Banging, thumping, blinding

When is a headache more than just a headache? Find out how to tell the difference between different types of headache, what to advise and when to refer

While headaches are usually minor and will go away on their own, they can sometimes be a sign of something more serious. And although this might not be common, it’s important for pharmacy staff to be able to identify the different types of headache and be able to refer appropriately. So what are the differences and how should customers be advised to tackle them?

Tension and cluster headaches

People often think the cause of their headache is stress, lack of sleep, dehydration or wearing the wrong spectacles, but Kate MacNamara – who wrote the headache pathway for the Abertawe Bro Morgannwg University (ABMU) Health Board, and is practice pharmacist at Fforestfach Medical Centre – says: “There is no one clear attributable cause for each type of headache, with the exception of medication overuse headache, and all headache diagnoses need to be made on the basis of a sound history.”

The most common type of headache that pharmacy staff will see in their customers is tension headache, according to Farah Ali, general manager at Perrigo’s centre of excellence, Warman-Freed Pharmacy in Golders Green, London. “These feel like a constant ache on both sides of the head and can be associated with tightening of neck muscles or pressure behind the eye”, she says.

A cluster headache causes severe pain on one side of the head, usually around the eye or temple, and often start without warning. They normally happen in clusters over six to 12 weeks and their rapid onset mean that OTC painkillers are generally ineffective. Kate says: “There are no OTC treatments available for cluster headache and these patients should be referred back to the GP if their current treatment is not helpful.”

A new innovation

Cluster headache affects approximately 66,000 people in the UK, and was recently recognised by the NHS as one of the top 20 most painful conditions.

To address this issue, NICE has recently published a Medtech Innovation Briefing (MIB) on ElectroCore’s GammaCore cluster headache treatment for adults.

GammaCore is a small handheld, patient-controlled, non-invasive vagus nerve stimulator (nVNS), which is applied to the neck and delivers a small electric current for two minutes at a time. The aim is to modify pain signals by stimulating the vagus nerve through the skin of the neck.

Clinical experts suggest the treatment could be an option for people who haven’t responded to, or can’t tolerate currently available treatments, but NICE says key uncertainties around the evidence and technology are that people with episodic and chronic cluster headaches respond differently to treatment with GammaCore, and the optimal use of GammaCore in the different populations is unclear.

However, the opinion of four leading clinical experts and the advocacy group Migraine Trust, who were consulted in the development of the MIB, is that the use of GammaCore has led to improvements for some people, allowing them to return to work and resume normal activities.

Migraine

Migraine symptoms are different for everyone, and some may be mistaken for other conditions. For example, younger children can experience abdominal migraine, which consists of abdominal pain with no headache at all, and some people get a more severe form of migraine known as hemiplegic migraine, where they experience stroke-like symptoms.

Such a complicated condition has long been misunderstood, according to Una Farrell from the Migraine Trust. She says: “It used to be believed that migraine was vascular, but it’s now known to be a neurological condition, although we still don’t know exactly why people get it.”

Una explains that “if the pain is in the side of the head and lasting for several days then it’s a migraine, not headache. Some 10 per cent of people experience visual disturbance known as ‘aura’, and there are those who report nausea and vertigo.”

Other common migraine symptoms include:

  • Vomiting
  • Increased sensitivity to light and sound – which is why many people with a migraine want to rest in a quiet, dark room
  • Poor concentration
  • Feeling very hot or very cold
  • Abdominal pain
  • Diarrhoea.

Managing headache and migraine

Headache diaries are an essential
tool to help identify triggers

“Many patients will report individual trigger factors for migraine and tension-type headache, which are two of the hardest headache types to distinguish from one another, and it is obviously important to avoid these as much as possible,” explains Kate. “The use of headache diaries is an essential tool to help patients identify what may be bringing on or increasing the frequency of their headaches and it’s really important to encourage both new and existing headache sufferers to use these.”

When it comes to recommending OTC treatment, Kate says: “There is some evidence to suggest that paracetamol monotherapy may be less effective in both migraine and tensiontype headache, but as NSAIDs or high dose aspirin are the other recommended single agent options, individual comorbidities and drug history need to be carefully considered. For migraine, triptans may be used alone or in combination with an NSAID or paracetamol, and sumatriptan is available OTC for existing sufferers meeting specifi c criteria,” says Kate.

Due to the risk of medication overuse headache, Kate warns that caution should always be exercised when recommending analgesia: “Opioids should never be recommended for headache, even if [the patient is] not responding to fi rst line treatment,” she says.

Farah adds that “tips and hints on lifestyle, environmental and dietary changes, such as drinking enough water, which can help ease the pain”, can also be useful.

Medication overuse headaches

Medication overuse headache (MOH) is the one headache type that does have a clear, attributable cause, and diagnosis can be confi rmed when symptoms resolve on discontinuation of medication.

The International Headache Society defi nes medication overuse as taking pain relief for a headache more than twice a week (eight days a month) for more than three months. Medication overusers are at high risk of developing medication overuse syndrome – a condition where their headaches are actually caused or made worse by the medication rather than the condition for which they were originally taken.

Compound analgesics such as cocodamol are most commonly associated with MOH, but it has been known to occur with a variety of simple analgesics and even triptans. The thing to alert customers to, according to Kate, is that “using a low dose of a painkiller on a regular basis to treat a headache is more likely to lead to a medication overuse headache than intermittent treatment at full dose a couple of times a month.”

MOH may be a more common problem than expected. A recent survey of over 1,300 people with migraine carried out by Migraine Action in partnership with Cefaly, the nonpharmaceutical anti-migraine device, found that 58 per cent per cent of migraine sufferers are overusing their pain relief medication, with nearly one in five (18 per cent) of those already formally diagnosed with medication overuse syndrome.

“Migraines can be an extremely unpleasant and debilitating occurrence and it is completely understandable that people might reach for medication to either prevent or relieve migraine,” says Dr Andrew Dowson, migraine specialist and medical advisor to Migraine Action.

However, if you are overusing your pain relief medication and either not aware of it or not dealing with it, then you are at real risk that over time the threshold level of your pain and sensitivity tolerance will drop and you will get more migraine headaches. Some people too, may become physically dependent to the painkillers themselves, particularly if they are codeine or caffeine based. Effectively, it creates a whole new condition for the patient to deal with on top of their migraine,” says Dr Dowson.

Kate says pharmacy staff have a vital role in raising awareness of and identifying medication overuse headache: “Getting patients on board can be challenging as the headache usually increases in severity on stopping treatment, but community pharmacy teams are ideally placed to help support and encourage patients through this in conjunction with their GP.”

As with so many conditions, information is a crucial part of the toolkit when it comes to supporting customers, in particular helping them understand the type of headache they are suffering from and how to manage it. Reassuring them that most headaches will go away on their own or with simple over the counter analgesics – and are therefore not a sign of something serious – can make a huge difference, although referring them to their GP when necessary is important.

Headaches and red flags

There are of course more serious causes of headaches and fear of these can be very distressing for customers. As ever, the skill of pharmacy teams in using effective questioning techniques is key to ensuring that people reporting red flag symptoms are identified and referred to their GP for prompt treatment, or offered reassurance and relevant support in the pharmacy if that is deemed more appropriate for their symptoms.

Kate says reminding patients that serious causes of headaches are “very rare” can help to allay any anxiety and stress, and adds that getting a good history and identifying red flags is key.

So what are these red flags? Kate says: “All new headaches should be investigated. The British Association for the Study of Headache (BASH) recommends that fundoscopy – looking at the blood vessels at the back of the eye – and a neurological exam should be conducted for all new presentations, so anyone with a new or different type of headache that hasn’t been diagnosed before should be referred.”

The BASH guidelines list the following as red flags or warning signs for headaches:

  • Headache that is new or unexpected in an individual patient
  • Thunderclap headache (intense headache with abrupt or ‘explosive’ onset)
  • Headache with atypical aura (duration >1 hour, or including motor weakness)
  • Aura occurring for the first time in a patient during use of combined oral contraceptives
  • New onset headache in a patient older than 50 years
  • New onset headache in a patient younger than 10 years
  • Persistent morning headache with nausea
  • Progressive headache, worsening over weeks or longer
  • Headache associated with postural change
  • New onset headache in a patient with a history of cancer
  • New onset headache in a patient with a history of HIV infection.

Kate says that in particular, “thunderclap headache should be considered a medical emergency” and highlights the risk of carbon monoxide poisoning, which can lead to new headache symptoms. “Although rare, this can often be missed so questioning the patient about the heating in their home is worthwhile. The possibility of transient ischemic attacks (TIA) should also always be considered, so remember the FAST test for stroke,” Kate adds.

Migraine and mental health

People who get migraine are three times more likely to have depression and people with depression are also three times more likely to get migraine, according to The Migraine Trust. It is not just the frequent and debilitating pain experienced, but the negative impact on work, studies and relationships that affects their mental health.

Wendy Thomas, chief executive of The Migraine Trust, advises anyone who is struggling with their mental health to seek help. She says: “Migraine can be such a disempowering condition. It can often feel like migraines are controlling your life. That’s why it’s crucial to seek help and not suffer through what can be a very lonely illness. Help is available from charities such as The Migraine Trust, mental health charities or your GP. The important thing is to seek support once you realise that you are struggling with your mental health and not go through this alone.”

The Migraine Trust has two support services for people affected by migraine: an information service about migraine and its management, and an advocacy service that supports people with migraine in their employment, education and accessing healthcare.

Practice pharmacist Kate MacNamara says: “Stigma around mental illness is sadly still high in our society and people are often reluctant to speak freely about their mood. If pharmacists pick up on subtle signs when asking patients about their illness, these should be explored further, and reassurance that the person is not alone can be helpful in encouraging them to seek further help. Despite this, many people may still be nervous about contacting their GP to discuss this further, and it may be helpful for the pharmacist to offer to get in touch with the GP themselves. Simply getting someone to open up about how they are feeling can be a huge step towards getting them the help they need.”

Thunderclap headache should be considered a medical emergency

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