All in the head
Headaches are one of the most common reasons why people visit their local pharmacy, so it’s essential that pharmacy staff are able to give the best possible advice.
Most people experience headaches from time to time and say they know how to manage them. Yet many don’t follow the recommended advice, instead delaying treatment or only taking half the recommended analgesic dose. And research shows that at least 60 per cent of headache sufferers never consult a GP because they mistakenly think that nothing can be done to help them.
Headaches can vary greatly in their duration, cause and severity. According to National Institute for Health and Care Excellence (NICE) guidance, people should consider keeping a diary for at least eight weeks, recording the frequency, duration and severity of their headaches, any associated symptoms (e.g. nausea or visual problems), how long the attacks last and when they tend to occur (e.g. after particular events or at certain times of the day).
Many common headaches – from tension-type headaches to sinus headaches – can be treated with over-the-counter (OTC) products. If customers experience regular headaches, it’s important that they see a GP to get a proper diagnosis.
Around 80 per cent of people suffer from occasional, or episodic, tension-type headaches. Tension-type headaches are usually described as a tight band around the head (on both sides) or a weight on top of it. According to a Nurofen campaign in early 2015, the real cause of these headaches is actually strained muscles in the head and neck, and many people notice that these muscles feel sore and tense when the headache occurs.
A tension-type headache can last from 30 minutes to several days. If it occurs daily, it’s called chronic tension-type headache. “Tension headache is often a manifestation of stress, tiredness, alcoholic drink-like hangover, a change in lifestyle or alteration in daily routine,” says Dr Fayyaz Ahmed, neurologist at Hull Royal Infirmary.
OTC painkillers are commonly used to treat acute tensiontype headaches. But taking painkillers (especially products containing caffeine or codeine) for a headache more than twice a week can increase the risk of developing rebound headaches. Doctors can prescribe muscle relaxants if tension-type headaches occur regularly.
But removing the underlying cause, especially muscle tension, is the best long-term solution. NICE guidance suggests various approaches, including a course of up to 10 sessions of acupuncture over five to eight weeks for chronic symptoms.
“It’s important to look at posture, as muscle tension in the neck can cause headaches,” says Dr Katy Munro, headache specialist at the National Migraine Centre in London. “Using laptops, phones and other technology, in particular, moves the neck into an unnatural forward position. Osteopathy or acupuncture can help to reduce headache frequency. Customers may also benefit from physiotherapy, massage, ice/heat or a magnesium spray to the neck muscles.”
Migraine is more than just a headache. Symptoms include throbbing headaches associated with sensitivity to light and noise, nausea, vomiting and lethargy. They usually last from four to 72 hours and most people are free from symptoms between attacks.
People with migraine tend to have a nervous system that’s particularly sensitive to change, and genetics seem to play an important role in determining susceptibility. Migraine triggers vary from person to person.
In summer 2015, the Curelator Headache Study looked at key factors that increase and decrease the risk of a migraine attack in 145 people. It found that top triggers included neck pain, stress, bright lights and tiredness/ fatigue and top ‘protectors’ (i.e. factors that reduce the risk of an attack) included waking refreshed, activity and happiness. Surprisingly, triggers in some people were found to be protectors in others.
“More than one trigger is usually involved in provoking an attack,” says Dr Munro. “The brain is sensitive to change and sometimes it’s an accumulation of triggers that’s the problem, rather than an individual trigger. Often it’s a case of looking at what’s changed in that person or their environment and determining how it can be dealt with. If it’s a change in blood sugar, for example, it’s important to eat regularly. Too little or too much sleep means sleep patterns need to be assessed.”
The most common types of migraine fall into two categories – migraine with aura and migraine without aura. “Around 10 per cent of people with migraine experience sensory disturbances – auras – before every headache,” says Dr Andrew Dowson, director of headache services at King’s College Hospital, London, and spokesperson for Migraine Action. “An aura lasts for five to 60 minutes and includes visual disturbances and peripheral sensory changes [e.g. numbness]. Most people panic when they have their first aura, worrying that they are having a stroke.”
According to NICE guidance, an acute migraine attack can be treated with a non-steroidal anti-inflammatory drug (NSAID), such as ibuprofen, or with paracetamol (with or without an oral triptan). “Migraine should first be treated with simple over-thecounter analgesics rather than complex versions,” says Dr Dowson. “If these don’t work, customers can try sumatriptan, which is available from pharmacies. Ideally though, they should get a prescription from their GP first and then use the OTC product as a top up.”
If migraine occurs regularly, customers can ask their GP for some prophylactic treatment (e.g. topiramate or propranolol) to reduce the frequency of their migraine attacks. Some people also benefit from CoQ10, vitamin B2 or magnesium supplements. There’s some evidence to suggest that people with migraine tend to be deficient in magnesium. Dr Dick Middleton, pharmacist and chair of the British Herbal Medicine Association, says the herb feverfew can also be taken to reduce the frequency and severity of migraine in patients.
Some people with migraine find electrostimulation devices effective if they don’t want to use drug treatment. These can be worn around the head and deliver a small steady current to the trigeminal nerve branches in the brain. Although the devices are available over the counter from some pharmacies, they are expensive to purchase, so customers may wish to trial one for two months before they make a commitment.
Another option for some suitable patients is botulinum toxin A injections, which are licensed for chronic migraine, although how and why these work isn’t yet fully understood. The injections are available from some specialist headache centres.
According to Dr Dowson, hangover headaches have many of the same features as migraine, particularly as they are also triggered by dehydration and blood sugar changes.
To reduce the chance of getting a hangover headache, customers should drink plenty of fluids before, during and after their alcohol consumption. Eating before and while drinking will also help to slow down the absorption of alcohol into the bloodstream. A hangover headache usually disappears within a few hours, but can be eased with simple analgesics.
Eye strain headaches
Reading or focusing on digital devices such as smartphones, computers or games consoles for too long can strain the eye muscles, leading to headaches, dry, sore or irritated eyes and blurred or double vision. The headaches generally start around the eyes and then spread to the forehead and temples.
Having an eye test, wearing glasses or contact lenses if necessary, and adjusting the workstation may prevent symptoms from developing in the first place. It’s also important to take regular screen breaks. If a headache occurs, simple analgesics should relieve the pain.
Some people’s headaches are located over the sinuses in their forehead and across the nose and cheekbones. Sinus headaches may occur after a cold or allergy and tend to get worse when the customer bends over or makes sudden movements. Most cases of sinusitis are viral and won’t respond to antibiotics, but many GPs still prescribe these medicines when patients come to the surgery with sinus symptoms.
It’s now believed that some pain around the sinus area may be caused by migraine, rather than an infection. “Sinus trouble can lead to headaches at the front of the forehead, but some ‘sinus headaches’ are actually migraine,” says Dr Munro.
“Pharmacy customers should be discouraged from using antibiotics if there are no other signs of a bacterial infection. Obviously, it’s important to make sure the diagnosis is right by taking a history to check for nasal congestion. The headache may be managed easily with simple decongestants and anti-inflammatory analgesics.”
Headaches will often occur with viral infections, alongside nasal congestion, fever and fatigue. A headache with a very high temperature could be meningitis, especially if it also causes a stiff neck, vomiting, drowsiness, sensitivity to light and/or a rash. Customers with any combination of these symptoms (especially babies or young children) must seek medical attention immediately.
According to Claire Donovan, helpline nurse at Meningitis Now, recurring headaches are a common after-effect of viral meningitis, as well as being a symptom of meningitis. “In many cases, these headaches gradually improve over time,” she says. “For some people, postmeningitis headaches continue to be an ongoing problem. A survey conducted by Meningitis Now found that complementary therapies such as cranial osteopathy and acupuncture brought some relief to post-meningitis headaches.”
A serious issue
Headaches tend to be seen as a minor ailment, so they are often ignored or under-treated. Yet they can have an enormous impact on people’s work, family and social lives. They are one of the most common neurological problems presented to GPs and neurologists and are a substantial burden on society. The World Health Organization has classified headaches as a major health disorder and has rated migraine among the top 20 most disabling lifetime conditions. Cluster headache is much less common than migraine, but is one of the most painful conditions anyone can experience.
Migraine is more prevalent than diabetes, epilepsy and asthma combined, affecting eight million people in the UK, where there are an estimated 190,000 migraine attacks every day. Over half of people with migraine experience one or more attacks every month, and 13 per cent claim one or more attacks per week.
Cluster headaches affect around one in every 1,000 people in the UK. The pain is always on one side of the head and may be associated with other symptoms, such as watering eyes, nasal congestion, facial sweating and drooping eyelids. The pain often starts at night, waking people one to two hours after they have gone to sleep. “This is the most painful condition to affect mankind,” says Dr Ahmed.
“The pain is 1,000 times worse than migraine and patients often feel suicidal and want to bang their head on the wall. Due to it being uncommon, the diagnosis is often delayed and an average patient sees many healthcare professionals before getting the right diagnosis.”
Cluster headache attacks have several triggers. Alcohol is the most well known, and most common, often bringing on the pain within an hour of drinking. Other triggers include exercise, becoming overheated and strong-smelling substances, such as paint, petrol and perfume.
For cluster headaches, ordinary painkillers aren’t effective so customers must be referred to a GP. They may be offered various treatments, including 100 per cent oxygen with/without triptans for acute episodes. “Oxygen is the gold standard treatment prescribed by GPs, particularly with an on-demand valve so people can control their dosing themselves,” says Dr Munro. “Other medication is available on prescription, but isn’t so effective. Neuromodular devices, which stimulate the vagus nerve, are also helpful.”
Medication overuse headaches
Overusing OTC or prescribed analgesics for headaches or migraine can lead to medication overuse headaches. As the medication wears off, the withdrawal triggers the next headache, which often occurs in the morning after no analgesic has been taken overnight. “If people get regular headaches, they often just take more analgesics, rather than look for a potential cause that could be addressed,” says Dr Dowson. “This then increases the risk of further headaches.”
Medication overuse headache may be diagnosed in people whose headache developed or worsened while they were taking certain headache treatments for three months or more:
- Paracetamol, aspirin or NSAIDs, alone or in combination, on 15 days a month or more, or
- Triptans, opioids, ergots or combination analgesic medicines on 10 days a month or more.
The headaches develop when people take the painkillers for too long, not because they have exceeded the recommended dose.
“Pharmacy staff need to clarify with customers the difference between days and doses,” says Dr Munro. “It’s fine to take several regular analgesic doses over one day within the recommended limits (i.e. on day one in the month). But problems develop in people who take a small dose of headache medicine every day on too many days over the month, even if the number of analgesic doses is the same overall. People can take analgesics daily for other conditions, just not headaches, as it seems that the brain is prone to irritation to the chronic use of analgesics.”
The only way to tackle medication overuse headaches is to stop taking all analgesics straight away. The headache may get worse immediately after stopping the analgesics, and some people also feel sick or experience problems sleeping during this time, but these symptoms will disappear once the painkillers are out of their system completely. “Customers may get rebound headaches, so their GP may prescribe a preventer to dampen down the withdrawal headaches,” says Dr Munro. “Once they have been off medicines for 12 weeks, they can start taking analgesics again with care.”
It’s important to look at posture, as muscle tension in the neck can cause headaches
When to refer
Most headaches are nothing to worry about, but if they are regular, severe or persistent, customers should consult a GP. Particular warning signs to look for include:
- New regular headaches, especially in the over 50s
- Worsening headache with fever
- Recent (past three months) head trauma
- Onset of thunderclap headache (a sudden, severe headache which reaches maximum intensity within one minute)
- Aura leading to weakness or speech problems that don’t resolve
- Headaches triggered by exercise
- Headaches that change with posture.