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 The leading web portal for pharmacy resources, news, education and careers March 21, 2018
Pharmacy Choice - Headache Disease State Management - March 21, 2018

Headache Disease State Management

Clinical Management of Headache
by JoAnne Conrad, MS, LD, Licensed Dietitian

Headache disorders are among the most common disorders of the nervous system.1 Over 45 million Americans suffer from some type of chronic headache. 2

There are three primary types of headache disorders: tension-type headaches, migraine headaches, and cluster headaches.

Tension-type headaches are most common. These may be stress-related or associated with musculoskeletal problems in the neck. They are usually bilateral and the pain may be mild to moderate. Duration of headache may be several minutes to several days.

Migraine and cluster headaches are less common but are more debilitating than tension headaches. Researchers are uncertain as to the cause of migraines although changing hormone levels, stress, and certain foods can trigger them. This type of headache is more common in women. Migraines are typically moderate to severe in pain intensity and are often accompanied by nausea, vomiting, and visual disturbances. Pain is usually unilateral, pulsating, and located near the eye on the affected side. Untreated pain can last 4-72 hours.2

Cluster headaches are relatively uncommon, affecting less than 1 in 1000 adults, and are more common in men than women.1 The cause is unknown. This type of headache is characterized by frequent clusters of severe to extremely severe unilateral, orbital or retro-orbital pain. Cluster headaches may last from a few minutes to several hours. A cluster period can last weeks to months.

Treatment of Headache
Headache therapy should focus on treating an acute attack as well as preventing recurrent attacks.2 Acetaminophen, aspirin or nonsteroidal anti-inflammatory drugs are usually the first line of treatment for tension headaches or mild-to-moderate migraines. For moderate to severe migraine attacks, the triptans or ergot alkaloids are typically used.2 Treatment of an acute cluster headache includes inhaled oxygen, triptans, octreotide, local anesthestic, and dihydroergotamine.3 There are a few nutritional supplements that are used for headache treatment.

Caffeine is used as an adjunct in many OTC analgesics. It appears to enhance the analgesic activity of NSAIDs and can help reduce pain associated with tension and migraine headaches. Herbal headache products often contain extracts that provide caffeine, such as mate and guarana. Caution is advised when using any product that contains large amounts of caffeine especially if caffeine-containing beverages are included in the diet. Excessive caffeine can cause headache, jitteriness, and anxiety.2

Magnesium appears to be useful for some patients with migraine or cluster headaches. The benefit is more pronounced in those with low levels of magnesium that can cause cerebral arterial vasoconstriction, increased platelet aggregation, and increased serotonin release. Magnesium sulfate,1 gram IV, has been used to treat acute attacks.

Peppermint oil may be used topically for relief of tension headache pain. Initial evidence indicates that 10% peppermint oil applied to the forehead and temples might reduce headache pain. Most peppermint oil contains menthol that may work to soothe and relax the muscles. Peppermint oil should not be applied near the nose due to the potential for bronchospasm when inhaled.2

Prevention of Headache
Preventive therapy should be considered in individuals with frequent or severe migraine or cluster headaches. Preventive treatments are usually taken everyday. Cluster can be prevented by calcium channel blockers, lithium, and possibly, divalproex and topiramate.3

The American Academy of Neurology issued new 2012 evidence-based pharmacologic treatment guidelines and complementary treatment guidelines for episodic migraine prevention in adults.4,5 The guidelines recommend the use of divalproex sodium, sodium valproate and topiramate, as well as metoprolol, propranolol and timolol as preferred initial choices.4

The Academy guidelines list several natural medicines as options for prevention of migraine.

Level A (Established Effectiveness)
Butterbur (Petasites) – A specific butterbur extract standardized to 15% petasin and isopetsin (Petadolex) can decrease the frequency, intensity and duration of migraine headaches. Butterbur is thought to have anti-inflammatory properties and antispasmodic effects on smooth muscle and vascular walls. A dose of 75 mgs BID is recommended. Long-term safety of butterbur beyond 16 weeks is unknown.2,5

Level B (Probably Effective)
Riboflavin – Riboflavin plays a role in mitochondrial function and migraine headaches could be partly due to mitochondrial dysfunction. A dose of 400 mg/day is usually used. This dose can cause diarrhea and polyuria and should be used only in persons with normal kidney function.2,5

Magnesium – Use of 600 mg magnesium TID has been reported to reduce frequency of migraine and cluster headaches.2 High doses may cause loose stools and diarrhea, possibly cause arrhythmias in patients with heart disease, and possibly hypermagnesemia in patients with poor kidney function.

Feverfew – Some clinical studies have shown that feverfew can reduce the frequency of migraines and decrease the symptoms of pain, nausea and vomiting when a migraine does appear. It is theorized that feverfew inhibits platelet aggregation, serotonin release, and prostaglandin synthesis. Doses of 50-100 mg/day have been used. Patients allergic to ragweed or related plants should not use feverfew. Patients taking warfarin along with feverfew should have their INR monitored.2,5

  1. "Headache Disorders"; Fact Sheet #277, October, 2012, World Health Organization.
  2. "Natural Medicines in the Clinical Management of Headache"; Natural Medicines Comprehensive Database, June 14, 2012.
  3. Mayo Clinic Staff. Cluster Headache: Treatment and Drugs. February 8, 2011. Available from:
  4. Silberstein SD, Holland S, Freitag F, Dodick DW, Argoff C, Ashman E. Evidence-based guideline update: Pharmacologic treatment for episodic migraine prevention in adults: Report of the Quality Standards Subcommittee of theb American Academy of Neurology and the American Headache society; Neurology 201 Apr 24;78;1337-1345.
  5. Holland S, Silberstein SD, Freitag F, Dodick DW, Argoff C, Ashman E. Evidence-based guideline update: NSAIDs and other complementary treatments for episodic migraine prevention in adults: Report of the Quality Standards Subcommittee of theb American Academy of Neurology and the American Headache society; Neurology 2012 Apr 24;78;1346-1353.

American Migraine Foundation

American Academy of Neurology

American Headache Society

National Headache Foundation

National Institute of Neurological Disorders & Stroke

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