Headache

Description
  • Headache is a symptom of many disorders and can be broken down into primary and secondary headache disorders.
    • Primary headache disorder:  No other condition is causing the headache; this commonly includes migraines, tension-type headaches, and cluster headaches.
    • Secondary headache disorder: Headache can be attributed to another condition, such as trauma, stroke, medication withdrawal syndrome, medication overuse headache, insomnia or psychiatric disorders.
  • Tension-type headaches and migraines are the most common.
  • Tension headaches will occur in 70-80% of people at least once.  50% of adults over 40 years old will experience episodic tension headaches and is more prevalent in women than in men.  May be triggered by mental stress or tension, and is sometimes chronic (3% of tension headaches are chronic -  defined as 15 or more episodes per month), rather than episodic.
  • Migraines occur in about 18% of women, and 8% of men.  May be episodic or chronic (15 or more episodes per month) and sometimes presents with an aura in 15% of patients.
  • Cluster headaches are uncommon, occurring in about 0.2% of the population.
  • Headaches (both tension and migraine) are quite common in children and adolescents; 25% of 12-13 year olds experience a headache once weekly, and 5-23% experience headaches between 7-11 years old.
  • Rarely, more than one type of headache disorder may be present.

For more information, see:

Signs and Symptoms
  • Once secondary causes of the headache and red flags are ruled out (see Differential Assessment and Referral, below), determine if the headache is an episodic tension-type headache, chronic tension-type headache, or a migraine.
    • Tension headache:
      • Pressing / tightening pain
      • Mild to moderate intensity
      • Bilateral
      • Lasts 30 minutes to 7 days
      • Not aggravated by physical activity
      • No nausea or vomiting

    • Migraine
      • Throbbing / pulsating pain
      • Usually moderate to severe intensity
      • Usually unilateral
      • Lasts 4-72 hours
      • Aggravated by physical activity
      • Usually has nausea and/or vomiting, photophobia and/or phonophobia

        • A diagnosis of a migraine requires at least TWO of the above characteristics, AND one of nausea/vomiting, photophobia or phonophobia

      • Migraine may progress through four phases in some patients
        • Prodrome (60% of people) - depression ,irritability, yawning, neck stiffness, 24-48 hours prior to headache
        • Aura (25%) - onset one hour before headache begins; visual, auditory and motor issues
        • Headache phase
        • Postdrome - feeling of exhaustion, and sudden head movement can cause transient pain

    • Cluster headache
      • Rarest form of headache
      • Onset age 25-50 years old
      • Will have several attacks over a period of time, and then goes into remission for months or years
      • Severe unilateral, orbital or temporal pain
      • Each attack lasts 15 minutes to three hours
      • May also cause tearing, nasal congestion, rhinorrhea, forehead/facial swelling, miosis and headache
      • Patients with suspected cluster headaches must be referred to their physician.

  • A severity assessment should also be done to determine if mild, moderate or severe:
    • Scale of 1/10 pain description - greater than 6 is considered severe
    • Number of headaches - headaches for more than 15 days per month is considered severe

  • Other important details should be gathered during the headache assessment:
    • History of headaches
      • Age at onset
      • Frequency, intensity, and duration of attack
      • Number of headache days per month
      • Other symptoms associated with headache
      • Precipitating and relieving factors
      • Effect of activity on pain
      • Relationship with food/alcohol
      • Response to any previous treatment
    • Family history of headache
    • Any recent change in vision
    • Recent trauma
    • Any recent changes in health, activities
    • Lifestyle e.g. smoking, alcohol use
    • Medical history e.g. hypertension, diabetes, hyperlipidemia
    • Medication profile
Differential Assessment
  • Must rule out secondary causes of headache:
    • Trauma to the head
    • Stroke or TIA (transient ischemic attack) -- evident by simultaneous onset of neurological impairment of speech, sensation, strength or consciousness
    • Intracranial infection (eg. meningitis) – headache occurs with fever, neck stiffness, impaired consciousness or photophobia
    • Fever and general malaise
    • Medications that can cause headaches (eg. tetracycline, sulfamethoxazole-trimethoprim, nitrates, tamoxifen, ACEIs, beta-blockers, calcium channel blockers, hydralazine, methyldopa, birth control, corticosteroids, hormone replacement therapy, decongestants, SSRIs)
    • Withdrawal from medications (eg. opioids, caffeine, benzodiazepines, SSRIs, psychotropics)
    • Uncontrolled hypertension
    • Shingles and post-herpetic neuralgia – head and facial pain near area of herpetic eruption
    • Sinusitis, otitis media or a dental abscess may cause headache symptoms; suspect if pain is localized to structures in the head and neck (eg. eyes, ears, sinuses, temporomandibular joint, teeth or neck)

  • Medication overuse (MOH) headache:
    • Can occur with frequent use of any symptomatic treatment of headaches, most commonly with acute treatment of episodic migraines or tension headaches.
    • Typically occurs after using the following drugs for 3 months or more:
      • Triptans, opioids, ergots alone or in combination for >10 days per month for >3 months
      • Acetaminophen, aspirin, or NSAIDs, alone or in combination for >15 days per month for >3 months
    • Suspect MOH if chronic headaches occur on more than 15 days per month and are worsened or not improved by pain medications
    • Symptoms typically resemble tension headaches or migraines.  Patients overusing triptans are more likely to have migraine symptoms
    • Typically resolves within 2 months after withdrawing offending pain medication; however, original headache disorder likely to return
    • Ideally, patients should be free of acute medications for at least 20 days a month to reduce this risk
When to Refer

Emergency Room referral

  • Suspected stroke, TIA, meningitis or head trauma
  • A new headache that presents with a cognitive change
  • Any headache that becomes progressively severe, changes in headache pattern, or is accompanied by symptoms such as blackout or memory loss
  • Presents with unilateral eye pain with red eye, fixed and dilated pupil or diminished vision; suspect glaucoma
  • If the headache came on suddenly (rapid time to peak headache intensity, such as from a few seconds to 5 minutes)
  • If the headache is the patient’s worst headache
  • Concurrent fever, neck stiffness or impaired consciousness

Non-emergent referral to MD

  • Any secondary cause of a headache must be referred for treatment of the underlying condition
  • Chronic tension-type headaches or frequent migraines should be referred to MD for investigation or consideration of prophylactic therapy (migraines).  A frequency of >6 headaches per month should be strongly considered for prophylactic therapy; >15 episodes per month should definitely receive prophylactic therapy.  However, in the interim, can treat as an acute episode (see Treatment, below) as long as medication-overuse headache is ruled out.
  • Suspected medication-overuse headache should be referred to MD; also consider discussing management strategies with physician.
  • If the headache is a patient’s first headache.
  • A new headache when a clear diagnostic pattern has not emerged after 8 weeks.
  • Patient is >50 years old and presents with a new, undiagnosed headache.
  • Patient is >50 years old and the headache is associated with tenderness in the temporal artery (runs along side of head, near ears).
  • Onset with exercise or sexual activity.
  • Pain >6 on a scale of 1-10 should be considered a severe headache and referred for investigation; however, pain scales are subjective.  Pain scale should not be used in isolation to determine if referral is necessary.  Other questions, such as impact on daily life, are important.
  • Suspected medication-induced headache, or withdrawal from certain medications
  • Uncontrolled hypertension
  • Shingles or post-herpetic neuralgia
  • Sinusitis, otitis media or dental abscess
Treatment

Goals of Treatment

  • Relieve or abolish pain and any associated symptoms such as nausea/vomiting, photophobia, phonophobia rapidly
  • Relieve migraine-related disability so that the patient can return quickly to normal function.
  • Prevent complications of medication usage

1) Non-pharmacologic treatment

For episodic or chronic Tension-type headache, and migraines

  • Rest in a dark, quiet room
  • Apply cold cloth / ice pack to head
  • Sleep
  • Avoid bright lights and loud sounds
  • Avoid triggers if any have been identified.  A headache diary to record frequency, intensity, suspected triggers, and the effect of medication is useful.  Common triggers are:
    • Food (missing meals, or food containing  nitrites, MSG, aspartame or tyramine)
    • Environmental (weather changes, strong odours, bright lights)
    • Chemical (insecticides, perfumes, benzene)
    • Hormonal (menstruation, pregnancy (1st trimester), perimenopause)
    • Drugs
    • Others (sleep-wake cycle alterations, stress / anxiety, intense activity)
  • Stress management achieved through relaxation training, cognitive behaviour therapy, or massage therapy may be useful (limited evidence).
  • Physiotherapy and chiropractic care useful if mechanical problems in neck or shoulders identified.
  • Certain lifestyle adjustments may be beneficial:
    • Reduce caffeine intake
    • Ensure regular exercise
    • Avoid irregular or inadequate sleep

 

2. Over-the-counter drugs

Episodic Tension headache

  • Various analgesics appear equally effective in treating episodic tension headaches.  Make choice based on side-effect profile and patient’s previous tolerability to a medication.
    • Ibuprofen 200-400mg  every 4-6 hours, max of 1.2g per day
    • Aspirin 1300mg once (loading dose) or 650mg every 4-6 hours
    • Acetaminophen 1300mg once (loading dose) or 650mg every 4-6 hours
    • Naproxen 220mg every 12 hours
    • Products with caffeine added may be more effective (weak, limited evidence)
    • Codeine is NOT recommended for acute treatment of tension headache, due to increased potential for medication overuse headache, more side-effects, and limited evidence for effectiveness
  • Limit the use of analgesics to 2 to 3 times per week to reduce risk of developing medication overuse headaches.
  • Avoid combining analgesics and opioids in those with frequent headaches, as this may increase the risk of medication overuse headaches.

Chronic Tension headache

  • Can be treated as above, but should also be referred to MD for investigation and / or strong consideration of prophylactic treatment.
  • Ensure medication overuse headache not a factor.

Migraine

  • An acute migraine can be treated the same as episodic tension headaches.
  • Randomized controlled trial compared combination of acetaminophen 500mg, aspirin 500mg, and caffeine 130mg (AAC) to ibuprofen 400mg found AAC was more effective in relieving pain at two hours. (Combination product not available in Canada but the individual ingredients are.)
  • An anti-emetic, such as dimenhdyrinate, can be recommended if nausea or vomiting is associated with the patient's migraine.

3) Prescription drug options

 Episodic Tension headache

  • Prescription dose NSAIDs may be prescribed.
  • Evidence suggests equal efficacy among NSAIDs.  See table under product section.
  • Limited evidence for using triptans in episodic tension headache; early evidence shows no benefit in tension headache and should not be recommended.

Chronic Tension headache

  • Can be treated as above, but should also be referred to MD for preventative treatment.
  • Ensure medication overuse headache not a factor.

Migraine

  • Can use NSAIDs as above.
  • May also prescribe triptans.
    • All triptans require EDS for coverage.  You may still prescribe and bill the assessment fee without EDS approval.  If previous physician diagnosis, may apply for EDS coverage.
  • Equal efficacy found between triptans: base choice on patient preference for formulation, prior experience with product, and cost.
    • Almotriptan: 6.25 to 12.5 mg per dose; may repeat in 2 hours (max 2 doses/24h)
    • Naratriptan: 1 to 2.5mg per dose; may repeat in 4 hours (max of 5mg/24h)
    • Rizatriptan: 5 to 10mg per dose; may repeat in 2 hours (max of 20mg/24h)
    • Sumatriptan:
      • Oral: 50 to100mg; may repeat in 2 hours (max of 200mg/24 hours)
      • Nasal spray: 5 to 20mg in one nostril; may repeat in 2 hours (max of 40mg/24h)
    • Zolmitriptan:
      • Oral: 2.5 to 5 mg;  may repeat in 2 hours (max of 10mg/24h)
      • Oral dispersible tablet: 2.5 to 5 mg;  may repeat in 2 hours (max of 10mg/24h)
      • Nasal spray: 2.5 to 5 mg in one nostril;  may repeat in 2 hours (max of 10mg/24h)
    • Eletriptan (non-formulary):
      • Oral: 20 mg; may repeat in 2 hours (max of 40mg / 24h)
    • Frovatriptan (non-formulary):
      • Oral: 2.5mg; may repeat in 2 hours (max of 5mg / 24h)

  • Although most evidence shows equal efficacy between triptans, there are some potentially important clinical differences:
    • Nasal sprays work faster than oral tablets: 15 minutes vs. 30 to 120 minutes.  Subcutaneous injections work the fasters (5-10 minutes).
    • Eletriptan and Rizatriptan may have the best 2 hour pain-free response.
    • Eletriptan may have the highest 24 hour pain-free rate with few recurrence.
    • Frovatriptan and Naratriptan may have the lowest 2 hour pain-free response, but migraine recurrence less likely.
    • Choose a nasal spray or waterless formulations (rizatriptan wafers, zolmitriptan rapid melt) if nausea or vomiting present.
    • If the patient previously did not tolerate a triptan, try naratriptan, sumatriptan, eletriptan or almotriptan, as fewer side effects are reported with these.
  • Sumatriptan 50mg may be as effective as 100mg and as well tolerated as 25mg.
  • Small randomized controlled trial found AAC (acetaminophen, ASA, caffeine) was more effective than sumatriptan 50 mg but less effective than sumatriptan 100 mg.
  • A triptan combined with naproxen may increase effectiveness of therapy.
  • Should take triptan at onset of migraine pain, but taking during the aura phase may be too early.
  • A maximum of 10 doses/month likely acceptable to avoid medication overuse headache, but caution still warranted.
  • Sulfa allergies have not shown cross-reactivity to triptans, despite their warnings.  Caution still recommended if previous anaphylaxis.
  • Watch for drug interactions with triptans:
    • MAOIs, SSRIs, TCAs or lithium -- possible serotonin syndrome, though unlikely
    • Dihydroergotamine and other ergots -- additive vasoconstriction and coronary vasospasm.  Clinically significant and contraindicated if an ergot taken within 24 hours.

4) Pregnancy and Lactation

  • Nonpharmacologic measures are first choice during pregnancy. Migraine headaches often improve during pregnancy so medication may not be necessary. If needed, the occasional dose of acetaminophen is recommended. Triptans are relatively contraindicated during pregnancy although recent data suggests they may not increase risk to the fetus. Refer to MD if symptoms not controlled with acetaminophen.
  • Tension headaches do not lessen during pregnancy. Nonpharmacologic measures and occasional acetaminophen are the treatments of choice. Refer to MD if symptoms not controlled with acetaminophen.
  • Breastfeeding tends to reduce migraine frequency. If necessary, nonpharmacologic measures and occasional acetaminophen are the treatments of choice. Tension headaches may be treated with ibuprofen. Sumatriptan is compatible with breastfeeding infants two or more months of age. Data is lacking for the other triptans.

5) Children and adolescents

  • Treatment options are somewhat more limited (see product table for doses):
    • Acetaminophen and ibuprofen are effective and safe in this age group
    • Triptans can be used, but only nasal sumatriptan and almotriptan are officially approved for use >12 years of age; however, good safety data for all triptans.
      • Should be reserved for moderate to severe headaches unresponsive to conventional analgesics
    • No age limit for when you can prescribe for headache; same referral criteria as adults


6) Cardiovascular and/or Cerebrovascular disease

  • Treatment with NSAIDs must be undertaken with caution in patients with pre-existing cardiovascular disease (CVD) or cerebrovascular disease, or presenting risk factors for CVD. For these patients, treatment options other than non-steroidal anti-inflammatory drugs (NSAIDs) should be considered first.
    • CVD includes:
      • Myocardial infarction, angina, heart failure
      • Peripheral artery disease (eg. intermittent claudication)
      • Atherosclerosis
    • Cerebrovascular disease includes:
      • Stroke or transient ischemic attack
    •       Risk factors for include:
      • Age >65
      • Family history of premature cardiovascular disease
      • Uncontrolled hypertension
        • NSAIDs may raise blood pressure somewhat and should be monitored during therapy, even if patient has controlled hypertension
      • Uncontrolled dyslipidemia
      • Diabetes
      • Kidney disease

  • Naproxen has been found to be the lowest risk NSAID in patients with cardiovascular or cerebrovascular concerns.
  • Short-term use of NSAIDs still carries risk in this population.
  • Triptans are contraindicated in patients with a history or signs / symptoms of:
    • myocardial infarction / angina
    • arrhthymias
    • cerebrovascular disease (stroke or transient ischmic attack)
    • valvular heart disease
    • atherosclerosis
  • Patients with the following risk factors of cardiovascular or cerebrovascular disease are strongly recommend to avoid triptans:
    • Age >65
    • Family history of premature cardiovascular disease
    • Uncontrolled hypertension
    • Uncontrolled dyslipidemia
    • Diabetes
    • Kidney disease

  •  A patient with the above conditions or risk factors should be referred to a physician for treatment if non-NSAID or triptan treatment is not possible.
General Advice / Monitoring

  • Counsel the patient on potential triptan side effects:
    • Chest discomfort or tightness (unrelated to CV issues)
    • Nausea
    • Facial flushing
    • Tingling and paresthesia
    • Dizziness, fatigue, drowsiness
  • Headache or migraine should be aborted within 2-6 hours after treatment has started
  • The patient can be followed up with, if possible, in 2 hours after taking the medication.  Discuss:
    • Was there significant relief 2 hours after taking the medication?
    • Was the medication well tolerated?
    • Was only one dose required?
    • Could you resume normal activity after taking the medication?
  • If prompt follow-up is not possible, ask the above questions when initiating future treatment for new episodes
    • If there was no improvement, choose a different treatment option.  May try two trials before referral to MD
  • Advise patient to report all significant adverse effects (severe GI upset with NSAIDs / triptans, severe chest pain/tightness with triptans)
  • Encourage patient to keep a headache diary to log the number of headaches per month, possible triggers, and effectiveness of treatment
  • Monitor monthly usage of acetaminophen, NSAIDs and triptans to help prevent medication overuse headache
Products

Detailed information on contraindications, cautions, adverse effects and interactions is available in individual drug monographs in the CPS (e-CPS), Lexi-Comp, AHFS, www.drugs.com or other reliable drug monograph references. For comprehensive drug comparisons, see RxFiles charts (www.rxfiles.ca).
This information should be routinely consulted before prescribing.

OTC Products

Product

Adult Dosage

Pediatric Dosage
(not to exceed adult dosage)

Ibuprofen

200-400mg q4-6h, max of 1.2g per day

7.5-10mg/kg/dose, up to QID

Aspirin

1300mg once (loading dose) or 650mg q4-6h

-

Acetaminophen

1300mg once (loading dose) or 650mg q4-6h

10-15mg/kg/dose q4h

Naproxen

220mg q12h

5-7mg/kg/dose q8-12h

 

Prescription Products

Ingredient

Dosage

Pediatric Dosage
(not to exceed adult dosage)

Ibuprofen

400-800mg q4-6h, maximum of 2 doses

7.5-10mg/kg/dose, up to QID

Naproxen

500mg q2-6h, maximum 1000mg  day

5-7mg/kg/dose q8-12h

Almotriptan malate

EDS required

6.25 to 12.5 mg: may repeat in 2 hours (max of 2 doses/24 hrs)

Children >12:
6.25mg stat, may repeat in 2 hours (max of 2 doses in 24h period)

Naratriptan

EDS required

1-2.5mg per dose; may repeat in 4 hours (max of 5mg/24h)

-

Rizatriptan oral, dispersible tablet

EDS required

5-10mg per dose; may repeat in 2 hours (max of 20mg/24h)

-

Sumatriptan oral

EDS required

50-100mg; may repeat in 2 hours (max of 200mg/24 hours)

Children >12:
25mg stat, may repeat in 2 hours (max of 2 doses in 24h)

Sumatriptan nasal

EDS required

5-20mg in one nostril; may repeat in 2 hours (max of 40mg/24h)

Children >12:
5-20mg in one nostril; may repeat in 2 hours (max of 40mg/24h)

Zolmitriptan oral, dispersible tablet

EDS required

2.5 to 5 mg;  may repeat in 2 hours (max of 10mg/24h)

-

Zolmitriptan nasal

EDS required

2.5 or 5 mg in one nostril; may repeat in 2 hours (max of 10 mg/24 h)

-

Eletriptan oral

Non-formulary

20mg; may repeat in 2 hours (max of 40mg/ 24h)

-

Frovatriptan oral

Non-formulary
2.5mg; may repeat in 2 hours (max of 5mg / 24h) -

*EDS requires physician diagnosis.  May still prescribe and receive minor ailment assessment fee, even without EDS.

Prescribing and Billing Details
  • pseudoDIN: 00951097
    • Max of 3 claims per 365 days per patient

  • May prescribe sufficient quantity to treat up to 4 headaches or migraines (no refills).
    • If tolerability of chosen treatment is uncertain, may prefer to give only enough for one treatment, then assess.
    • If the patient returns with a future headache, it is to be treated as a distinct episode and re-assessed.
    • Always ensure patients is not at risk of medication over-use headache.

  • If an OTC strength of ibuprofen is chosen (200mg or 400mg), it will NOT be eligible for the assessment fee.  This means only ibuprofen 600mg products are eligible.

  • Only products with an official indication from Health Canada for headache or migraines are considered for these guidelines.  Only the active ingredients in the "products" section are approved for pharmacist prescribing.  
Treatment Flowchart
Pharmacist Assessment Documents
References / Suggested Reading

  1. Worthington, I.  CNS Conditions: Headache.  In: Minor Ailments. e-Therapeutics Complete [Internet]. Canadian Pharmacists Association. Available from: http://www.e-therapeutics.ca.
  2. Purdy, R. Neurologic Disorders: Headache in Adults. In: Compendium of Therapeutic Choices. e-Therapeutics Complete [Internet]. Canadian Pharmacists Association. Available from: http://www.e-therapeutics.ca.
  3. Chawla J. Migraine headache. In : Medscape online databases. Available at http://emedicine.medscape.com/article/1142556-overview.
  4. Headache. In: DynaMed. Available at https://dynamed.ebscohost.com/ by subscription.
  5. Bajwa, Z. Evaluation of headache in adults. In: UpToDate. Available at www.uptodate.com by subscription.
  6. Headache. In: Mayo Clinic. www.mayoclinic.org. (Free access)
  7. Bunka D, Jin M. Migraine: Overview of Preventive & Acute Therapies. In RxFiles online. Available at www.rxfiles.ca .
  8. Regier L, Jensen B , Downey S. Migraine: Agents for acute treatment. In RxFiles online. Available at www.rxfiles.ca .
  9. Worthington I, Pringsheim T, Gawel MJ et al. Canadian Headache Society guideline: Acute drug therapy for migraine headache. Can J Neurol Sci 2013;40(5 Suppl 3):S1-80.
  10. Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia 2013;33:629-808.
  11. Becker, J.  Acute Migraine Treatment in Adults  Headache: 2015;55:778-793.
Prepared by medSask.
Funded by the Saskatchewan College of Pharmacists
Posted May 2010; Updated Feb 2016.