Kathy Oxtoby looks at different types of headache, ways to manage them and the red flags that signal the need for a referral…

Headaches are a common reason why people visit their community pharmacy for advice and treatments. According to NHS England, around 10 million people aged 15-69 in the UK suffer from migraine headache.¹

Headaches may be an everyday health problem, but they can also be debilitating, and occasionally even a sign of an underlying serious condition, such as a brain tumour or an aneurysm. Despite their prevalence, there is evidence that headache disorders are under-diagnosed and under-treated.²

When supporting patients, pharmacies should not be giving only advice about headaches and medication, but also be looking to identify any serious issues and make referrals, says Lila Thakerar, the superintendent pharmacist at Shaftesbury Pharmacy in Harrow.

The British Association for the Study of Headache (BASH) guidelines provide support on the diagnosis and management of headaches.² Produced by headache specialists, the BASH guidelines suggest strategies to manage common headache disorders that have been found to work well. “The BASH headache management system is ideal for professionals like pharmacists who have face-to-face consultations with patients with various types of headaches,” says Ms Thakerar.

The guidelines help to differentiate between the diverse types of headaches, as well as advising on treatments, medication over-use headaches, and any ‘red flags’.

There are many different types and causes of headache, which means taking a history is all-important, BASH guidelines advise.² “A headache history requires time to elicit, and not finding the time to take it fully is the probable cause of most misdiagnosis,” the guidelines say.

The guidelines go on to recommend patients keep a diary to chart their headaches over a few weeks, saying: “The pattern of attacks is a very helpful pointer to the right diagnosis.”²

Headache types

The many different types of headaches are broadly divided into two groups - primary and secondary. Primary headaches, such as migraine, tension headache and cluster headache, represent nearly 98 per cent of all headaches. However, secondary headaches are important to recognise as they are serious and may be life threatening.³

The causes of the most common secondary headaches include intracranial tumours, meningitis or encephalitis, subarachnoid haemorrhage, and cerebral venous thrombosis.³

Sid Dajani, a contractor at Wainrights Chemist in Bishopstoke, Hampshire, says: “Primary headaches are far more common but secondary headaches are more worrying and can lead to complications.”

He stresses that the “severity of pain” is not an indicator of whether it is a primary or secondary headache. And he adds: “ It is important to be aware of the significance of a sudden new headache – even if a patient already has a primary headache disorder – as this could indicate a stroke or bleed on the brain.”

Mr Dajani says he tends to refer patients “straight away” if it’s a headache they have not had before, if they are aged over fifty, or symptoms appear in young children.

He also advises that “while taking a careful history, keep red flags in mind”, including checking blood pressure, if there’s a fever, and neck stiffness. “And know when to refer patients immediately, as it could be a life-or-death situation.”

When to refer…

Red flags highlighted by BASH include:

• ‘thunderclap headache’ (intense, exploding and hyperacute onset)
• new-onset headache in patients over 50 or under 10 or with a history of cancer
• persistent morning headache with nausea, headaches that occur for the first time on using the oral contraceptive pill
• progressive headaches worsening over weeks.

One of the most common types of headache is migraine, described by the Migraine Trust as a “severe and painful long-term health condition”.⁶ Common symptoms of migraine attack can include head pain; problems with sight such as seeing flashing lights; sensitivity to light, sounds and smells; fatigue; and being sick. Migraine attacks usually last for between four hours and three days.⁶

Migraine treatment usually includes acute treatment such as painkillers and anti-sickness medication to stop or shorten an attack. Patients who are having more than four attacks a month can be advised to ask their GP about preventive treatment.⁶

Most people get tension-type headache. It usually has little long-term impact and they rarely need medical help. Its most common cause is stress. Tension-type headache is usually described as a pain that feels like a tight band round the head or a weight on top of it.

The pain can last from 30 minutes to several days. Over-the-counter painkillers such as ibuprofen, aspirin, and paracetamol are commonly used to treat tension-type headache, and it shouldn’t be necessary to take stronger medications.⁷

Cluster headache is a rare type of headache - approximately 1 in 1,000 people suffer with it.⁷ Its main symptom is an excruciating headache on one side of the head, often around the eye - the pain is described as burning or piercing. These headaches most often occur in cycles or clusters. Attacks usually last between 15 minutes and three hours.

Some people may have multiple attacks in a day. The main acute treatment for cluster headache is sumatriptan, while verapamil is the preventive treatment of choice for this type of headache.⁷

Medication overuse headache (MOH) results from the frequent use of medicines such as triptans, ergotamines, opiates, non-steroidal anti-inflammatory drugs (NSAIDs) and paracetamol.⁸

MOH develops in people with a primary headache disorder, such as migraine, or a family history of migraine, and who usually suffer with headache on 15 or more days per month. In such situations the medicine itself causes more headaches, which are sometimes referred to as rebound headaches.⁸

Ms Thakerar says “alarm bells ring” when a patient has been buying a headache medication frequently or has been taking a medication for a while, but their headache is worse. To manage MOH she advises gradually weaning the patient off the overused painkiller.

Signposting support

The Migraine Trust: Provides information and support to help people live with migraine. https://migrainetrust.org/

The Brain Charity: Provides practical help on living with cluster headaches. https://www.thebraincharity.org.uk/condition/cluster-headaches/

References

1 NHS England (2020) Improved NHS migraine care to save thousands of hospital stays. https://www.england.nhs.uk/2020/01/improved-nhs-migraine-care/#:~:text=Around%2010%20million%20people%20aged,neurological%20reasons%20for%20attending%20A%26E

2 British Association for the Study of Headache (BASH) (2010) Guidelines for All Healthcare Professionals in the Diagnosis and Management of Migraine Tension-Type Headache Cluster Headache Medication-Overuse Headache https://www.bash.org.uk/wp-content/uploads/2012/07/10102-BASH-Guidelines-update-2_v5-1-indd.pdf

3 Fayyaz A. (2012) Headache disorders: differentiating and managing the common subtypes. British Journal of Pain. 2012 Aug; 6(3): 124–132. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4590146/

4 Walling A. (2020) Frequent Headaches: Evaluation and Management. American Family Physician 2020; 101:419-428.  https://www.aafp.org/pubs/afp/issues/2020/0401/p419.html

5 Edvinsson L. , Haanes  K.A. (2021) Identifying New Antimigraine Targets: Lessons from Molecular Biology. Trends in Pharmacological Sciences. Volume 42, Issue 4, April 2021, 217-225.

6 The Migraine Trust (2021)  What is Migraine? https://migrainetrust.org/understand-migraine/what-is-migraine/

7 The Migraine Trust (2021) Other Headache Disorders.  https://migrainetrust.org/understand-migraine/types-of-migraine/other-headache-disorders/

8 The Migraine Trust (2021) Medication Overuse Headache.  https://migrainetrust.org/understand-migraine/types-of-migraine/medication-overuse-headache/