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2017 HCHB_digital

Migraine Migraines are a

Migraine Migraines are a type of severe headache, and one of the most common headache disorders seen by doctors, occurring in 18% of women and 6% of men. Symptoms of a migraine differ from other types of headache (see Headache). Migraine attacks are typically unilateral (only one side of the head is affected), although occasionally bilateral migraines (both sides of the head) occur. The pain is usually described as a dull throb or tightening which intensifies into a concentrated and severe pain. Most people feel sick; however, only about 30% will vomit. The exact cause of migraines is unknown, but chemical and vascular changes within the brain as well as strong genetic factors are thought to play a role. An aura – which may take the form of a funny smell, taste, feeling or visual disturbance – is experienced by almost one quarter of people with migraine. This may be present for up to an an hour before the headache starts. Migraine sufferers may also have difficulty seeing or speaking. Other common symptoms that occur in addition to the pain of migraine include: • osmophobia (sensitivity to smells) • phonophobia (sensitivity to noise) • photophobia (sensitivity to light) • visual disturbances (blurred vision, flashes of light, zigzag lines, blind spots) • weakness, numbness or tingling in the face, arm or leg • yawning, sleepiness, lack of energy. Migraines can last from four hours to two or three days and may occur once a year to once every few days. Most people have a family history of migraine. First attacks often occur in adolescence, and attacks tend to become less severe and less frequent with age. Migraine attacks can substantially impair a person's functioning during an attack. Research has shown quality of life is also diminished between attacks. Initial assessment Ask your customer to "Tell me about your headache", and listen to their response. A headache is more likely to be a migraine if nausea and/or vomiting TREATMENT OPTIONS Category Examples Comments Simple analgesics Non-steroidal antiinflammatory drugs (NSAIDs) Combination analgesics Antiemetics Serotonin (5-HT) receptor agonists Natural / herbal products / supplements [GENERAL SALE] eg, paracetamol (Panadol range, Paracare) [GENERAL SALE] eg, aspirin (Aspro, Disprin range), ibuprofen up to 25s (Advil, Nurofen Migraine Pain, Nurofen Zavance) [PHARMACY ONLY MEDICINE] eg, diclofenac (Voltaren Rapid 12.5), ibuprofen >25s (Advil, Nurofen range), naproxen (Sonaflam) [PHARMACIST ONLY] eg, diclofenac (Voltaren Rapid 25) [GENERAL SALE] eg, ibuprofen + paracetamol (Maxigesic [16], Nuromol [12]) [PHARMACY ONLY MEDICINE] eg, ibuprofen + paracetamol (Maxigesic [50, 100], Nuromol [24]) [PHARMACIST ONLY MEDICINE] eg, paracetamol + codeine (Panadeine, Panadeine Extra), ibuprofen + codeine (Ibucode Plus, Nurofen Plus), paracetamol + doxylamine + codeine (Mersyndol*) [PHARMACIST ONLY MEDICINE] eg, prochlorperazine (Antinaus) [PHARMACIST ONLY MEDICINE] eg, sumatriptan 50mg (Sumagran Active), zolmitriptan nasal spray 5mg (Zomig) 5-HTP, caffeine, butterbur, coenzyme Q10, feverfew, magnesium, riboflavin (Clinicians MigraDol) Generally effective at relieving mild-type pain. May not be strong enough as the sole analgesic for migraine. Few adverse effects. Products with an asterisk have a detailed listing in the Migraine section of OTC Products, starting on page 250. NSAIDs generally last longer than paracetamol. Ibuprofen is the NSAID least likely to cause stomach irritation. NSAIDs may not be suitable for people on certain other medications or with some medical conditions (eg, asthma, kidney disease – see Refer to Pharmacist). Advise customer to stop taking if stomach upsets, increased bruising or prolonged bleeding occur. Aspirin products require the same warnings as other NSAID products. Aspirin is not recommended for adolescents or children under 12 years old, or for children under 16 years old with a viral-related fever, or fever with chickenpox (see Childhood Pain and Baby Teething: Treatment options). See also Reference Section, OTC Medicines – Precautions. Try paracetamol or NSAIDs first. Warn customers that codeine is an addictive substance and should not be used for more than three days at a time. Constipation or drowsiness may also occur. Monitor sales and be alert for any customers who may be misusing codeine-containing preparations. Mersyndol also contains doxylamine, so can cause drowsiness. Can be sold by a pharmacist in quantities of 10 or fewer tablets for nausea associated with migraine. Proven effectiveness in migraine. Small packs may be sold by a pharmacist for adults with a stable, well-established pattern of migraine symptoms for relief of acute attacks. Follow packet instructions strictly. Caffeine in combination with analgesics is effective at treating migraine. Other supplements may be more effective for preventing migraines when taken daily for at least three months. Significant learning opportunity: Wound care Your new Group 3 CPD project Page 106 HEALTHCARE HANDBOOK 2017-2018 Common Disorders

CONTINUING OTC EDUCATION are present in combination with two of the following three symptoms: sensitivity to light, sensitivity to loud sounds, and sensitivity to smells. Many people also get tension type headaches in addition to migraines (see Headache). If the symptoms they are describing seem typical of migraine, and they have never had a formal diagnosis of migraine from a doctor, refer them to a pharmacist who may choose to refer them to a doctor for further tests. Also refer any customers over 50 with a first episode of headache or customers with other symptoms of concern (see RED FLAGS in the Refer to Pharmacist text box). Treatment available over the counter includes analgesics, serotonin (5- HT) agonists and antiemetics, many of which are Pharmacist Only. Stronger analgesics and preventive medications are available from the doctor. Causes or triggers Although the cause of migraine is not fully understood, some people prone to migraine have found exposure to certain things can trigger their migraine. These are called trigger factors and the most common ones include: • certain foods (eg, alcohol, cheese, chocolate, caffeine, artificial sweeteners) • environment and temperature changes (eg, exposure to heat or cold, altitude) • exercise • flickering/flashing lights or loud noises • hunger • mood (eg, anxiety, stress) or hormonal changes (eg, menstruation) • sleep – too little or too much • strong smells (such as perfume, paint, cleaning solutions, fumes, smoke). Advice for customers • Rest in a quiet, darkened room. Reusable heat pads may provide relief. • Keep a diary of when the migraines occur, paying particular attention to occurrence with food, stress or other events (eg, menstrual cycle). • Analgesics or serotonin agonists, with or without antiemetics, should be taken at the first sign of an attack (once the attack has started gastric motility is slowed, which decreases absorption of the medicine). • Be careful not to overuse analgesics since medication overuse headache can coexist with migraine (see Headache). • Drink plenty of water, maintain regular exercise and a healthy diet. • Consider acupuncture, hypnosis and relaxation training. Refer to PHARMACIST Refer to the pharmacist anybody who has not had the diagnosis of migraine confirmed by a doctor. RED FLAGS (ALARM SIGNALS) – REFER TO A DOCTOR • First episode of migraine in a person aged over 50 • Description of migraine as "The worst headache of my life" (requires urgent referral) • Headaches that have worsened over several months • Any headache that is severe right from the start (as compared with one that gradually develops) • A headache that develops after a head injury or major trauma • A headache that is brought on by lying down, a cough, sneeze, bending or with exertion • Concurrent symptoms such as fever, high blood pressure, muscle aches, weight loss or scalp tenderness which may suggest a whole body disorder • Seizures, confusion, changes in consciousness or difficulty waking. Other questions to ask For customers with a previous diagnosis of migraine, decide if any further questions still need to be asked and refer any “yes” answers to a pharmacist. • Does the person have any other health conditions (eg, heart disease, diabetes, is pregnant or breastfeeding)? • Does the person take any other medication or complementary therapies, either prescribed by a doctor or bought from a shop? • Does the person wish to purchase a migraine-specific medicine or have their symptoms persisted despite taking analgesics? • Is the person a child or young adult aged less than 18, or elderly? • Does the person also have a fever, rash or a stiff or sore neck (see Childhood Diseases and Immunisation: Meningococcal Disease)? • Does the person have frequent migraines (more than two a month) or is buying a lot of analgesics? • Is there any pain within the eye? • Does the person have any allergies to medicines? Visit ELearning to start your project www.pharmacytoday.co.nz Facilitated by Dr Alesha Smith Page 107

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