Guidelines for community pharmacists on the management of headache

Pharmacists are likely to have an enhanced role in headache management in the future after the switch of drugs, such as sumatriptan, from prescription only (POM) to pharmacy (P) medicine status. NHS reform is providing an opportunity for pharmacists to expand their role by becoming supplementary and independent prescribers or by providing minor ailments services in community pharmacies: this is now a core service in Scotland. The main challenges for implementing a pharmacy-run headache service are the provision of training and management algorithms, payment for these enhanced services and auditing their success.The guidelines presented here put a framework in place to help pharmacists manage headache better. The guidelines may be customised for use by other healthcare professionals, such as dentists, opticians and complementary practitioners. Headache is a widespread condition, with estimates of 93 per cent of the population experiencing one or more headaches in their lifetimes, while 11 per cent of men and 22 per cent of women have a headache at any point in time. The most frequently reported headaches are the benign primary headaches of episodic tension-type headache (TTH), episodic migraine and chronic daily headache (CDH, now categorised primarily as chronic migraine and chronic TTH, together with some rarer headaches). CDH comprises daily or near-daily headaches that last for more than four hours on average, often linked to medication overuse. In the UK overuse of products that contain codeine, such as Nurofen Plus, Solpadeine and Syndol, may be a major contributor to medication overuse headache (MOH). Patients often do not realise these drugs contain codeine and it can be a problem to identify codeine users in pharmacy practice. However, it is worth taking time to establish whether codeine is implicated. CDH usually arises from a primary, episodic headache disorder (migraine or TTH). Other headache subtypes are relatively uncommon, affecting less than 1 per cent of the population. Panel 1 shows the prevalence and clinical features of common headache subtypes. For such a common condition, it might be expected that effective healthcare services would be available to treat most sufferers. Unfortunately, this is not so, and headache remains under-recognised, under-diagnosed and under-treated in primary care. In particular, half or more of migraine sufferers do not consult a physician, remain undiagnosed and rely on over-the-counter (OTC) medicines. This means that many of them pass through the doors of community pharmacies for treatment. There is a need for best practice guidance for the pharmacist on how to manage patients with headache. Recently, evidencebased guidelines for the management of migraine in primary care have been developed in the UK, US and Canada, and for chronic headaches in the UK. From the UK guidelines, recommendations have been published to help nurses and patients to manage migraine. This article describes the development of headache guidelines for pharmacists in the UK. The UK headache guidelines initiative was co-ordinated by the Migraine in Primary Care Advisors (MIPCA) charity, which is dedicated to the improvement of headache services in primary care in the UK. Pharmacy headache guidelines were developed at a MIPCA meeting of pharmacist, GP and nurse members, in association with the UK patient support group Migraine Action Association. Drafting the guidelines involved extensive input from community pharmacists, pharmacy advisers, an optometrist, GPs and nurses. Research included literature searches accessed via MedLine, monitoring of relevant presentations at international headache and neurology congresses and outputs sourced from the Department of Health and the Royal Pharmaceutical Society.