Mitigating the Pain of Migraines

Migraine headaches are among the most common neurologic ailments affecting Americans today. It is estimated that 6% of men and 18% of women in the United States experience migraine headaches, representing about 28 million Americans; however, many go undiagnosed and/or undertreated.^1,2

There are 2 classifications for migraines: aura (classic migraine) and without aura. Classic migraines are relatively uncommon compared with migraine without aura, but they do affect up to 31% of migraine sufferers at some point.³ Aura usually precedes the headache but it may occur with the headache as well. Manifestations of aura include neurologic symptoms such as visual and auditory hallucinations, difficulty speaking, one-sided muscle weakness, and visual impairment.³

For the headache phase, patients usually present with unilateral throbbing pain that has a sudden onset lasting from a few hours to 2 days. They may also experience nausea, vomiting, photophobia, tinnitus, vertigo, irritability, sinus symptoms, and light-headedness with routine physical activity.⁴ Many of these symptoms can be incapacitating, leading to migraines being a frequent and significant cause of decreased work productivity and absenteeism in the workplace.⁴ Migraines also have the capacity to affect familial and platonic relationships.⁴

Patients frequently turn to OTC medications to counteract these symptoms, and pharmacists are in a key position to assist these patients and to help improve their quality of life.

Treatment

The ideal intervention for migraine headaches is to identify and avoid migraine triggers, which may include certain drug products such as caffeine, alcohol, analgesics, and hormonal agents, as well as certain foods, behavioral triggers, and environmental cues.³ Most migraine sufferers will utilize nonpharmacologic and pharmacologic OTC therapy to seek relief.

Nonpharmacologic

A variety of nonpharmacologic therapies are available to patients who suffer from migraines. These options are usually considered before or in combination with drug therapy. One of the most important things that a patient should know to do is to identify and avoid headache triggers, which can drastically reduce the frequency of the migraine headaches. Once triggers are identified, it is recommended that patients keep a headache diary to keep track of their personal triggers to prevent the headaches from reoccurring.³

Other nonpharmacologic options include using cold packs on the affected area, relaxation techniques, massage, yoga, biofeedback, hypnosis, cognitive behavioral therapy, and acupuncture.^1,5 Nonpharmacologic therapy may be considered an option in patients who prefer no drug therapy; have poor response, tolerance, or contraindications to drug therapy; have significant stress or deficient coping strategies; or have a history of long-term analgesic use.¹

Pharmacologic

Nonsteroidal anti-inflammatory drugs (NSAIDs) are first-line agents in treating mild to moderate migraines for their effectiveness and favorable safety profiles.^1,3 Acetaminophen alone may not be used for the treatment of mild to moderate migraines but is recommended in combination therapy with caffeine and aspirin as another first-line option.¹ Overuse of these medications can lead to rebound headaches, so it is currently recommended to use analgesic therapy for up to 2 days per week to decrease the risk of developing these headaches.¹

NSAIDs

Aspirin, ibuprofen, and naproxen sodium are utilized to relieve migraine pain through their anti-inflammatory and analgesic effects. For migraines, the dose for aspirin is 500 to 1000 mg every 4 to 6 hours. Ibuprofen is dosed 200 to 800 mg every 6 hours and naproxen sodium is dosed 550 to 825 mg at the onset of the headache with the option to repeat 220 mg in 3 to 4 hours. Maximum daily doses of the NSAIDs are 4000 mg for aspirin, 2400 mg for ibuprofen, and 1375 mg for naproxen sodium to decrease the risk of gastrointestinal bleeding.³

Side effects of this class include gastrointestinal disturbances such as nausea, vomiting, diarrhea and dyspepsia, and central nervous system side effects such as somnolence and dizziness.³ To limit these side effects, patients should be counseled to take these medications with food. Patients should not be using multiple NSAIDs at the same time because it can lead to worsening adverse effects, especially gastrointestinal bleeding.

Acetaminophen and Combination Formulations

Acetaminophen is utilized for its analgesic effects in the treatment of migraine headaches. It is generally not recommended to use acetaminophen as monotherapy; however, it is frequently used in combination with aspirin and caffeine as an alternate first-line option for patients.¹ While on this combination, patients should be counseled to avoid taking any NSAIDs, other acetaminophen-containing products, or other caffeine-containing products, as this can increase the risk of developing adverse effects as well as rebound headaches from overuse.

For migraine formulations containing acetaminophen 250 mg, aspirin 250 mg, and caffeine 25 mg, patients should be directed to take 2 tablets at the onset of the migraine and every 6 hours as needed.³ Side effects are generally mild and include nausea, nervousness, dizziness, dyspepsia, and upset stomach. ⁶ Patients should not exceed 8 tablets in 1 day to avoid hepatotoxicty and to decrease bleeding risk.

Acetaminophen may be considered as monotherapy in the case of a pregnant patient suffering from migraine headaches.¹ The dose of acetaminophen is 1000 mg at the onset of the migraine and can be repeated every 4 to 6 hours as needed. The maximum daily dose for acetaminophen is 4 g to avoid hepatotoxicity.¹

Conclusion

Pharmacists are in a unique position to assist patients in managing their migraine headaches because of how accessible pharmacists are to patients, how common the ailment is, and the many OTC and nonpharmacologic measures patients can take to treat it. Prior to any recommendation, a thorough check of the patient’s medication history, health conditions, allergies, and their current medications is warranted to weed out any potential contraindications, drug interactions, or cautions to therapy.

Many NSAIDs have age limitations, such as the use of naproxen only for patients 12 years or older and aspirin use for patients older than 17 years. It is also important to counsel patients on the adverse effects of the analgesics and the frequency with which they should be used to avoid any undue effects. Working with migraine sufferers to identify and manage or avoid their specific triggers, as well as guiding them toward the appropriate therapy, can help improve upon their health and well-being.

Ms. White is a PharmD candidate at the Ernest Mario School of Pharmacy at Rutgers University, and Dr. Prescott is vice president of Clinical and Scientific Affairs for Pharmacy Times.

References

1. Silberstein SD. Practice parameter: Evidence-based guidelines for migraine headache (an evidence-based review): Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2000;55;754

2. Wenzel RG, Sarvis CA, Krause ML. Over-the-Counter Drugs for Acute Migraine Attacks: Literature Review and Recommendations. Pharmacotherapy. 2003;23(4):495-505.

3. Minor DS. Headache Disorders. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, eds. Pharmacotherapy: A Pathophysiologic Approach. 8th ed. New York: McGraw-Hill; 2011. http://www.accesspharmacy.com/content.aspx?aID=7986542. Accessed May 21, 2012.

4. Wilkinson JJ. Headache. In: Berardi R, Newton G, McDermott JH, et al, eds. Handbook of Nonprescription Drugs. 17th ed. Washington, DC: American Pharmacists Association; 2012. http://www.pharmacylibrary.com.proxy.libraries.rutgers.edu/content/609218. Accessed May 22, 2012.

5. Nicholson RA, Buse DC, Andrasik F, et al. Nonpharmacologic Treatments for Migraine and Tension-Type Headaches: How to Choose and When to Use. Current Treatment Options in Neurology. 2011;13:28-40.

6. Lipton RB, Stewart WF, Ryan RE, et al. Efficacy and Safety of Acetaminophen, Aspirin, and Caffeine in Alleviating Migraine Headache Pain. Three Double-blind, Randomized, Placebo-Controlled Trials. Arch Neurol. 1998;55(2):210-17.