Migraine Prevention: What Pharmacists Need to Know
Activity Date: January 2007  — Activity Info: Volume 4, (1)
Goals & Objectives | Faculty | Introduction | Full Activity Content | CME Test & Evaluation (CME Expired)

Migraine Prevention: What Pharmacists Need to Know
Glen E. Farr, PharmD*

Recurrent head pain, alone or in combination with other symptoms, is a feature of many different medical conditions. In general, headache disorders may be classified into 2 broad groups. Secondary headache disorders are caused by another identifiable medical condition, such as a brain tumor. Primary headache disorders, which include tension headache and migraine headache, are not caused by another condition.1 Although tension headache is the most common type of primary headache, migraine headache is the primary headache disorder that is the most likely to cause the sufferer to seek medical attention.1 Estimates of migraine prevalence suggest that approximately 1 out of every 4 households in the United States has at least 1 person who experiences migraine headaches.2 Families with at least 1 individual with migraines have medical expenses that are significantly greater than other families, and the costs are especially great when a parent and a child are affected.3 Nearly 33% of individuals with migraine miss at least 1 day of work during a 3-month period of time.2 A significant problem with migraine headache is the eventual conversion to very frequent, or even daily, headaches. In some cases, these chronic headaches develop as part of the natural progression of migraine headache. In other cases, chronic headache is a consequence of the overuse of analgesics and acute pain medications, especially products that contain butalbital.4

Knowledge of the biology of migraine headache has improved substantially in the last few years.
Migraine was formerly viewed as primarily a disorder of the cerebral blood vessels.5 However, it is now known that migraine headache is related to over-excitability of nerve cells within the central nervous system, and brain imaging studies have demonstrated structural abnormalities within the brains of patients with migraine headaches.6 New medications have become available for the acute treatment and long-term prevention of migraine headache attacks. Acute medications (eg, the triptans) provide substantial pain relief for many patients, especially when taken early during a migraine episode.7 Preventive agents reduce the number of migraine attacks and may also reduce the need for acute medications and the likelihood of progression to chronic headache.8 Despite the considerable advances in the biology and treatment of migraine headaches during the past decade, many individuals who would be good candidates for migraine therapy never receive appropriate treatment. Many people who have migraine headaches never seek medical care, and the condition is often misdiagnosed or inadequately treated.

Pharmacists are uniquely positioned to help improve the recognition and management of migraine headache. Many people with headaches first seek help from their pharmacist. By recognizing signs of migraine and knowing the right questions to ask, pharmacists have the potential to guide patients to the treatment that is best for their degree of pain and disability. Pharmacists also provide essential education to their patients, helping them to understand the beneficial effects and the potential side effects of treatment. Patient education is especially important in migraine prevention, as patients may have unrealistic expectations about the effectiveness of treatment, or they may not understand that preventive medications are not effective immediately. In addition, migraine pharmacotherapy can be quite complex, and many patients require treatment with combined preventive and acute medications—and sometimes more than one of each.4 Pharmacists also serve an essential role in identifying patients who are overusing acute pain medications and who are therefore at risk of chronic headache. However, many pharmacists have misconceptions or misunderstandings about the biology, clinical presentation, and treatment of migraine headache. A recent survey of pharmacists in a range of practice settings illustrated several significant problems with headache care in current pharmacy practice.9 Of the community pharmacists surveyed, 80% said that headache is an important part of their practice, 85% made 1 to 5 recommendations for over-the-counter headache medications per day, and 12% made more than 5 recommendations per day. However, few of the pharmacists surveyed said that they were aware of or used current migraine treatment guidelines, and few recognized migraine headache as a neurologic disorder or asked their patients about headache-related morbidity.

This issue of University of Tennessee Advanced Studies in Pharmacy provides pharmacists with an update on the impact, recognition, and prevention of migraine headaches. It will not delve into treatment of the acute attack with triptans, ergot alkaloids and analgesics, but rather focus on prevention. In the first article, Jennifer H. Lofland, PharmD, MPH, PhD, of Thomas Jefferson University, describes the prevalence of migraine and its effects on the lives of individual patients and society as a whole. The second article, also by Dr Lofland, reviews the clinical presentation of migraine headache and the biological rationale for migraine prophylaxis. The third article, by Carla Rubingh, PharmD, of the University of Nebraska Medical Center, provides an overview of the use of pharmacologic and nonpharmacologic strategies for migraine prevention. The issue closes with a summary by Richard G. Wenzel, PharmD, of the Diamond Headache Clinic Inpatient Unit in Chicago, of practical steps for the pharmacist to improve the recognition and management of migraine headaches. After completing this monograph, readers should be better equipped to help their patients with headache disorders find the optimal treatment.


1. Lipton RB, Bigal ME. The epidemiology of migraine. Am J Med. 2005;118:3S-10S.
2. Lipton RB, Stewart WF, Diamond S, et al. Prevalence and burden of migraine in the United States: data from the American Migraine Study II. Headache. 2001;41:646-657.
3. Stang PE, Crown WH, Bizier R, et al. The family impact and costs of migraine. Am J Manag Care. 2004;10:313-320.
4. Garza I, Swanson JW. Answers to frequently asked questions about migraine. Mayo Clin Proc. 2006;81:1387-1391.
5. Blau JN. Migraine: a vasomotor instability of the meningeal circulation. Lancet. 1978;2:1136-1139.
6. Haut SR, Bigal ME, Lipton RB. Chronic disorders with episodic manifestations: focus on epilepsy and migraine. Lancet Neurol. 2006;5:148-157.
7. D´Amico D, Moschiano F, Usai S, Bussone G. Treatment strategies in the acute therapy of migraine: stratified care and early intervention. Neurol Sci. 2006;27:S117-S122.
8. Loder E, Biondi D. General principles of migraine management: the changing role of prevention. Headache. 2005;45:S33-S47.
9. Wenzel RG, Lipton RB, Diamond ML, Cady R. Migraine therapy: a survey of pharmacists´ knowledge, attitudes, and practice patterns. Headache. 2005;45:47-52.

*Professor of Clinical Pharmacy, Associate Dean for Continuing Education, University of Tennessee College of Pharmacy, Knoxville, Tennessee.
Address correspondence to: Glen E. Farr, PharmD, Professor of Clinical Pharmacy, Associate Dean for Continuing Education, University of Tennessee College of Pharmacy, 600 Henley Street, Suite 213, Conference Center, Knoxville, TN 37996. E-mail:

The content in this monograph was developed with the assistance of a staff medical writer. Each author had final approval of his/her article and all its contents.
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