Independent Insights, a Health Mart Podcast

The Pharmacist's Pivotal Role in Managing Migraine Headaches

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Headaches are a common yet complex condition, requiring pharmacists to differentiate between primary and secondary causes while providing effective treatment options. This episode explores evidence-based strategies for the management of headaches, emphasizing the pharmacist’s role in improving outcomes for patients with headaches. Stay informed and enhance your clinical expertise to better support patients dealing with this challenging condition.
 
HOST
Joshua Davis Kinsey, PharmD
VP, Education
CEimpact

GUEST
Alison Martin, PharmD
Clinical Pharmacist
VA Healthcare System

Pharmacists, REDEEM YOUR CPE HERE!
CPE is available to Health Mart franchise members only
To learn more about Health Mart, click here: https://join.healthmart.com/

CPE INFORMATION
 Learning Objectives
Upon successful completion of this knowledge-based activity, participants should be able to:
1. Classify a headache as either primary or secondary.
2. Explain evidence-based strategies for the management of migraines, including pharmacologic and non-pharmacologic approaches.

0.05 CEU/0.5 Hr
UAN: 0107-0000-25-119-H01-P
Initial release date: 4/21/2025
Expiration date: 4/21/2026
Additional CPE details can be found here.

Speaker 1:

Hi, Health Mart pharmacists From your education partner, CEi mpact. This is Game Changers, and each week we have a conversation on a hot clinical topic that will keep you current in practice and position you as a resource for prescribers and patients. Thanks for listening in.

Speaker 2:

Welcome to the Game Changers Clinical Conversations podcast. I'm your host, josh Kinsey, and, as always, I'm excited about our conversation today. Headaches are one of the most common health complaints, but their management can be surprisingly complex, especially when distinguishing between primary and secondary causes. In this episode, we'll explore evidence-based strategies for treating headaches and discuss how pharmacists can play a pivotal role in improving outcomes for patients struggling with this challenging condition, and it's so great to have Allison Martin with us today as our guest for today's episode. Allison, thanks for joining us.

Speaker 3:

Thank you so much for having me.

Speaker 2:

Yeah, we appreciate you taking time. She's in her clinic setting today, so again taking time out of your busy schedule and we're very grateful. So thank you so much. Before we jump into our topic for today, allison, I will let you kind of introduce yourself to the learner. So take a couple of minutes and tell us about yourself. Your practice site I referenced and I always like to let the learner know why you're passionate about today's subject. Why have we brought you on for the episode?

Speaker 3:

Yeah, okay, great. Well, thank you again for having me. So I currently practice in the ambulatory care neurology clinic at the Ralph H Johnson VA healthcare system and my role here? I've been in this role for 10 years almost 10 years and we developed a pharmacist-led pharmacotherapy clinic for comprehensive medication management within the neurology practice. So how my practice works patients get consulted to the neurology service after they've seen the neurologist, had their diagnosis established. If a need is identified for more fine-tuning of the medications or a closer follow-up on medications, then they are referred to my clinic using my scope of practice. Then I'll work on those medication adjustments. Hopefully we'll get them to a place where we're meeting patient and provider goals and can send them with continued care. So my consults are quite diverse within the general neurology practice, although about 50% of my consults, you know, year to year, have pretty predictably been various headache disorders. It is certainly one of those neurologic conditions I'm very passionate about. I have somewhat of a personal connection. My mother suffers from migraines and especially later in life she's had quite debilitating challenges.

Speaker 3:

So it's been an area that I've been personally passionate about and I think is such a great area where pharmacists can really work at the top of their license and offer support across multiple practice settings.

Speaker 2:

Yeah, no, that's great, and what a great resource for your mom to have the headache expert there to kind of help her through the process as well. So, yeah, Well, thanks again, Allison. We're so excited to have you and for you to share your expertise and your knowledge on headaches with us today. So, without further ado, let's jump into our content. So one of the things I always like to do is to ensure that we're kind of just laying the foundation for the topic for today. So let's just kind of take a step back and just reiterate and discuss again just the prevalence and impact of headaches. Like what is this doing to our patients? The impact on their quality of life. Like, obviously you see this firsthand. What is this doing to our patients? The impact on their quality of life? Like, obviously you see this firsthand. So just kind of let's set the stage and just kind of everybody go back and remember what headaches are, how they're classified and, you know, how they impact others.

Speaker 3:

So, right, absolutely, I mean pretty predictably this has been one of the most common neurologic conditions that we see, and I mean even worldwide. You, worldwide recent reports have been over 3 billion patients suffering with headache disorders.

Speaker 3:

So, and you think about a lot of these headache disorders and when they often present and are most common, you're thinking a lot of younger individuals times when they are working and so the impacts you can see, not just on the healthcare system and utilizing healthcare resources, like the emergency department or urgent care visits, but also on the patient's productivity days away from work, their impact on ability to function, their quality of life. So it certainly is a significant condition that can have a lot of impacts.

Speaker 3:

You mentioned, you know kind of diagnosing or characterizing the different headache types, and I think we'll get into that a little bit more later, and that also becomes quite an important consideration as we're stepping down this pathway, thinking about treatments and different recommendations.

Speaker 2:

Right Cause. That I mean obviously isn't going to inform which path you take based on the management of of what is classified as right.

Speaker 3:

Absolutely.

Speaker 2:

Yeah, yeah, those numbers were mind blowing, Like that's. That is a lot of people that suffer from headaches and you know, you bring up a great point as well in the fact that it's not just the quality of life of the patient that it's impacting. Obviously, that's important and that's one of the things that we want to try to affect with the managing and as a pharmacist. But it's like you said, the missed work or the missed productivity, or the fact that they maybe can't drive because of debilitating headaches and so therefore, you know, then they have difficulty getting around, running errands, getting to work, you know that kind of thing. So just a lot of things can kind of blossom and grow from just a headache diagnosis that really affect and impact not just the patient's quality of life but everything around them. So, yeah, that's a great point.

Speaker 3:

Absolutely.

Speaker 2:

I'll add to that I always find interesting you know it's a disorder that many also self-treat and manage over the counter, so even some of those numbers we may not have complete and accurate assessments and it may be more prevalent than we know Exactly, yeah, because I mean, how many times do you say, oh man, I have a splitting headache and you just, you know, pop a couple of pills and at home and it's, you know, not anything that you actually get follow-up care with or be officially diagnosed with something? So, yeah, well, I think it's a great way to kind of go into it. Let's, let's go and set the stage for what are the different types of, or the different classifications of, headaches, just so that we can kind of know. We don't have to go into great detail there, but it'll kind of help inform the decision as to how we're talking about the management of them later.

Speaker 3:

Absolutely Well. Usually we start pretty broad based in classifying either as a primary or secondary headache. So secondary headaches, you kind of think in secondary nature to something else that has caused this. So this could be post-traumatic headaches. If they've had a history of head trauma, this could be cervicogenic headaches. This could be one of the most common ones that we may encounter, especially as pharmacists, is medication overuse headaches resulting from overuse of various analgesic or even migraine specific medications for acute treatment. So those are secondary headaches and we'll talk a little bit too about how to tease out or know when to refer on for additional evaluation and red flag symptoms. But primary headaches, the key three that you'll see are the tension type headaches, migraine headaches and cluster headaches. And migraine headaches specifically, that tends to be one of the more prevalent, certainly is one of the most common primary headache disorders I see come through my clinic and it's also been really the focus of a lot of medication, drug development and research.

Speaker 3:

So, for migraines alone. We've had, gosh in the last decade, nine different novel medication approvals just for migraines alone. So yeah, a lot of exciting time to be a pharmacist in neurology and learning about all of these for sure.

Speaker 2:

Yeah, for sure, yeah, for sure. It's sad sometimes that we geek out when you know things I guess promoted are really kind of shown that they're impacting a lot of people. But yeah, you make a great point because you know what other disease state can make that claim. I would say very few that you know have had that much dedication to new, novel medications being kind of developed and studied. So yeah, that's great information to know. Okay, so then you mentioned that migraines were the most common there, and this is where I'll ask potentially a dumb question. I guess I kind of always thought or remembered that clusters were just multiple migraines, but you kind of made them sound like they're different classifications, is that?

Speaker 3:

right, it is, yeah, so you know you can. Then, many times you see all of these primary headache disorders, then subclassified as either episodic or chronic. And so that may be where some of that thought is coming from. But, yes, cluster headaches are their own separate primary headache diagnosis. And this is all outlined from the ICHD-3, or the International Classification of Headache Disorders, the third edition. That's what is our gold standard for diagnosis criteria.

Speaker 2:

Okay, great, yeah, all right. So now that we've kind of set the stage for primary versus secondary and kind of what fits into those under those additional subcategories, let's talk a little bit about the management and maybe how that's. You know what are some recent updates or movement in that space, or you know what are some of the things that we need to know as pharmacists. As far as you said, multiple new novel products out there, so how they impacted the management and what we're going to be doing from a pharmacist perspective.

Speaker 3:

Absolutely and I think, maybe focusing on migraine headaches specifically for this next part.

Speaker 2:

Sure.

Speaker 3:

Yes.

Speaker 1:

That sounds great, yes.

Speaker 3:

I mean in general for approaching the treatment and management of headaches, I think, ideally freedom from pain, relief from headache, but at least an ability to return to function and a lower intensity of the headache pain, managing acute symptoms along with that. So with migraine we can see a lot of nausea, vomiting, sensitivity to light, sensitivity to sound, many others. So that's one whole arm, acute treatment of the migraine itself. But then the other treatment path that we have to consider is preventive treatment, and so this is usually with a routine, scheduled medication, which could be a daily basis or we have some of these newer medications on a monthly or quarterly basis with the intent of preventing the migraines. And so what we're looking for from this treatment arm is a reduction in headache frequency, a reduction overall headache and migraine days in a month. So I think, going into treatment, it's important to know those two different sides of the coin.

Speaker 3:

Many times I see patients coming to me and are mixing the coin. Many times I see patients coming to me and are mixing the two. You know we're we're thinking some of our preventive medicines are really they're using it as needed as acute treatments and vice versa, others where we're using acute treatments on a daily basis to help manage the headache. So this is a great spot where setting that foundation, having good understanding to the treatment approach to migraines and headache disorders, is paramount.

Speaker 2:

Dr Justin Marchegiani. Yeah, and you know our podcasts are shorter in time so we don't have enough time to dig into all the different new novel medications and which ones do what and whatever. That would be a whole nother course, but in general I just wanted to kind of go back. The ones that you mentioned are monthly or quarterly. Are those injectables? Is that what we're talking about here?

Speaker 3:

Yes, well, so you know, most of the new migraine medications we've had are through a whole new pathway, a whole new mechanism of action. So these are. They call them CGRP targeting therapies. So CGRP, the calcitonin gene-related peptide. The calcitonin gene-related peptide Basically it's from the research that we found and what we know is part of the pathophysiologic process in a migraine. So we're trying to block that CGRP rise in activity. And so our medications we've had some that are approved specifically for acute treatment. So those are often CGRP small molecules, oral tablets that you can take, or one that's a nasal spray that you take on an as-needed basis as an acute treatment. And then we have others that are one that's an oral, three that are subcutaneous injections and one that's an IV infusion that's either on a daily, monthly or quarterly basis, depending on the dosage form, for migraine prevention, and one medicine that's the first and only migraine medicine approved, for both you can use it for acute treatment and can be a preventive agent.

Speaker 2:

Okay, great, and is the dual one? Is that? What formulation is that?

Speaker 3:

It is actually an ODT, a dissolvable tablet.

Speaker 2:

Okay, got it Okay.

Speaker 3:

A lot of new action, yeah that's great.

Speaker 2:

That's a great overview, and you know again. We could spend another hour digging into the specifics in each individual. You know medication and whatnot, but so what I want to go into now is what informs, obviously. What guidelines do we refer to when treating and managing migraine headaches? So where are the discussions on what to use, when to use, how to use that kind of thing?

Speaker 3:

Absolutely Great question and an area of a lot of literature and topics we could discuss further too.

Speaker 2:

Open to Pandora's box.

Speaker 3:

The last major guidelines that we've had were from the American Academy of Neurology, published in 2012, specifically for the prevention of episodic migraines. This is where you see a lot of our older medications that are not necessarily FDA approved or specifically designed for migraine, but we know have established evidence for helping prevent migraines. So you think of some of your anti-seizure medicines and your antihypertensives, for example. So 2012, quite a few years ago, yeah, and starting around.

Speaker 2:

I mean well, especially since you know that's 13 years and you said there's been so many new novel products in the last decade, like I feel like there's a missing guideline update.

Speaker 3:

So the AAN guideline update is in progress, but I have not heard a release date on when we may expect that to be out of circulation yet.

Speaker 1:

Got it.

Speaker 3:

But really to address that. Yeah, we've had quite a few different organizations that have put out guidelines or position statements, consensus statements, to try to address where these new therapies may fit into practice. So my practice site is at the VA. You mentioned the VA DOD clinical practice guidelines. We have had a guideline update for our population. It was published in 2023, an update from 2020. And it comments on some of these newer therapies as well.

Speaker 3:

The private sector or, more globally, we have the American Headache Society that has published several position statements and most recently had a publication just last year specifically addressing how we integrate these new CGRP targeting therapies and even commenting or almost advocating for considering these options, sometimes as first line options. Now, those are not formal guidelines. It is still a position or consensus statement, so you do need to take that with a grain of salt, but I think it does give some helpful perspective and helps to really help consider this really vast increase in medical literature that we have to sort through and navigate as clinicians to try to decide where these fit in practice right now.

Speaker 2:

Yeah for sure. Wow, yeah, that's a great overview and it sounds like you're in need, or your division, of what you're doing there. You all are in need of those updates and those changes, so hopefully that's coming soon. So let's segue into what is the role of the pharmacist here. You know, like, what are we positioned to do as pharmacists in managing headaches for our patients? And you can specifically, you know, speak to migraines, if that's really probably the majority, I would assume, of what we would see in practice setting. But let's just, I want to talk about what exactly can pharmacists do in this space.

Speaker 3:

Yeah, absolutely Well. I mean, just knowing that headaches are so prevalent, I think it's very likely that pharmacists will encounter patients with different headache disorders across multiple practice settings, whether we're in the community, whether we're in the hospital, whether ambulatory care.

Speaker 3:

So you know, patient education is very important. We talked a little bit about educating on the treatment approach to migraines the acute versus preventive treatment. One reason why I think that becomes so important is because of the secondary headache that I mentioned earlier the medication overuse headache, what was formerly known as rebound headache. Many still refer to it as rebound headaches.

Speaker 2:

I was going to circle back to that because you mentioned that the meds cause headaches themselves. That was intriguing. So yes, let's go down that path. Yeah, for sure.

Speaker 3:

Absolutely, and it's kind of counterintuitive for patients. They may have found a medicine or even an over-the-counter or a prescription-specific migraine medication to manage those symptoms and it has benefits. So why not take it on a daily basis or why not take it for every single migraine? So medication overuse headache and this is another specific secondary headache that is outlined in those diagnostic criteria I referenced. Essentially it's a headache that can arise after consistent overuse of acute treatments, and so this can be different analgesics, whether it's over-the-counter medications like acetaminophen, ibuprofen, naproxen. It can be some of our prescription options and some of our migraine-specific acute treatments. The triptans, like sumatriptan, risotriptan that whole class has been associated with these.

Speaker 3:

Some of our other acute treatments, like ergotamines and then acute treatments that are generally not recommended anymore for migraines are butalbitol containing products and opioid analgesics.

Speaker 3:

They have an even higher risk of medication overuse headache. So but in general, when you look at those different treatments, for the most part we're talking less than 10 doses a month, and when we're starting to exceed those numbers. So if you have a sumatriptan prescription for acute headache management, acute migraine that's why it's often limited to a quantity of nine. So 10 doses or more is where we see that association with medication overuse headache, where it can either cause the secondary headache or the migraine diagnosis that they had as their primary headache maybe can convert into chronic migraine and it can be very difficult to manage once we get into this cycle and overusing these acute treatments. So prevention really is the key and I think that education and you know, kind of like smoking cessation, you ask about it at every visit. I kind of feel like that here with medication overuse headache, ask about it at every visit. How often are you using it? Try to really reiterate those points and provide that education so we don't get into that cycle and have worsening outcomes.

Speaker 2:

Yeah, and I mean you know pharmacists are well positioned, especially those that have access to the field data. You know we can see how often they're filling those medications. You know, I would assume the triptans now a lot of them have been generic for a while. A lot of them are probably very affordable now, and so some patients probably say, oh well, my insurance doesn't pay for more than nine, well, I'll just pay cash for another refill or something. So I think that would be a red flag in a sense of are you overusing them? Not a red flag in a sense of you're committing insurance fraud or you shouldn't be doing this, but more of a again asking those thorough questions how often are you actually using these and providing the education and making sure that they're aware that overuse of them can cause the rebound headaches, right? So that's a great position for a pharmacist to kind of jump in.

Speaker 3:

Absolutely. You know you mentioned red flags. We use sometimes a mnemonic for red flag symptoms for headaches and one of them does reference painkiller overuse. So we have the SNOOP criteria is what it's referred to sometimes. So that is one of those refer on because they may need a preventive therapy that's added, or they may need further evaluation to help get a handle on their headaches.

Speaker 2:

Right, and this may be opening up a whole different avenue of discussion. That would take longer. But how do we rectify the issue of having a rebound headache? Like are they ever able to go back to using those preventative or to using those acute medications?

Speaker 3:

There's some different schools of thought. You know, many times we're considering a preventive medication. Many times we're considering a preventive medication, we're, at minimum, trying to taper down or even taper off of the acute medication that is the culprit and trying a different option. One thing that's interesting to note is that I mentioned the CGRP targeting therapies, the GPANTS, that are approved for acute treatment. We have not seen this medication class associated with medication overuse headache, and so this could be one place where, if you have someone you know really struggling with this, has tried our standard options. We're not making much headway. Maybe this is where we go next with one of these oral CGRP inhibitors.

Speaker 2:

Okay, interesting. I would imagine that, one being new, that it's probably very expensive and possibly not often covered and whatnot, so may run into barriers there, but again it sounds like it would be a down the line option. So if they've already kind of failed on previous therapies or struggled, then maybe it would be something that could get approved. So, yeah, no, that's a great another great place for pharmacists to interject in in being able to say, you know, with that continuity of care, like, oh well, they've tried this, this and this before, so you know, maybe they're a candidate for this. So right, okay, that's very helpful in kind of setting the stage for those rebound. Headaches. Again, I feel like something that is not really commonly discussed. So I think that's a great key point for pharmacists to educate patients on that phenomenon and just to make sure that patients are aware and are not overusing. So that's great. What other opportunities besides patient education do you see pharmacists have in the management of headaches space?

Speaker 3:

Yeah, Well, I mean, I think this is an area where we can make a lot of great recommendations. I mentioned. We have so many medications, so many that appear in the guidelines and these updated position statements, for both treatment, arms prevention and acute treatment, and they cross a lot of different mechanisms and a lot of different specialties. And you know we've you may be seeing someone in clinic for blood pressure management and you're managing their hypertension, but they're also having migraines that have been worsening. So maybe even just knowing what some of the key areas are where we can overlap and use a medication as a dual treatment, for those different comorbidities.

Speaker 3:

Try to minimize polypharmacy.

Speaker 1:

Absolutely.

Speaker 3:

Certainly is an opportunity where I think pharmacists can jump in and use that drug knowledge.

Speaker 2:

Yeah, for sure, and you know we touched on I think we didn't speak to it specifically but adherence obviously we touched on I think we didn't speak to it specifically, but adherence obviously. And again, the education on when is it appropriate to use a preventative versus an acute, and those kinds of things, and then watching for the refill data and determining, you know, are they adherent and whatnot you mentioned earlier, and this is something I want to go down the path before our time runs out. I swear I'm going to extend these podcast sessions. I say every time like our time just comes to an end so quickly. So one thing I wanted to go down the path of and just briefly discuss again, because you mentioned it. There are often some side effects from the medications themselves, right, but there are also other side effects that they're treating, other than the headache itself. So let's talk briefly about that and how the medications play into that and what pharmacists can maybe Right, Absolutely Well.

Speaker 3:

You know, I think a huge takeaway point and this has also been consistently reiterated in guidelines and position statements is that headache management is not a one size fitall approach. Every patient is so unique in how they may respond to a different medication, how they may tolerate a different medication, so I think you have to go into each unique situation, each unique patient, with that in mind and treat that one patient.

Speaker 3:

Know that we've got this now plethora of different options, from both nonspecific and migraine specific to even a lot of new non-pharmacologic and neuromodulation devices and different options for management. So you have to find what is going to meet the patient's goals where can we minimize drug interactions, where can we prevent those side effects, or maybe where we can provide some overlapping benefits. That's really, really is what I love about my job. It's kind of every day is a little bit like a puzzle. How can we make a bigger impact with one small adjustment.

Speaker 2:

Yeah, yeah.

Speaker 3:

That goes even down to the dosing you know with preventive medicines. This is something I tell my learners when they're on rotation. All the time, when you're thinking about an adequate trial of preventative medicine, you need to ask yourself did they get to the right dose? Were they there for the right amount of time, right dose, right time? And so sometimes that titration needs to go slower for some patients. Maybe we need to target a lower dose or a little higher dose. And did they have an adequate trial to really give that medicine a fair shot of working?

Speaker 3:

So I think those are also questions you can kind of ask yourself. If a patient is showing up and saying, oh, I started this topiramate and I've been taking it for two weeks, it's not doing anything, we need to know that that's not an adequate trial, that's not enough time to see that benefit captured and again, another great place for an interjection from the pharmacy team.

Speaker 2:

And you know, with that continuity of care, collaborating with the other providers, making sure that they're aware, you know they only took this for two weeks. That probably wasn't sufficient, you know, before you just start jumping around to another medication choice. So yeah. Right yeah.

Speaker 3:

Since I gave you my my go-to for preventive medicine, I guess I'll give you my my one liner for acute treatment. I tell learners hit it hard, hit it fast. So, that's another consideration. Sometimes, you know, you may be having someone coming in treating with the 325 milligram of acetaminophen. That may not cut it for a migraine of moderate severity, you know so we may need to hit it with 1000 milligrams.

Speaker 3:

So hit it hard, hit it fast. Another key education component is these acute treatments are going to work best if you can take them right away at that first sign of a migraine presenting or even sometimes in that aura phase or craniomal phase so hit it hard, hit it fast, get it in quick for best response and so that's another place where I think we can support and provide that education for patients that may optimize their medications effectiveness.

Speaker 2:

Yeah, that's great. That's great. Well, I still have a lot of things on my list. I'm going to just have to have you back for another episode. So, briefly, we can talk just quickly. Are there any challenges or barriers that you've seen in managing headaches that you want to kind of touch on or share any kind of tips or tricks about?

Speaker 3:

Right. Managing the medication overuse headaches sometimes can be a big challenge, like that perception coming in of needing that acute treatment and having to, you know, think about those motivational interviewing techniques and that shared decision making process to try to reframe our goals and expectations. So that may be one challenge. I'll just kind of reiterate that.

Speaker 2:

And, to be fair, it's not logical. It's not logical right, Like it doesn't even like the fact of the medication you're taking to treat your headache might cause a headache Like that. So I can see where patients get really confused or lost with that. So that's a great, a great opportunity for the pharmacist to really step in and educate and to support with that. So, okay, Well, with that, I will like to I always like to kick it back to this, our guest, and ask you what's our game changer here, what's our take home point for our listeners?

Speaker 3:

Dr Amy Moore Right. I think the take home overall is that we have to treat every single patient individually. Look at each unique case comprehensively, look at what are those specific goals that we're trying to achieve and that the patient has, using the shared decision making to find the best fit and the best regimen, since every patient is so different.

Speaker 2:

Yeah, so the game changer here is pharmacists. You do have a role. It's a very important role, and you need to be sure that you are individualizing the care for your patients. So, yeah, that's great. Well, allison, that's all we have time for. Thank you so much for joining us. This was great. I learned a lot. It's been a while since I've talked about headaches, yeah, so this was great. Thank you so much Great.

Speaker 3:

Thank you so much for having me, yeah absolutely.

Speaker 1:

And that's it for this week. Be sure to log in to Health Mart University to claim your CE credit for this episode. As always, have a great week and keep learning. We'll talk to you next week.