When is a headache more than just a headache? Find out how to tell the difference between different types of headache, what to advise and when to refer

While headaches are usually minor and will go away on their own, they can sometimes be a sign of something more serious. And although this might not be common, it’s important for pharmacy staff to be able to identify the different types of headache and be able to refer appropriately. So what are the differences and how should customers be advised to tackle them?

Tension and cluster headaches

People often think the cause of their headache is stress, lack of sleep, dehydration or wearing the wrong spectacles, but Kate MacNamara – who wrote the headache pathway for the Abertawe Bro Morgannwg University (ABMU) Health Board, and is practice pharmacist at Fforestfach Medical Centre – says: “There is no one clear attributable cause for each type of headache, with the exception of medication overuse headache, and all headache diagnoses need to be made on the basis of a sound history.”

The most common type of headache that pharmacy staff will see in their customers is tension headache, according to Farah Ali, general manager at Perrigo’s centre of excellence, Warman-Freed Pharmacy in Golders Green, London. “These feel like a constant ache on both sides of the head and can be associated with tightening of neck muscles or pressure behind the eye”, she says.

A cluster headache causes severe pain on one side of the head, usually around the eye or temple, and often start without warning. They normally happen in clusters over six to 12 weeks and their rapid onset mean that OTC painkillers are generally ineffective. Kate says: “There are no OTC treatments available for cluster headache and these patients should be referred back to the GP if their current treatment is not helpful.”

Migraine

Migraine symptoms are different for everyone, and some may be mistaken for other conditions. For example, younger children can experience abdominal migraine, which consists of abdominal pain with no headache at all, and some people get a more severe form of migraine known as hemiplegic migraine, where they experience stroke-like symptoms.

Such a complicated condition has long been misunderstood, according to Una Farrell from the Migraine Trust. She says: “It used to be believed that migraine was vascular, but it’s now known to be a neurological condition, although we still don’t know exactly why people get it.”

Una explains that “if the pain is in the side of the head and lasting for several days then it’s a migraine, not headache. Some 10 per cent of people experience visual disturbance known as ‘aura’, and there are those who report nausea and vertigo.”

Other common migraine symptoms include:

• Vomiting
• Increased sensitivity to light and sound – which is why many people with a migraine want to rest in a quiet, dark room
• Poor concentration
• Feeling very hot or very cold
• Abdominal pain
• Diarrhoea.

Managing headache and migraine

“Many patients will report individual trigger factors for migraine and tension-type headache, which are two of the hardest headache types to distinguish from one another, and it is obviously important to avoid these as much as possible,” explains Kate. “The use of headache diaries is an essential tool to help patients identify what may be bringing on or increasing the frequency of their headaches and it’s really important to encourage both new and existing headache sufferers to use these.”

When it comes to recommending OTC treatment, Kate says: “There is some evidence to suggest that paracetamol monotherapy may be less effective in both migraine and tensiontype headache, but as NSAIDs or high dose aspirin are the other recommended single agent options, individual comorbidities and drug history need to be carefully considered. For migraine, triptans may be used alone or in combination with an NSAID or paracetamol, and sumatriptan is available OTC for existing sufferers meeting specifi c criteria,” says Kate.

Due to the risk of medication overuse headache, Kate warns that caution should always be exercised when recommending analgesia: “Opioids should never be recommended for headache, even if [the patient is] not responding to fi rst line treatment,” she says.

Farah adds that “tips and hints on lifestyle, environmental and dietary changes, such as drinking enough water, which can help ease the pain”, can also be useful.

Medication overuse headaches

Medication overuse headache (MOH) is the one headache type that does have a clear, attributable cause, and diagnosis can be confi rmed when symptoms resolve on discontinuation of medication.

The International Headache Society defi nes medication overuse as taking pain relief for a headache more than twice a week (eight days a month) for more than three months. Medication overusers are at high risk of developing medication overuse syndrome – a condition where their headaches are actually caused or made worse by the medication rather than the condition for which they were originally taken.

Compound analgesics such as cocodamol are most commonly associated with MOH, but it has been known to occur with a variety of simple analgesics and even triptans. The thing to alert customers to, according to Kate, is that “using a low dose of a painkiller on a regular basis to treat a headache is more likely to lead to a medication overuse headache than intermittent treatment at full dose a couple of times a month.”

MOH may be a more common problem than expected. A recent survey of over 1,300 people with migraine carried out by Migraine Action in partnership with Cefaly, the nonpharmaceutical anti-migraine device, found that 58 per cent per cent of migraine sufferers are overusing their pain relief medication, with nearly one in five (18 per cent) of those already formally diagnosed with medication overuse syndrome.

“Migraines can be an extremely unpleasant and debilitating occurrence and it is completely understandable that people might reach for medication to either prevent or relieve migraine,” says Dr Andrew Dowson, migraine specialist and medical advisor to Migraine Action.

However, if you are overusing your pain relief medication and either not aware of it or not dealing with it, then you are at real risk that over time the threshold level of your pain and sensitivity tolerance will drop and you will get more migraine headaches. Some people too, may become physically dependent to the painkillers themselves, particularly if they are codeine or caffeine based. Effectively, it creates a whole new condition for the patient to deal with on top of their migraine,” says Dr Dowson.

Kate says pharmacy staff have a vital role in raising awareness of and identifying medication overuse headache: “Getting patients on board can be challenging as the headache usually increases in severity on stopping treatment, but community pharmacy teams are ideally placed to help support and encourage patients through this in conjunction with their GP.”

As with so many conditions, information is a crucial part of the toolkit when it comes to supporting customers, in particular helping them understand the type of headache they are suffering from and how to manage it. Reassuring them that most headaches will go away on their own or with simple over the counter analgesics – and are therefore not a sign of something serious – can make a huge difference, although referring them to their GP when necessary is important.

Headaches and red flags

There are of course more serious causes of headaches and fear of these can be very distressing for customers. As ever, the skill of pharmacy teams in using effective questioning techniques is key to ensuring that people reporting red flag symptoms are identified and referred to their GP for prompt treatment, or offered reassurance and relevant support in the pharmacy if that is deemed more appropriate for their symptoms.

Kate says reminding patients that serious causes of headaches are “very rare” can help to allay any anxiety and stress, and adds that getting a good history and identifying red flags is key.

So what are these red flags? Kate says: “All new headaches should be investigated. The British Association for the Study of Headache (BASH) recommends that fundoscopy – looking at the blood vessels at the back of the eye – and a neurological exam should be conducted for all new presentations, so anyone with a new or different type of headache that hasn’t been diagnosed before should be referred.”

The BASH guidelines list the following as red flags or warning signs for headaches:

• Headache that is new or unexpected in an individual patient
• Thunderclap headache (intense headache with abrupt or ‘explosive’ onset)
• Headache with atypical aura (duration >1 hour, or including motor weakness)
• Aura occurring for the first time in a patient during use of combined oral contraceptives
• New onset headache in a patient older than 50 years
• New onset headache in a patient younger than 10 years
• Persistent morning headache with nausea
• Progressive headache, worsening over weeks or longer
• Headache associated with postural change
• New onset headache in a patient with a history of cancer
• New onset headache in a patient with a history of HIV infection.

Kate says that in particular, “thunderclap headache should be considered a medical emergency” and highlights the risk of carbon monoxide poisoning, which can lead to new headache symptoms. “Although rare, this can often be missed so questioning the patient about the heating in their home is worthwhile. The possibility of transient ischemic attacks (TIA) should also always be considered, so remember the FAST test for stroke,” Kate adds.

Thunderclap headache should be considered a medical emergency