Ask the Pharmacist

Q. I suffer from headaches frequently and I am not sure what the options are for relief. What would you recommend for treatment of these?

A. First off, before discussing options for treatment of severe or ongoing headaches, it is best to assess just what might be the cause of these headaches. Many times, there is no major underlying disorder, such as a tumor or other serious medical condition, but it is best to rule them out to be on the safe side. Questions a family doctor (or neurologist, the doctors who specialize in treating headaches) might ask you to better assess the situation include: the severity and/or progressive severity (i.e. are they getting worse and worse) of them, did the headaches come on suddenly, at what age were you when they started, has there been a change in the headache pattern and besides head pain are there any other systemic effects (like light sensitivity, nausea…)? Besides asking these questions, your doctor may well run a number of tests to help rule out these same rare but serious causes. Once major concerns have been ruled out and pain relief is sought, there are a number of non-drug and drug options to try.

The first thing to address is that for many people, their headaches are caused by actions that they themselves take. These so-called actions are called ‚Äútriggers‚ÄĚ. If you know what your triggers are then in some cases it can be obvious as to what you can do to avoid those triggers. Many common triggers are:

· not enough or too much sleep

· not eating at regular times

· lack of exercise

· stress (too much or surprisingly, lack thereof)

· dietary triggers (caffeine, artificial sweeteners, alcohol, chocolate, MSG containing foods, cured meats, aged cheeses etc..)

Beyond avoiding the triggers, you can apply cold packs and/or seek a dark, quiet place to rest. There is also a number of alternative therapies that can be tried such as acupuncture and/or nerve blocks, biofeedback, relaxation therapy (especially if stress induced), cognitive behavioural therapy and psychotherapy. These alternative therapies do hold merit and are worthwhile to try if you can get access to them.

As for medication options, there are many to choose from that can provide quick relief (let’s face it, we are all busy and most of us do not make time for the non-medication treatments). The most sought-after medications that you do not need a prescription for are acetaminophen (Tylenol), ASA (Aspirin), ibuprofen (Advil) and naproxen (Aleve). Many people believe these choices are safe to take since you can access them without consulting a health care practitioner. Unfortunately, if these medications are used on a regular basis, not only does it put you at risk of potential liver and kidney problems and ulcers but it also lends itself to a phenomenon called medication-overuse headaches. These headaches are dull daily headaches that occur on top of the episodic ones you already have and the process to get rid of them once they occur is nothing short of brutal. To specifically avoid medication overuse headaches, it is recommended to limit the use of these headache remedies to less than 15 days each month. If you take an opioid and analgesic combination product (e.g. acetaminophen with codeine, acetaminophen with oxycodone etc.), then it is suggested to limit the use to less than 10 days each month. Codeine and tramadol are not recommended for headaches since there isn’t any evidence to support their use and they also have a strong potential for dependency, medication-induced headache and also withdrawal symptoms.

There are many triptans available by prescription that are effective and usually well tolerated such as almotriptan (Axert), eletriptan (Relpax), frovatriptan (Frova), naratriptan (Amerge), rizatriptan (Maxalt), sumatriptan (Imitrex), and zolmitriptan (Zomig). They all work by constricting blood vessels and preventing inflammation in the central nervous system (CNS). The quickest onset is subcutaneous sumatriptan injection and is a great choice for severe migraine attacks and acute cluster headaches. For the most part, the differences between the triptans are not significant. Among the oral triptans, rizatriptan may have a slightly faster onset of action while naratriptan’s effects peak at 4 hours due to its slower onset of action and almotriptan may be associated with less side effects. Naratriptan is also known for having a lower headache recurrence rate and very minimal side effects so it is a great choice for moderately severe migraines. Despite these slight differences, patients do report personal preferences so it is best to trial them and decide for yourself if any work for you. Medication-overuse headaches unfortunately is also associated with the triptans and therefore their use should be limited to less than 10 days each month.

Sometimes, people need to resort to corticosteroids for relief and they have been used to lengthen the time between migraines however it is not recommended to use these drugs for acute treatment of migraine or headache pain. Ketorolac (Toradol) is a strong anti-inflammatory that can given by injection in emergency departments to help with severe pain and meperidine (Demerol) injections are used as a last resort when all else fails.