Expert comment: Leyla Hannbeck, NPA chief pharmacist

A patient is talking to a pharmacist about their headache. Which symptoms warrant a referral?

It is important for the pharmacist to rule out secondary causes of headache, where the headache can be attributed to another condition.

Serious causes will require immediate or urgent referral, for example:

- A headache following trauma to the head

- An intense headache that peaks very suddenly - this could suggest a subarachnoid haemorrhage

- A headache with neurological impairment such as slurred speech – this could be a sign of stroke

- The presence of fever and impaired consciousness, photophobia or stiffness of the neck – this may suggest an intracranial infection such as meningitis

- Tenderness over the temporal artery in a customer aged 50 years and over – indicative of giant cell arteritis

- Severe unilateral eye pain – suggestive of acute glaucoma

- A headache associated with nausea and impaired concentration could be caused by possible exposure to carbon monoxide

Other secondary causes of headache should also be ruled out. These could include: caffeine withdrawal, ear infection, dental abscess, neck pain, shingles, sinusitis or systemic infection. Such causes could be confirmed by the patient’s description of associated symptoms.

If the customer is taking certain medications that are known to cause headaches – such as calcium channel blockers or nitrates – this should also be referred.

If all of these referral points are ruled out, then the pharmacist may consider a diagnosis of tension type headache (TTH) and migraine. TTH should be managed with paracetamol, aspirin or a non-steroidal anti-inflammatory drug (NSAID) such as ibuprofen.

The pharmacist can reassure the customer that symptomatic treatment is usually sufficient. If the customer’s headache appears to be chronic TTH, it will be pertinent for the pharmacist to look out for possible indications of depression, which could warrant a referral to their GP.

If migraine is suspected, the pharmacist should assess the nature and severity of attacks, as well as their frequency and any potential triggers. They should then give advice on avoiding triggers where possible and could encourage the customer to keep a headache diary for a minimum of eight weeks.

Migraine sufferers should be treated with an oral triptan and either paracetamol or an NSAID. Over-the-counter preparations of sumatriptan should only be used where there is a prior diagnosis of migraine.

Category focus: Analgesics

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