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Headache and, in particular, migraine can be disabling for some people, preventing them from getting on with their normal lives. Independent pharmacists can offer sufferers valuable advice on prevention and management, says Steve Titmarsh…

Headaches are estimated to affect two thirds of men and over 80% of women in the UK. Migraine is the most prevalent, disabling, long term neurological condition.¹ It affects about 10 million people in the UK. Headache is one of the most common neurological symptoms prompting a visit to accident and emergency departments.²

Community pharmacists on hand to help

Deborah Evans, FFRPS FRPharmS FRSPH, Managing Director, Remedi Health, says: ‘Pharmacists are a great first point of call – we can help patients choose the right treatment, spot any warning signs and avoid overusing painkillers.’

Pharmacists can advise on identifying and avoiding common headache and migraine triggers, such as dehydration, stress, poor sleep, certain foods and alcohol, says Deborah. We can listen to symptoms, timing, intensity, etc, and advise on potential lifestyle solutions such as maintaining a regular routine, having good quality sleep, avoiding alcohol, staying hydrated and managing stress.

Pharmacists can suggest appropriate over-the-counter treatments, advise on when to seek medical help (assessing red flags), and educate on the safe use of medicines to avoid medication-overuse headaches, Deborah adds. They can also help patients track headache patterns and refer to a GP if necessary for preventative treatments.

Paracetamol or ibuprofen – which is best for headaches?

Deborah Evans comments that paracetamol and ibuprofen can be effective for tension-type headaches.³

Ibuprofen may be more effective because it reduces inflammation as well as pain.

Paracetamol is a good option if someone cannot take anti-inflammatories (for example, due to stomach issues or asthma). The choice depends on an individual’s health, risk factors, and personal response to each medicine. ‘If headaches are frequent, severe, or changing in pattern, it’s important to get medical advice – it could be a sign that something else needs to be checked,’ Deborah adds.

Atogepant

Atogepant, one of a newer class of preventive medicines for migraine, is recommended by the National Institute for Health and Care Excellence (NICE) ‘as an option for preventing migraine in adults who have at least 4 migraine days per month, only if at least 3 preventive medicines have failed’.

If migraine frequency has not fallen by at least half in patients with episodic migraine (defined as fewer than 15 headache days per month) or by at least 30% in patients with chronic migraine (defined as 15 or more headache days per month, with at least 8 of those having features of migraine) the drug should be stopped. People who started treatment with the drug before the guidance was published in May 2024 can continue treatment until they and their healthcare professional consider it appropriate to stop.⁴

Individual management

Tailoring treatment to each individual patient is a key part of improving outcomes. When recommending a strategy to manage headache and migraine pharmacists should take account of each patient’s circumstances (including medical history, comorbid conditions and risk factors), preferences, values and the impact their symptoms have on their everyday lives as well as what they hope to gain from any intervention. It is important to give patients as much information as they need, in a format that is most suited to them to help them make informed decisions about their management. That should be done in partnership, with health professionals guiding and advising them on managing their symptoms.⁵

Lifestyle advice to help avoid medicines

Patients can be encouraged to keep a headache diary to help them understand factors that may trigger attacks such as dehydration, stress, certain foods, irregular sleep or hormonal changes.²

Regular mild aerobic exercise such as jogging, swimming, dancing, cycling or brisk walking can be beneficial for people with migraine.⁶

Recently approved migraine medicines

Atogepant is one of new class of migraine drugs called calcitonin gene-related peptides (CGRP). Others include rimegepant, epitinezumab, fremanezumab and galcanezumab.⁷

An analysis of 12 randomised controlled trials involving 7,909 people taking preventive drugs for chronic migraine such as eptinezumab, erenumab, fremanezumab, galcanezumab, botulinum toxin A and topiramate looked at effectiveness.⁸

In eight trials all the drugs were found to reduce the number of days with headache, with eptinezumab 300mg being the most effective – participants had 2.5 fewer days with headache compared with placebo.

Topiramate reduced the number of days with headache by 1.1 per month compared with placebo. Eleven trials found that the drugs also reduced the number of days with migraine, ranging from a reduction of 2.8 fewer days per month with fremenezumab compared with placebo to 1.5 fewer days with migraine per month with topiramate compared with placebo.

All the drugs, with the exception of topiramate, improved headache-related quality of life – a measure of a person’s pain or discomfort and the extent to which headaches impaired their ability to carry on with their daily activities.

The researchers commented that the differences between the drugs appeared to be modest with the caveat that because most of the trials compared drugs with placebo, they did not provide strong evidence for comparisons between different drugs.⁹ 

A combination of meloxicam and rizatriptan has been approved in the United States but is not yet approved in the UK.¹⁰

Is progress being made?

The development of biologic drugs such as monoclonal antibodies like the CGRPs marks a significant development in therapeutic approaches to migraine treatment, which are a result of a greater understanding of the causes of migraine.¹¹ Another neuropeptide implicated in migraine is pituitary adenylate cyclase activating polypeptide (PACAP), which, like CGRP, is involved in regulating vasodilation. Blocking PACAP is thought to be another potential therapeutic target for people with migraine. Trials are ongoing to test the idea.

Different formulations of drugs, for example for intranasal use, may provide benefits for some patients such as rapid relief and helping people with nausea and vomiting for whom oral formulations may not be suitable.¹²

Non-drug approaches are being developed as well. Examples include neuromodulation such as transcranial magnetic stimulation (TMS) and external vagus nerve stimulation (eVNS).¹²

So-called digital health solutions, such as mobile apps and wearable devices that can help track migraine triggers, provide an adjunct to management strategies by offering real-time headache management support and monitoring drug efficacy, are also gaining in popularity.¹²

References

1. Headache Research. Driving Pioneer Research for Patients Affected by Headache Disorders. From Bench to Bedside (www.headache-research.com; accessed May 2025).

2. NHS England. RightCare: Headache & Migraine Toolkit optimising a headache and migraine system (www.england.nhs.uk/rightcare/wp-content/uploads/sites/40/2020/01/rightcare-headache-and-migraine-toolkit-v1.pdf; accessed May 2025).

3. National Institute for Health and Care Excellence (NICE). Headaches in over 12s: diagnosis and management. Clinical guideline CG150 (www.nice.org.uk/guidance/cg150/ifp/chapter/Treatments-for-tensiontype-headache; accessed May 2025).

4. National Institute for Health and Care Excellence (NICE). Atogepant for preventing migraine. Technology appraisal guidance (TA973) (www.nice.org.uk/guidance/ta973/resources/atogepant-for-preventing-migraine-pdf-82615848254917; accessed May 2025).

5. National Institute for Health and Care Excellence (NICE). Community pharmacies: promoting health and wellbeing (www.nice.org.uk/guidance/ng102; accessed May 2025).

6. The Migraine Trust. Managing your migraine (https://migrainetrust.org/live-with-migraine/self-management/exercise; accessed May 2025).

7. British National Formulary. Atogepant: other drugs in class (https://bnf.nice.org.uk/drugs/atogepant; accessed May 2025).

8. Olesen J. International Classification of Headache Disorders. Lancet Neurol 2018;17(5):396–7.

9. National Institute for Health and Care Research. Chronic migraine: which drugs are best? (https://evidence.nihr.ac.uk/alert/chronic-migraine-which-drugs-are-best; accessed May 2025).

10. Ciccone I. FDA Approves Axsome Therapeutics’ AXS-07 for Migraine Treatment. Neurology Live (www.neurologylive.com/view/fda-approves-axsome-therapeutics-axs-07-for-migraine-treatment; accessed May 2025).

11. Pharmiweb. Migraine Drugs Market Overview: A Comprehensive Guide 2025-2035 (www.pharmiweb.com/press-release/2025-02-21/migraine-drugs-market-overview-a-comprehensive-guide-2025-2035; accessed May 2025).

12. British National Formulary. Migraine (https://bnf.nice.org.uk/treatment-summaries/migraine/#acute-migraine-treatment; accessed May 2025).