoking or being in proximity to smokers, caffeine withdrawal, loud or sudden noise, motion sickness, emotional stress, depression, anxiety, hangover, hormonal changes related to the menstrual cycle or pregnancy, and bright/flashing lights.2,6
Patients may mention that their migraine was preceded by an aura, which often involves visual abnormalities such as a blind spot, flashing lights that obstruct vision, zigzag lines moving across the visual field, eye pain, and/or tunnel vision. The aura may also include tingling paresthesias in the extremities. Patients describe migraine pain as a throbbing, pounding, or pulsating ache that is usually unilateral.6 A dull ache at pain onset usually worsens to full intensity that may persist for 6 to 48 hours. Ancillary manifestations reported by patients may include fatigue, photophobia, phonophobia, nausea or vomiting, sweating, and chills.
Tension Headache
Patients may ask pharmacists about headaches that appear to have been brought about by tension, stress, or anxiety. This is the most common type, reflecting the widespread existence of tension and stress in the lifestyles of many Americans. The cause is thought to be a reaction to stress, which is to contract the muscles of the neck and scalp.7 Tension headache is a dull pressure that does not throb. It may feel as though a tight band or vise is encircling the head, with the most severe pain in the scalp and temples and possible involvement of the back of the neck and shoulders. There is no aura, and tension headaches seldom cause nausea or vomiting.
Cluster Headache
Cluster headache, the most severe type of primary headache, is a type of trigeminal autonomic cephalgia in which the patient experiences severe pain in and around one eye.2,8 The headache may be preceded by an aura and/or nausea. Attacks occur in clusters in which the patient has headaches almost every day for a period of weeks to months, followed by a pain-free period before another closely spaced cluster of attacks begins.
Cluster headache is characterized by a set of physiological problems on the same side of the face as the pain, including redness and tearing of the eye, ptosis of the eyelid, rhinorrhea from one nostril, unilateral nasal congestion, inflammation under or around the painful eye, and/or redness or flushing of the face.8 The constellation of problems that accompany cluster headache aids the pharmacist in recognizing this type of headache.
Nonprescription Internal Analgesics
Nonprescription internal analgesics carry labeling for treatment of headache. Pharmacist questioning at the point of sale can ensure that the patient is treating an appropriate type of primary headache and that there are no warning signals that would necessitate referral to a physician. If the pharmacist considers nonprescription products appropriate, treatment choices include aspirin, acetaminophen (APAP, e.g., Tylenol), ibuprofen (e.g., Advil, Motrin IB) and naproxen (e.g., Aleve). The risk of Reye syndrome in children coupled with a long list of adverse reactions and warnings with aspirin use has sidelined it as a first-line medication for headache and other minor aches and pains, but APAP, ibuprofen, and naproxen are useful if the labeled warnings are followed.
Labeling Issues With Nonprescription Products
Each internal analgesic carries numerous label instructions meant to ensure safe use when they are followed.9-13 Some are age restrictions—ibuprofen in the appropriate dosage form can be used down to the age of 6 months, but APAP is not safe for unsupervised use under the age of 2 years, and naproxen is restricted to those aged ≥12 years. APAP may be used up to any age without supervision, but ibuprofen and naproxen labels caution patients aged ≥60 years to speak to a physician before use due because of a heightened risk of gastric bleeding.9-11
Acetaminophen
Acetaminophen carries a prominent set of warnings meant to prevent liver damage.9 Product labeling cautions patients that severe liver damage can occur if the patient takes more than 4,000 mg of APAP daily, takes the nonprescription form of APAP with other medications also containing the drug, or has three or more alcoholic drinks every day while using the product. APAP labels also warn against unsupervised self-use if the patient takes warfarin, develops new symptoms, is pregnant or breastfeeding, has pain that worsens or persists for more than 10 days, or if erythema or inflammation is present.9
NSAIDs: Ibuprofen and Naproxen
The nonsteroidal anti-inflammatory drugs (NSAIDs) ibuprofen and naproxen carry a set of warnings meant to prevent stomach bleeding.10,11 These products warn patients against unsupervised self-use if the patient is aged ≥60 years, has a history of stomach ulcers or bleeding problems, is taking an anticoagulant or corticosteroid, is taking a medication containing any other NSAID, takes three or more alcoholic drinks every day while using it, or exceeds the labeled time for self-use. They warn against use if the patient has ever had an allergic reaction to any other pain reliever or fever reducer; just before or after heart surgery; or if the patient is pregnant or breastfeeding. Labels point out the specific risks of use during the last trimester of pregnancy in order to avoid problems for the fetus and complications during delivery.10,11
Labels also caution patients to speak with a physician if the stomach bleeding warnings apply to them; if they have a history of problems or serious adverse reactions from previous use of pain relievers or fever reducers; if they have a history of gastric problems (e.g., heartburn); if they have hypertension, heart disease, hepatic cirrhosis, renal disease, or asthma; or if they are taking a diuretic.10,11 Labels instruct patients to stop use and speak to a physician if they experience signs of gastric bleeding (faintness, vomiting of blood, bloody/black stools, stomach pain that does not improve); if the pain worsens or persists for more than 10 days; if new symptoms appear; or if redness or swelling is present in the painful area. Aleve labels also warn patients to stop use and speak to a physician if they have difficulty swallowing or it feels as if a tablet is stuck in the throat.11
Migraine-Specific Products
Pharmacists may recommend one of two specific migraine products, Excedrin Migraine and Advil Migraine.12,13 The former contains APAP, aspirin, and caffeine, and the latter contains ibuprofen. In addition to the precautions listed above, the labels warn potential purchasers against self-use if they have never had migraine diagnosed by a physician; if this headache is different from their usual migraines; if it is the worst headache of their life; if they have fever or stiff neck; if the headache began after or was caused by head injury, exertion, coughing, or bending; if they experience daily headaches; or if the migraine is so severe as to require bed rest.12,13
PATIENT INFORMATION
Which Types of Headache Can I Treat Myself?
There are several types of headache that are not due to any serious underlying cause, and you may treat them yourself. They include migraine (diagnosed by a doctor), tension headache, and cluster headache. If you have not yet obtained a formal diagnosis, your pharmacist can assist you in deciding whether your headache might belong to one of these categories.
Furthermore, consult your pharmacist for assistance in choosing a specific OTC product for your headache. Treatment choices include acetaminophen (e.g., Tylenol), ibuprofen (e.g., Advil, Motrin IB), and naproxen (e.g., Aleve). Be sure to carefully read all directions and precautions on the label of these products, including age restrictions.
What Is Considered a Dangerous Cause of Headache?
While you can safely self-treat some headaches, there are times you should see a physician instead. If a blow to the head preceded the headache, it is mandatory to see a doctor to make sure you do not have a concussion. If you think your headache might stem from a sinus infection, an antibiotic prescribed by a physician is the best course of action. If a temporomandibular joint disorder (TMJ or “clicking jaw”) might be causing the headache, you may need surgical intervention to correct the situation.
If you have a persistent, nagging headache at the time of year when you just turned on the heating in your house or apartment, you should consider carbon monoxide as a cause. Faulty heating systems allow this deadly odorless gas to enter your living spaces, causing headache, nausea, vomiting, dizziness, fatigue, weakness, confusion, fainting, disorientation, visual problems, and seizures. You must leave the dwelling immediately and call 911 for transport to an emergency room if you suspect carbon monoxide exposure.
Alarming Signs
There are other times when you should be sufficiently alarmed about headache to seek immediate medical care. Is it the first headache you have ever had? This could mean you have a neurologic problem. If the headache was brought about by exertion or exercise, it may be due to an aneurysm (ruptured blood vessel). If you became less aware of your surroundings or your mental function has changed, a stroke may have occurred. If the headache is the worst one you have ever had or is unusually severe, you must seek care for diagnosis of the cause.
If your headache occurred like a “bolt from the blue,” this might indicate that you have suffered a hemorrhage inside the skull, which demands immediate attention. If your headache occurred along with stiff neck, sensitivity to light, nausea, vomiting, and/or loss of consciousness, you may have meningitis, and this must be medically treated. Headache with pain around the eye(s) may be due to glaucoma. If left untreated, glaucoma may cause irreversible loss of vision, so you must seek immediate care.
Remember, if you have questions, Consult Your Pharmacist.
REFERENCES
1. Headache overview. MedlinePlus. www.nlm.nih.gov/medlineplus/headache.html. Accessed January 18, 2014.
2. Headache: hope through research. National Institute of
Neurological Disorders and Stroke (NINDS).
www.ninds.nih.gov/disorders/headache/detail_headache.htm. Accessed
January 18, 2014.
3. NINDS headache information page. www.ninds.nih.gov/disorders/headache/headache.htm. Accessed January 18, 2014.
4. Pray WS. Nonprescription Product Therapeutics. 2nd ed. Baltimore, MD: Lippincott Williams & Wilkins; 2006.
5. Headache. MedlinePlus. www.nlm.nih.gov/medlineplus/ency/article/003024.htm. Accessed January 18, 2014.
6. Migraine. MedlinePlus. www.nlm.nih.gov/medlineplus/ency/article/000709.htm. Accessed January 18, 2014.
7. Tension headache. MedlinePlus. www.nlm.nih.gov/medlineplus/ency/article/000797.htm. Accessed January 18, 2014.
8. Cluster headache. MedlinePlus. www.nlm.nih.gov/medlineplus/ency/article/000786.htm. Accessed January 18, 2014.
9. Tylenol. McNeil-PPC, Inc. www.tylenol.com/products/tylenol-extra-strength-caplets. Accessed January 18, 2014.
10. Advil Tablets. Pfizer Consumer Healthcare. www.advil.com/advil. Accessed January 18, 2014.
11. Aleve Caplets. Bayer Healthcare. http://labeling.bayercare.com/omr/online/aleve-caplets.pdf. Accessed January 18, 2014.
12. Advil Migraine. Pfizer Consumer Healthcare. www.advil.com/advil-migraine. Accessed January 18, 2014.
13. Excedrin Migraine. Novartis Consumer Health, Inc. www.excedrin.com/migraine-center.shtml. Accessed January 18, 2014.
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