Migraine Awareness Month: A Pharmacist’s Role in Dynamic Management

Migraine awareness is globally recognized every year during the month of June to illuminate the second most common disability in the world.^1,2 Although head pain only accounts for fewer than 5% of acute medical care, migraines impact more than 1 billion people worldwide.^1,2 Although head pain only accounts for fewer than 5% of acute medical care, migraines impact more than 1 billion people worldwide.³

Migraines can result in an invisible struggle in which 1.3 years of the patient’s life is lost to debilitating discomfort.⁴ Migraines are often multifactorial and patient-specific, which causes accessible patient care and efficacious treatment to be sparce and overlooked.

Unfortunately, patients suffering from chronic headaches have a 2.49-fold higher risk of suicidal ideation and are 3 times more likely to suffer from depression.⁵ The increased negative health outcomes associated with migraines provide an opportunity for pharmacists in both the inpatient and outpatient setting to support patients suffering from this complex disability.

Within the outpatient setting, misuse of OTC headache agents, such as Excedrin, is frequent among patients and can cause a vicious cycle of chronic headache pain because of overuse. While medication overuse headaches (MOH) are a common topic of discussion within pharmacy, a questionnaire study in 2014 displayed that continuing education centered around MOH may be needed for pharmacy staff.

Out of 228 questionnaires dispersed to 44 pharmacies’ staff members, 90.6% of the respondents rated themselves as knowledgeable in MOH due to professional education, yet only 8.6% correctly indicated which medications can cause MOH.⁶ This discrepancy between self-perceived knowledge and actual knowledge can negatively impact migraine recommendations in retail pharmacies.

Therefore, continued education surrounding MOH can create a great learning opportunity for pharmacy staff to provide appropriate OTC advice to prevent MOH in the future.

Pharmacists practicing within acute care settings can also play a major role in improving migraine management. The American Headache Society’s guidelines for the Management of Adults with Acute Migraine in the Emergency Department recommends avoiding the use of injectable morphine and hydromorphone; however, opioids continue to be used in more than 50% of migraine emergency department (ED) visits.⁷

A meta-analysis examining the relative efficacy of frequently used meperidine compared to nonopioid comparators displayed that dihydroergotamine is more effective than meperidine (odds ratio 0.3), with meperidine having the most similar efficacy to ketorolac (odds ratio 1.75).⁸ The increased opioid use in migraine management is associated with several negative outcomes, such as chronic migraines, prolonged acute care visits, and increased disabling episodes without increased efficacy in abortive treatment.⁹

Consequently, inpatient pharmacists can share these data with other providers and promote the use of nonopioid agents in the abortive treatment of migraines to prevent the harm associated with opioid use in this patient population. The direct and indirect health expenses of migraine management in the United States is estimated to cost $14 billion annually, and this estimation does not include each patient’s additional economic burden that results from their many missed workdays.^10,11

This economic loss creates an incentive for the creation of new migraine treatment options that all pharmacists should be aware of. New preventative agents like erenumab and acute agents like ubrogepant have novel mechanisms that can provide more patient-specific care when first-line treatment fails.

In an observational study of participants who had failed 2 or more preventative treatments, 69.7% of those who had received 3 doses of erenumab had a 50% decrease in monthly migraine days and 71.9% no longer suffered from MOH.¹² These recent advances in migraine pharmacology provides pharmacists with another weapon to recommend from their drug arsenal when all other migraine options are exhausted.

Altogether, the detrimental impact that migraines have on health costs and personal burden creates several opportunities for pharmacists to adopt an expanding role in its management within both inpatient and outpatient settings. As the most accessible health care provider, pharmacists should strive to remain competent in MOH treatment through migraine-focused continued education to properly recommend patients on appropriate OTC agents.

To follow the ethical duty of “Do No Harm,” pharmacists should promote evidence-based nonopioid treatment for abortive therapy within the ED. Pharmacists should be proactive and remain up to date on recent literature and novel agents to better aid physicians with complex patient cases.

All these roles are critical factors in helping to advocate for the appropriate management of debilitating headaches while assisting patients in decreasing the disabling impact of migraine attacks and recurrent treatment failure.

References

1. Moseley S. Migraine Awareness Month 2022 [Internet]. Migraine Australia. 2022 [cited 2022May17]. Available from: https://www.migraine.org.au/mam2022
2. National Migraine & Headache Awareness month - 2021 [Internet]. National Headache Foundation. 2021 [cited 2022Apr21]. Available from: https://headaches.org/national-migraine-headache-awareness-month-2021/#:~:text=June%20is%20National%20Migraine%20%26%20Headache,2%20cause%20of%20disability%20worldwide
3. Doretti, A., Shestaritc, I., Ungaro, D. et al. Headaches in the emergency department –a survey of patients’ characteristics, facts and needs. J Headache Pain 20, 100 (2019). https://doi.org/10.1186/s10194-019-1053-5
4. Silberstein S. A Perspective on the Migraine Mind [Internet]. American Scientist. 2014 [cited 2022Apr21]. Available from: https://www.americanscientist.org/
5. Friedman LE, Gelaye B, Bain PA, Williams MA. A Systematic Review and Meta-Analysis of Migraine and Suicidal Ideation. Clin J Pain. 2017 Jul;33(7):659-665. doi: 10.1097/AJP.0000000000000440. PMID: 27648590; PMCID: PMC5357206.
6. Hedenrud T, Babic N, Jonsson P. Medication overuse headache: Self-perceived and actual knowledge among pharmacy staff. Headache: The Journal of Head and Face Pain. 2014Apr25;54(6):1019–25.
7. Minen M, Tanev K, Friedman B. Evaluation and Treatment of Migraine in the Emergency Department: A Review [Internet]. Headache: The Journal of Head and Face Pain. 2014 [cited 2022Apr21]. Available from: https://headachejournal.onlinelibrary.wiley.com/doi/full/10.1111/head.12399
8. Friedman BW, Kapoor A, Friedman MS, Hochberg ML, Rowe BH. The relative efficacy of meperidine for the treatment of acute migraine: a meta-analysis of randomized controlled trials. Ann Emerg Med. 2008 Dec;52(6):705-13. doi: 10.1016/j.annemergmed.2008.05.036. Epub 2008 Jul 16. PMID: 18632186; PMCID: PMC2587513.
9. Dodson H, Bhula J, Eriksson S, Nguyen K. Migraine Treatment in the Emergency Department: Alternatives to Opioids and their Effectiveness in Relieving Migraines and Reducing Treatment Times. Cureus. 2018 Apr 6;10(4):e2439. doi: 10.7759/cureus.2439. PMID: 29881652; PMCID: PMC5990028.
10. Fischer MA, Jan A. Medication-overuse Headache. [Updated 2021 Jul 19]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK538150/
11. Bonafede M, Cai Q, Cappell K, Kim G, Sapra SJ, Shah N, Widnell K, Winner P, Desai P. Factors Associated with Direct Health Care Costs Among Patients with Migraine. J Manag Care Spec Pharm. 2017 Nov;23(11):1169-1176. doi: 10.18553/jmcp.2017.23.11.1169. PMID: 29083975.
12. Ornello, R., Casalena, A., Frattale, I. et al. Real-life data on the efficacy and safety of erenumab in the Abruzzo region, central Italy. J Headache Pain 21, 32 (2020). https://doi.org/10.1186/s10194-020-01102-9