Headache Relief

Ms. Terrie is a clinical pharmacy writerbased in Haymarket, Virginia.

Headaches can range from mild tosevere and are considered to be one ofthe most common health complaintsin the United States. An estimated 45million individuals experience chronicheadaches each year that cost billionsof dollars in lost productivity.¹ Althoughthe majority of headaches are mild andlast only a few hours, some individualsmay experience headaches that persistfor weeks.

Types of Headaches

In general, headaches are categorizedas primary or secondary. Primary headachesaccount for approximately 90%of headaches and are not related to anunderlying illness.² Examples of primaryheadaches include tension headache,cluster headache, migraine, and medicationoveruse headaches (also known asrebound headaches).^1-4

A headache is classified as a secondaryheadache when it is the resultof another underlying medical condition.Examples include sinusitis, severehypertension, head trauma, hematomas,temporomandibular joint dysfunction,metabolic disorders, cerebral hemorrhage,and meningitis.^5-7

Patients experiencing secondaryheadaches,as well as those with chronicheadaches and/or severe headaches,should always be referred forfurther medical evaluation and treatment.Examples of when to seek furthermedical evaluation include individualswith severe head pain or head trauma,headaches that persist >10 days with orwithout treatment, and individuals withhigh fever or signs of infection.²

Characteristics of PrimaryHeadaches

Tension Headaches

Tension headaches, also known as musclecontraction headaches, affect an estimated75% of US adults and are consideredto be more prevalent in women.^2,5They are characterized by mild pain thatgradually initiates in the area in the backof the head and upper neck. The painis usually bilateral and often describedas tight, pressing, and constricting.^1,2,8Tension headaches may last from minutesto days.^1-3 Stress, anxiety, fatigue,eye strain, and muscular tension arecommon causes of these headaches.²

Migraine Headaches

Migraine headaches, which affect an estimated20% to 25% of individuals includingchildren, are considered to be the secondmost common type of primary headache.²Migraine sufferers usually have their firstattack before age 30, but migraines alsocan occur in children as young as age 3.¹As with tension headaches, women experiencea greater incidence of migraineswhen compared with men, affectingan estimated 18% of women and 6% ofmen.^2,5,9 Many women have premenstrualmigraine attacks; however, theycan occur at any time during the menstrualcycle.² The incidence of migraineheadaches is equal among boys and girlsbefore puberty, and incidence typicallydisappears in boys after puberty.^2,5

The pain associated with migraineheadaches often is unilateral and can bedescribed as intense and throbbing.^1,2,8The pain may be preceded by an aura,and onset may be sudden. Some individualsmay experience sensitivity to light,noise, or odors, as well as nausea andvomiting.^1,2,8 Migraine headaches maylast from hours to days.^1,2,8 Factors thatmay precipitate a migraine headacheinclude stress, anxiety, changes in weather,altitude, and/or air pressure, hormonalchanges, use of certain pharmacologicagents (eg, nitrates, oral contraceptives,nifedipine, estrogen replacement therapy),changes in sleep or eating patterns,environmental factors, food insensitivities,and alcohol consumption.^2,8

Cluster Headaches

Cluster headaches are the least occurringof the primary headaches affecting 1% ofthe population.^5,8 Cluster headaches aremore prevalent among men, accountingfor 85% to 90% of individuals experiencingcluster headaches.^3,5 Cluster headachesare often accompanied by painthat is throbbing and constant and typicallyis unilateral, occurring around orbehind one eye. The affected eye maybecome red, inflamed, and watery.^1,2,8These headaches may last 30 to 90minutes. Cluster headaches can occurdaily in clusters of weeks or months.Individuals suspected of having clusterheadaches should be encouraged to seetheir primary health care provider.^3,5

Table

Counseling Tips for UsingOTC Analgesics

• Patients should be advised not to use OTC analgesics for >10 days unless directed by a physician and to not exceed the recommended dosages.
• The use of OTC analgesics for treatment of headache should be restricted to 3 days per week to avoid the potential for medication overuse headaches.
• Naproxen should not be used in children <12 years of age.
• Patients who have allergies to ASA, asthma, or nasal polyps should not take ASAs or NSAIDs.
• Patients who are pregnant, breast-feeding, or have a preexisting medical condition should be encouraged to consult their primary health care provider prior to using any of these products.
• Patients currently taking medications for diabetes, gout, or arthritis should not use an ASA, unless directed by their primary health care provider.
• Individuals with a history of hepatic disease should avoid the use of APAPs.
• Do not administer ASAs or other salicylates to children <15 years of age who are recovering from chickenpox or symptoms of influenza.
• Patients on anticoagulation therapy should be advised to consult their primary health care provider.

APAP = N-acetyl-para-aminophenol (acetaminophen);ASA = acetylated salicylate; NSAID = nonsteroidalanti-inflammatory drug.

Adapted from reference 2.

OTC Therapies

The types of headaches that are mostoften amenable to self-treatment withthe use of OTC analgesics include tensionheadaches, diagnosed migraines(vascular), and sinus headaches.²Pharmacists are an important sourceof information for patients on the useand selection of these products (Table).These products include acetaminophen,acetylated salicylate, nonacetylated salicylates(choline salicylate, magnesiumsalicylate, and sodium salicylate), andnonsteroidal anti-inflammatory agents.

The Role of the Pharmacist

Prior to recommending any of theseagents, pharmacists should screen forpossible allergies and drug interactions,as well as possible contraindications(eg, individuals with renal and hepaticinsufficiencies, history of gastric ulcers,or those currently taking anticoagulants)and refer patients to seek further medicalevaluation when warranted. Patientswith a history of headaches should beencouraged to seek medical care toidentify potential precipitating factors.Patients also should be reminded aboutrebound headaches that may occur as aresult of excessive medication use andto not exceed recommended dosages.

Pharmacists also can recommendvarious nonpharmacologic measuresthat may alleviate or decrease the occurrenceof headaches, such as relaxationtechniques, avoiding stress, getting anadequate amount of sleep, and eating abalanced diet. It is important to remindpatients to contact their primary healthcare provider if headaches increase inintensity and/or frequency.

Table

Examples of OTC Analgesics for Headaches

Active Ingredient

Brand Name

Acetaminophen

Tylenol (Regular and Extra Strength)

Tylenol 8 Hour

Anacin

Aspirin

Bayer Rapid Headache Relief

Bufferin (Regular and Extra Strength)

Ecotrin

Ibuprofen

Advil

Advil Migraine

Motrin

Naproxen sodium

Aleve

Adapted from reference 2.

Table

Examples of Combination OTC HeadacheProducts

Active Ingredient

Brand Name

Acetaminophen,phenylephrine

Excedrin Sinus Headache

Sudafed PE Maximum Strength

Sinus Headache

Naproxen sodium andpseudoephedrine

Aleve Sinus and Headache

Acetaminophen, aspirin,caffeine

Anacin Advanced HeadacheFormula

Excedrin Migraine

Excedrin Extra Strength

Goody's Extra StrengthHeadache Powder

Vanquish Extra Strength

Aluminum hydroxide,aspirin calcium carbonate,magnesium hydroxide

Ascriptin Maximum Strength

Acetaminophen and caffeine

Excedrin Tension Headache

Table

Examples of Topical OTC HeadacheProducts

• WellPatch Migraine Cooling Headache Pads
• HeadOn Topical Treatments for Headache (available formulations include Tension, Extra Strength, Migraine, Sinus)
• Sinol Headache Relief Spray, Migraine Cluster Tension

For more information on headaches, please visitthe following Web sites:

• National Institute of Neurological Disorders and Stroke Web site atwww.ninds.nih.gov/disorders/headache/detail_headache.htm
• National Headache Foundation Web site at www.headaches.org
• American Headache Society Web site at www.achenet.org
• American Pain Society Web site at www.ampainsoc.org

References

• Headaches. American College of Physicians Web site. www.acponline.org/patients_families/diseases_conditions/headaches. Accessed December 30, 2008.
• Remington, T. Headache. In: Berardi R, Newton G, McDermott JH, et al, eds. Handbook of Nonprescription Drugs. 15th ed. Washington, DC: American Pharmacists Association; 2006:69-89.
• Headache Types. Excedrin Web site. www.excedrin.com/headache-types.shtml. Accessed December 30, 2008.
• Tension Type Headaches. Bayer HealthCare Web site. www.aspirin.com/aoi/hfh/tension_type_en.html. Accessed December 30, 2008.
• Headache. MedicineNet Web site. www.medicinenet.com/script/main/art.asp?articlekey=20628&pf=3&page=1. Accessed December 29, 2008.
• Secondary Headaches. American Headache Society Web site. www.achenet.org/education/patients/SecondaryHeadaches.asp. Accessed December 29, 2008.
• Headaches. Merck Manual Web site. www.merck.com/mmpe/sec16/ch216/ch216a.html#CACCDJAH. Accessed December 29, 2008.
• Causes of Headaches. Excedrin Web site. www.excedrin.com/headache-causes.shtml. Accessed December 30, 2008.
• Headache Information. National Institute of Neurological Disorders and Stroke Web site. www.ninds.nih.gov/disorders/headache/headache.htm. Accessed December 30, 2008.