April 21, 2025 • 31 mins
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
Pharmacist Members, REDEEM YOUR CPE HERE!
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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.
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:10):
Hey, ce Impact subscribers, Welcome to the Game
Changers Clinical Conversationspodcast.
I'm your host, josh Kinsey, and, as always, I'm excited about
our conversation today.
Headaches are one of the mostcommon health complaints, but
their management can besurprisingly complex, especially
when distinguishing betweenprimary and secondary causes.
In this episode, we'll exploreevidence-based strategies for
(00:34):
treating headaches and discusshow pharmacists can play a
pivotal role in improvingoutcomes for patients struggling
with this challenging condition.
And it's so great to haveAllison Martin with us today as
our guest for today's episode.
Allison, thanks for joining us.
Speaker 2 (00:49):
Thank you so much for having me.
Speaker 1 (00:50):
Yeah, we appreciate you taking time.
She's in her clinic settingtoday, so again taking time out
of your busy schedule and we'revery grateful.
So thank you so much.
Before we jump into our topicfor today, allison, I will let
you kind of introduce yourselfto the learner.
So take a couple of minutes andtell us about yourself.
Your practice site I referencedand I always like to let the
(01:14):
learner know why you'repassionate about today's subject
.
Why have we brought you on forthe episode?
Speaker 2 (01:18):
Yeah, okay, great.
Well, thank you again forhaving me.
So I currently practice in theAmbulatory Care Ne care
neurology clinic at the Ralph HJohnson VA healthcare system and
my role here?
I've been in this role for 10years, almost 10 years, and we
developed a pharmacist-ledpharmacotherapy clinic for
(01:40):
comprehensive medicationmanagement within the neurology
practice.
So how my practice workspatients get consulted to the
neurology service after they'veseen the neurologist, had their
diagnosis established.
If a need is identified formore fine-tuning of the
medications or a closerfollow-up on medications, then
(02:00):
they are referred to my clinicUsing my scope of practice.
Then I'll work on thosemedication adjustments.
Hopefully we'll get them to aplace where we're meeting
patient and provider goals andcan send them with continued
care.
So my consults are quitediverse within the general
neurology practice, althoughabout 50% of my consults, you
(02:24):
know, year to year, have prettypredictably been various
headache disorders.
It is certainly one of thoseneurologic conditions I'm very
passionate about.
I have somewhat of a personalconnection.
My mother suffers frommigraines and especially later
in life she's she's had quitedebilitating challenges.
So it's been an area that I'vebeen personally passionate about
(02:47):
and I think is such a greatarea where pharmacists can
really work at the top of theirlicense and offer support across
multiple practice settings.
Speaker 1 (02:57):
Yeah, no, that's great, and what a great resource
for your mom to have theheadache expert there to kind of
help her through the process aswell.
So, yeah, well, thanks again,allison.
We're so excited to have youand for you to share your
expertise and your knowledge onheadaches with us today.
So, without further ado, let'sjump into our content.
(03:17):
So one of the things I alwayslike to do is to ensure that
we're kind of just laying thefoundation for the topic for
today.
So let's just kind of take astep back and just reiterate and
discuss again just theprevalence and impact of
headaches Like what is thisdoing to our patients, the
impact on their quality of life,like obviously you see this
(03:40):
firsthand.
So just kind of let's set thestage and just kind of everybody
go back and remember whatheadaches are, how they're
classified and you know how theyimpact others.
Speaker 2 (03:49):
So right, absolutely I mean pretty predictably this
has been one of the most commonneurologic conditions that we
see, and I mean even worldwide.
You know recent reports havebeen over 3 billion patients
suffering with headachedisorders.
And you think about a lot ofthese headache disorders and
when they often present and aremost common, you're thinking a
(04:13):
lot of younger individuals timeswhen they are working and so
the impacts you can see, notjust on the healthcare system
and utilizing healthcareresources, 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.
(04:34):
So it certainly is asignificant condition that can
have a lot of impacts.
That can have a lot of impacts.
You mentioned, you know, kindof diagnosing or characterizing
the different headache types,and I think we'll get into that
a little bit more later and thatalso becomes quite an important
(04:56):
consideration as we're steppingdown this pathway, thinking
about treatments and differentrecommendations.
Speaker 1 (05:04):
Right, Because that, I mean, obviously isn't going to
inform which path you takebased on the management of what
is classified as right.
Speaker 2 (05:12):
Absolutely.
Speaker 1 (05:13):
Yeah, yeah, those numbers were mind blowing.
Like that is a lot of peoplethat suffer from headaches and
you know, you bring up a greatpoint as well in the fact that
it's not just the quality oflife of the patient that it's
impacting.
Obviously, that's important andthat's one of the things that
we want to try to affect withthe managing and as a pharmacist
(05:35):
.
But it's like you said, themissed work or the missed
productivity, or the fact thatthey maybe can't drive because
of debilitating headaches and sotherefore, 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 cankind of blossom and grow from
just a headache diagnosis thatreally affect and impact not
(05:58):
just the patient's quality oflife but everything around them.
So yeah, that's a great point.
Speaker 2 (06:03):
Absolutely.
I'll add to that I always findinteresting you know it's a
disorder that many alsoself-treat and manage over the
counter.
So even some of those numberswe may not have complete and
accurate assessments, and it maybe more prevalent than we know
Exactly.
Speaker 1 (06:19):
Yeah, because I mean, how many times do you say, oh
man, I have a splitting headacheand you just, you know, pop a
couple of pills and at home andit's, you know, not anything
that you actually get follow-upcare with or be officially
diagnosed with something?
So, yeah, well, I think it's agreat way to kind of go into it.
Let's, let's go and set thestage for what are the different
types of, or the differentclasses of classifications of,
(06:41):
headaches, just so that we cankind of know.
We don't have to go into greatdetail there, but it'll kind of
help inform the decision as tohow we're talking about the
management of them later.
Speaker 2 (06:49):
Absolutely Well.
Usually we start prettybroad-based in classifying
either as a primary or secondaryheadache.
So secondary headaches, youkind of think in secondary
nature to something else thathas caused this.
So this could be post-traumaticheadaches.
If they've had a history ofhead trauma, this could be
(07:09):
cervicogenic headaches.
This could be one of the mostcommon ones that we may
encounter, especially aspharmacists, is medication
overuse headaches resulting fromoveruse of various analgesic or
even migraine-specificmedications for acute treatment.
So those are secondaryheadaches and we'll talk a
little bit too about how totease out or know when to refer
(07:32):
on for additional evaluation andred flag symptoms.
But primary headaches the keythree that you'll see are the
tension-type headaches, migraineheadaches and cluster headaches
.
And migraine headachesspecifically, that tends to be
one of the more prevalent,certainly is one of the most
common primary headachedisorders I see come through my
(07:52):
clinic and has also been reallythe focus of a lot of medication
, drug development and research.
So, for migraines alone.
We've had, gosh in the lastdecade, nine different novel
medication approvals just formigraines alone.
So yeah, a lot of exciting timeto be a pharmacist in neurology
(08:17):
and learning about all of thesefor sure.
Speaker 1 (08:19):
Yeah, for sure, yeah, for sure.
It's sad sometimes that we geekout when you know things I
guess promoted are really kindof shown that they're impacting
a lot of people.
But yeah, you make a greatpoint because you know what
other disease state can makethat claim.
I would say very few that youknow have had that much
(08:40):
dedication to new, novelmedications being kind of
developed and studied.
So yeah, that's greatinformation to know.
Okay, so then you mentionedthat migraines were the most
common there, and this is whereI'll ask potentially a dumb
question.
I guess I kind of alwaysthought or remembered that
clusters were just multiplemigraines, but you kind of made
(09:06):
them sound like they'redifferent classifications, is
that?
Speaker 2 (09:08):
right, it is, yeah, so you know you can.
Then, many times you see all ofthese primary headache
disorders, then subclassified aseither episodic or chronic.
And so that may be where someof that thought is coming from.
But, yes, cluster headaches aretheir own separate primary
headache diagnosis.
And this is all outlined fromthe ICHD-3, or the International
(09:31):
Classification of HeadacheDisorders, the third edition.
That's what is our goldstandard for diagnosis criteria.
Speaker 1 (09:38):
Okay, great, yeah, All right.
So now that we've kind of setthe stage for primary versus
secondary and kind of what fitsinto those under those
additional subcategories, let'stalk a little bit about the
management and maybe how that's.
You know what are some recentupdates or movement in that
space, or you know what are someof the things that we need to
(09:59):
know as pharmacists.
As far as you said, multiplenew novel products out there, so
how they impacted themanagement and what we're going
to be doing from a pharmacistperspective.
Speaker 2 (10:09):
Absolutely and I think, maybe focusing on
migraine headaches specificallyfor this next part.
Speaker 1 (10:14):
Sure yes, that sounds great yes.
Speaker 2 (10:16):
I mean in general, for approaching the treatment
and management of headaches.
I think really the foundationfirst is to know there are two
arms to headache management.
So we have our acute treatments, which are those medications we
are often prescribing on anas-needed basis with the goal of
bringing acute relief, you know, ideally freedom from pain,
(10:40):
relief from headache, but atleast an ability to return to
function and a lower intensityof the headache pain, managing
acute symptoms along with that.
So with migraine we can see alot of nausea, vomiting,
sensitivity to light,sensitivity to sound and many
others.
So that's one whole arm, acutetreatment of the migraine itself
(11:00):
.
But then the other treatmentpath that we have to consider is
preventive treatment, and sothis is usually with a routine
scheduled medication which couldbe a daily basis, or we have
some of these newer medicationson a monthly or a quarterly
basis with the intent ofpreventing the migraines.
And so what we're looking forfrom this treatment arm is a
(11:24):
reduction in headache frequency,a reduction overall headache
and migraine days in a month.
So I think, going intotreatment, it's important to
know those two different sidesof the coin.
Many times I see patients comingto me and are mixing the two.
You know we're thinking some ofour preventive medicines are
(11:46):
really they're using it asneeded as acute treatments and
vice versa.
Others where we're using acutetreatments on a daily basis to
help manage the headache.
So this is a great spot wheresetting that foundation, having
good understanding to thetreatment approach to migraines
and headache disorders, isparamount.
Speaker 1 (12:04):
Yeah, and you know our podcasts are shorter in time
so we don't have enough time todig into all the different new
novel medications and which onesdo what and whatever.
That would be a whole nothercourse.
But in general, I just wantedto kind of go back Um.
The ones that you mentioned aremonthly or quarterly.
(12:25):
Are those injectables?
Is that what we're talkingabout here?
Yes, Well.
Speaker 2 (12:30):
So you know, most of the new migraine medications
we've had are through a wholenew pathway, a whole new
mechanism of action.
So these are.
They call them CGRP targetingtherapies.
So CGRP, the calcitoningene-related peptide.
The calcitonin gene-relatedpeptide Basically it's from the
research that we found and whatwe know is part of the
(12:52):
pathophysiologic process in amigraine.
So we're trying to block thatCGRP rise in activity.
And so our medications we'vehad some that are approved
specifically for acute treatment.
So those are often CGRP smallmolecules, oral tablets that you
can take, or one that's a nasalspray that you take on an
as-needed basis as an acutetreatment.
(13:14):
And then we have others thatare one that's an oral, three
that are subcutaneous injectionsand 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 andonly migraine medicine approved,
(13:35):
for both you can use it foracute treatment and can be a
preventive agent.
Speaker 1 (13:39):
Okay, great, and is the dual one?
Is that?
What formulation is that?
Speaker 2 (13:44):
It is actually an ODT , a dissolvable tablet.
Speaker 1 (13:47):
Okay, got it Okay.
Speaker 2 (13:49):
A lot of new action, yeah that's great.
Speaker 1 (13:52):
That's a great overview, and you know again.
We could spend another hourdigging 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 towhen treating and managing
(14:14):
migraine headaches?
So where are the discussions onwhat to use, when to use, how
to use that kind of thing?
Speaker 2 (14:23):
Absolutely Great question and an area of a lot of
literature and topics we coulddiscuss further too.
Speaker 1 (14:31):
Open to Pandora's box .
Speaker 2 (14:38):
The last major guidelines that we've had were
from the American Academy ofNeurology, published in 2012,
specifically for the preventionof episodic migraines.
This is where you see a lot ofour older medications that are
not necessarily FDA approved orspecifically designed for
migraine, but we know haveestablished evidence for helping
prevent migraines.
So you think of some of youranti-seizure medicines and your
(15:00):
antihypertensives, for example.
So 2012, quite a few years ago.
Speaker 1 (15:07):
Yeah.
Speaker 2 (15:07):
And starting around.
Speaker 1 (15:08):
I mean well, especially since you know that's
13 years and you said there'sbeen so many new novel products
in the last decade, like I feellike there's a missing guideline
update.
Speaker 2 (15:18):
So the AAN guideline update is in progress, but I
have not heard a release date onwhen we may expect that to be
out of circulation yet.
Speaker 1 (15:26):
Got it.
Speaker 2 (15:27):
But really to address that.
Yeah, we've had quite a fewdifferent organizations that
have put out guidelines orposition statements, consensus
statements, to try to addresswhere these new therapies may
fit into practice.
So my practice site is at theVA.
You mentioned the VA DODclinical practice guidelines.
(15:48):
We have had a guideline updatefor our population.
It was published in 2023, anupdate from 2020.
And it comments on some ofthese newer therapies as well.
The private sector or, moreglobally, we have the American
Headache Society that haspublished several position
(16:09):
statements and most recently hada publication just last year
specifically addressing how weintegrate these new CGRP
targeting therapies and evencommenting or almost advocating
for considering these options,sometimes as first line options.
Now, those are not formalguidelines.
(16:31):
It is still a position orconsensus statement, so you do
need to take that with a grainof salt, but I think it does
give some helpful perspectiveand helps to really help
consider this really vastincrease in medical literature
that we have to sort through andnavigate as clinicians to try
(16:53):
to decide where these fit inpractice right now.
Speaker 1 (16:56):
Yeah for sure.
Wow, yeah, that's a greatoverview and it sounds like your
need, or your division, of whatyou're doing there.
You all are in need of thoseupdates and those changes, so
hopefully that's coming soon.
So let's segue into what is therole of the pharmacist here.
(17:18):
You know, like, what are wepositioned to do as pharmacists
in managing headaches for ourpatients?
And you can specifically, youknow, speak to migraines, if
that's really probably themajority, I would assume, of
what we would see in practicesetting.
But let's just, I want to talkabout what exactly can
(17:38):
pharmacists do in this space.
Speaker 2 (17:40):
Yeah, absolutely Well .
I mean, just knowing thatheadaches are so prevalent, I
think it's very likely thatpharmacists will encounter
patients with different headachedisorders across multiple
practice settings, whether we'rein the community, whether we're
in the hospital, whetherambulatory care.
So you know, patient educationis very important.
(18:01):
We talked a little bit abouteducating on the treatment
approach to migraines the acuteversus preventive treatment.
One reason why I think thatbecomes so important is because
of the secondary headache that Imentioned earlier the
medication overuse headache,what was formerly known as
rebound headache.
Speaker 1 (18:20):
Many still refer to it as rebound headaches.
I was going to circle back tothat because you mentioned that
the meds cause headachesthemselves.
That was intriguing.
So yes, let's go down that path.
Yeah, for sure.
Speaker 2 (18:31):
Absolutely, and it's kind of counterintuitive for
patients.
They may have found a medicineor even an over-the-counter or a
prescription-specific migrainemedication to manage those
symptoms and it has benefits.
So why not take it on a dailybasis or why not take it for
every single migraine?
(18:51):
So medication overuse headacheand this is another specific
secondary headache that isoutlined in those diagnostic
criteria I referenced.
Essentially it's a headachethat can arise after consistent
overuse of acute treatments, andso this can be different
analgesics, whether it'sover-the-counter medications
(19:14):
like acetaminophen, ibuprofen,naproxen.
It can be some of ourprescription options and some of
our migraine-specific acutetreatments.
The triptans, like sumatriptan,risotriptan that whole class
has been associated with these.
Some of our other acutetreatments, like ergotamines and
(19:36):
then acute treatments that aregenerally not recommended
anymore for migraines arebutalbitol containing products
and opioid analgesics.
They have an even higher risk ofmedication overuse headache.
So but in general, when youlook at those different
treatments, for the most partwe're talking less than 10 doses
(19:59):
a month, and when we'restarting to exceed those numbers
.
So if you have a sumatriptanprescription for acute headache
management, acute migrainethat's why it's often limited to
a quantity of nine.
So 10 doses or more is where wesee that association with
medication overuse headache,where it can either cause the
(20:22):
secondary headache or themigraine diagnosis that they had
as their primary headache maybecan convert into chronic
migraine and it can be verydifficult to manage once we get
into this cycle and overusingthese acute treatments.
So prevention really is the keyand I think that education and
(20:44):
you know, kind of like smokingcessation, you ask about it at
every visit.
I kind of feel like that herewith medication overuse headache
, ask about it at every visit.
How often are you using it?
Try to really reiterate thosepoints and provide that
education so we don't get intothat cycle and have worsening
outcomes.
Speaker 1 (21:03):
Yeah, and I mean you know pharmacists are well
positioned, especially thosethat have access to the field
data.
You know we can see how oftenthey're filling those
medications.
You know, I would assume thetriptans now a lot of them have
been generic for a while.
A lot of them are probably veryaffordable now, and so some
patients probably say, oh well,my insurance doesn't pay for
more than nine, well, I'll justpay cash for another refill or
(21:26):
something.
So I think that would be a redflag in a sense of are you
overusing them?
Not a red flag in a sense ofyou're committing insurance
fraud or you shouldn't be doingthis, but more of a again asking
those thorough questions howoften are you actually using
these and providing theeducation and making sure that
(21:47):
they're aware that overuse ofthem can cause the rebound
headaches, right?
So that's a great position fora pharmacist to kind of jump in.
Speaker 2 (21:56):
Absolutely.
You know you mentioned redflags.
We use sometimes a mnemonic forred flag symptoms for headaches
and one of them does referencepainkiller overuse.
So we have the SNOOP criteriais what it's referred to
sometimes.
So that is one of those referon because they may need a
preventive therapy that's added,or they may need further
(22:19):
evaluation to help get a handleon their headaches.
Speaker 1 (22:22):
Right, and this may be opening up a whole different
avenue of discussion.
That would take longer.
But how do we rectify the issueof having a rebound headache?
Like are they ever able to goback to using those preventative
or to using those acutemedications?
Speaker 2 (22:39):
There's some different schools of thought.
You know, many times we'reconsidering a preventive
medication.
Many times we're considering apreventive medication, we're, at
minimum, trying to taper downor even taper off of the acute
medication that is the culpritand trying a different option.
One thing that's interesting tonote is that I mentioned the
CGRP targeting therapies, theGPANTS, that are approved for
(23:02):
acute treatment.
We have not seen thismedication class associated with
medication overuse headache,and so this could be one place
where, if you have someone youknow really struggling with this
, has tried our standard options.
We're not making much headway.
Maybe this is where we go nextwith one of these oral CGRP
(23:22):
inhibitors.
Speaker 1 (23:23):
Okay, interesting.
I would imagine that, one beingnew, that it's probably very
expensive and possibly not oftencovered and whatnot, so may run
into barriers there, but againit sounds like it would be a
down the line option.
So if they've already kind ofquote unquote, failed on
previous therapies or struggled,then maybe it would be
something that could getapproved.
(23:43):
So, yeah, no, that's a great,another great place for
pharmacists to interject in inbeing able to say, you know,
with that continuity of care,like, oh well, they've tried
this, this and this before, soyou know, maybe they're a
candidate for this.
So right.
Okay, that's very helpful andkind of setting the stage for
those rebound headaches.
Again, I feel like somethingthat is not really commonly
(24:07):
discussed.
So I think that's a great keypoint for pharmacists to educate
patients on that phenomenon andjust to make sure that patients
are aware and are not overusing.
So that's great.
What other opportunitiesbesides patient education do you
see pharmacists have in themanagement of headaches space
and these?
Speaker 2 (24:27):
updated position statements for both the
treatment arms prevention andacute treatment, and they cross
a lot of different mechanismsand a lot of different
(24:48):
specialties.
And you know, you may be seeingsomeone in clinic for blood
pressure management and you'remanaging their hypertension, but
they're also having migrainesthat have been worsening.
So maybe even just knowing whatsome of the key areas are where
we can overlap and use amedication as a dual treatment-
(25:09):
for those differentcomorbidities.
Try to minimize polypharmacy.
Certainly is an opportunitywhere I think pharmacists can
jump in and use that drugknowledge.
Speaker 1 (25:20):
Yeah, for sure, and you know we touched on I think
we didn't speak to itspecifically but adherence,
obviously, and again, theeducation on when is it
appropriate to use apreventative versus an acute,
and those kinds of things, andthen watching for the refill
data and determining, you know,are they adherent and whatnot
you mentioned earlier.
(25:40):
And this is something I want togo down this path before our
time runs out.
I swear I'm going to extendthese podcast sessions.
I say every time like our timejust comes to an end so quickly.
So one thing I wanted to godown the path of and just
briefly discuss again becauseyou mentioned it.
There are often some sideeffects from the medications
(26:01):
themselves, right, but there arealso other side effects from
the medications themselves,right, and, but there are also
other side effects that they'retreating, other than the
headache itself.
So let's talk briefly aboutthat and how the medications
play into that and whatpharmacists can maybe.
Speaker 2 (26:12):
Right, absolutely Well.
You know, I think a hugetakeaway point and this has also
been consistently reiterated inguidelines and position
statements is that headachemanagement is not a
one-size-fit-all approach.
Every patient is so unique inhow they may respond to a
different medication, how theymay tolerate a different
(26:33):
medication, so I think you haveto go into each unique situation
, each unique patient, with thatin mind and treat that one
patient.
Know that we've got this nowplethora of different options,
from both nonspecific andmigraine specific, to even a lot
of new non-pharmacologic andneuromodulation devices and
(26:54):
different options for management.
So you have to find what isgoing to meet the patient's
goals where can we minimize druginteractions, where can we
prevent those side effects, ormaybe where we can provide some
overlapping benefits.
That's really um, that reallyis what I love about my job.
It's kind of every day is alittle bit like a puzzle.
How, how can?
we make a bigger impact with onesmall adjustment yeah, yeah
(27:20):
that goes even down to thedosing you know with prevent
medicines.
This is something I tell mylearners when they're on
rotation.
All the time, when you'rethinking about an adequate trial
of preventative medicine, youneed to ask yourself did they
get to the right dose?
Were they there for the rightamount of time, Right dose,
right time?
And so sometimes that titrationneeds to go slower for some
(27:42):
patients.
Maybe we need to target a lowerdose or a little higher dose.
And did they have an adequatetrial to really give that
medicine a fair shot of working?
So I think, those are alsoquestions you can kind of ask
yourself.
If a patient is showing up andsaying, oh, I started this
topiramate and I've been takingit for two weeks, it's not doing
(28:03):
anything, we need to know thatthat's not an adequate trial,
that's not enough time to seethat benefit captured and again,
another great place for aninterjection from the pharmacy
team.
Speaker 1 (28:15):
And you know, with that continuity of care,
collaborating with the otherproviders, making sure that
they're aware, you know theyonly took this for two weeks.
That probably wasn't sufficient, you know, before you just
start jumping around to anothermedication choice.
So yeah.
Right yeah.
Speaker 2 (28:29):
Since I gave you my go-to for preventive medicine, I
guess I'll give you myone-liner for acute treatment.
I tell learners hit it hard,hit it fast.
So, that's anotherconsideration.
Sometimes, you know, you may behaving someone coming in
treating with the 325 milligramof acetaminophen.
That may not cut it for amigraine of moderate severity,
(28:50):
you know so we may need to hitit with 1000 milligrams.
So hit it hard, hit it fast.
Another key education componentis these acute treatments are
going to work best if you cantake them right away at that
first sign of a migrainepresenting or even sometimes in
that aura phase or craniomalphase so hit it hard, hit it
fast, get it in quick for bestresponse.
(29:13):
And so that's another placewhere I think we can support and
provide that education forpatients that may optimize their
medications effectiveness.
Speaker 1 (29:22):
Yeah, that's great.
That's great.
Well, I still have a lot ofthings on my list.
I'm going to just have to haveyou back for another episode.
So, briefly, we can talk justquickly.
Are there any challenges orbarriers that you've seen in
managing headaches that you wantto kind of touch on or share
(29:43):
any kind of tips or tricks about?
Speaker 2 (29:45):
Right Managing the medication overuse headaches
sometimes can be a big challengelike that perception coming in
of needing that acute treatmentand having to, you know, think
about those motivationalinterviewing techniques and that
shared decision making processto try to reframe our goals and
(30:06):
expectations, so that that maybe one challenge.
I'll just kind of reiteratethat.
Speaker 1 (30:11):
And, to be fair, it's not logical.
It's not logical right, like itdoesn't even like the fact of
the medication you're taking totreat your headache might cause
a headache like that.
So I can see where patients getreally confused or lost with
that.
So that's a great, a greatopportunity for the pharmacist
to really step in and educateand to support with that.
(30:33):
So, okay, well, with that, Iwill like to I always like to
kick it back to this, our guest,and ask you what's our game
changer here, what's ourtake-home point for our
listeners?
Speaker 2 (30:45):
Right.
I think the take-home overallis that we have to treat every
single patient individually,look at each unique case
comprehensively, look at whatare those specific goals that
we're trying to achieve and thatthe patient has, using the
shared decision-making to findthe best fit and the best
(31:06):
regimen, since every patient isso different.
Speaker 1 (31:09):
Yeah, so the game changer here is pharmacists.
You do have a role.
It's a very important role, andyou need to be sure that you
are individualizing the care foryour patients.
Yeah, that's great.
Well, allison, that's all wehave time for.
Thank you so much for joiningus.
This was great.
I learned a lot.
It's been a while since I'vetalked about headaches, yeah, so
(31:31):
this was great.
Thank you so much Great.
Speaker 2 (31:33):
Thank you so much for having me.
Speaker 1 (31:34):
Yeah, absolutely.
If you're a CE plan subscriber,be sure to claim your CE credit
for this episode of GameChangers by logging in at
CEimpactcom.
And, as always, have a greatweek and keep learning.
I can't wait to jump intoanother game-changing topic with
you all next week.
Hey, ce Impact subscribers, Welcome to the Game
Changers Clinical Conversationspodcast.
I'm your host, josh Kinsey, and, as always, I'm excited about
our conversation today.
Headaches are one of the mostcommon health complaints, but
their management can besurprisingly complex, especially
when distinguishing betweenprimary and secondary causes.
In this episode, we'll exploreevidence-based strategies for
(00:34):
treating headaches and discusshow pharmacists can play a
pivotal role in improvingoutcomes for patients struggling
with this challenging condition.
And it's so great to haveAllison Martin with us today as
our guest for today's episode.
Allison, thanks for joining us.
Speaker 2 (00:49):
Thank you so much for having me.
Speaker 1 (00:50):
Yeah, we appreciate you taking time.
She's in her clinic settingtoday, so again taking time out
of your busy schedule and we'revery grateful.
So thank you so much.
Before we jump into our topicfor today, allison, I will let
you kind of introduce yourselfto the learner.
So take a couple of minutes andtell us about yourself.
Your practice site I referencedand I always like to let the
(01:14):
learner know why you'repassionate about today's subject
.
Why have we brought you on forthe episode?
Speaker 2 (01:18):
Yeah, okay, great.
Well, thank you again forhaving me.
So I currently practice in theAmbulatory Care Ne care
neurology clinic at the Ralph HJohnson VA healthcare system and
my role here?
I've been in this role for 10years, almost 10 years, and we
developed a pharmacist-ledpharmacotherapy clinic for
(01:40):
comprehensive medicationmanagement within the neurology
practice.
So how my practice workspatients get consulted to the
neurology service after they'veseen the neurologist, had their
diagnosis established.
If a need is identified formore fine-tuning of the
medications or a closerfollow-up on medications, then
(02:00):
they are referred to my clinicUsing my scope of practice.
Then I'll work on thosemedication adjustments.
Hopefully we'll get them to aplace where we're meeting
patient and provider goals andcan send them with continued
care.
So my consults are quitediverse within the general
neurology practice, althoughabout 50% of my consults, you
(02:24):
know, year to year, have prettypredictably been various
headache disorders.
It is certainly one of thoseneurologic conditions I'm very
passionate about.
I have somewhat of a personalconnection.
My mother suffers frommigraines and especially later
in life she's she's had quitedebilitating challenges.
So it's been an area that I'vebeen personally passionate about
(02:47):
and I think is such a greatarea where pharmacists can
really work at the top of theirlicense and offer support across
multiple practice settings.
Speaker 1 (02:57):
Yeah, no, that's great, and what a great resource
for your mom to have theheadache expert there to kind of
help her through the process aswell.
So, yeah, well, thanks again,allison.
We're so excited to have youand for you to share your
expertise and your knowledge onheadaches with us today.
So, without further ado, let'sjump into our content.
(03:17):
So one of the things I alwayslike to do is to ensure that
we're kind of just laying thefoundation for the topic for
today.
So let's just kind of take astep back and just reiterate and
discuss again just theprevalence and impact of
headaches Like what is thisdoing to our patients, the
impact on their quality of life,like obviously you see this
(03:40):
firsthand.
So just kind of let's set thestage and just kind of everybody
go back and remember whatheadaches are, how they're
classified and you know how theyimpact others.
Speaker 2 (03:49):
So right, absolutely I mean pretty predictably this
has been one of the most commonneurologic conditions that we
see, and I mean even worldwide.
You know recent reports havebeen over 3 billion patients
suffering with headachedisorders.
And you think about a lot ofthese headache disorders and
when they often present and aremost common, you're thinking a
(04:13):
lot of younger individuals timeswhen they are working and so
the impacts you can see, notjust on the healthcare system
and utilizing healthcareresources, 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.
(04:34):
So it certainly is asignificant condition that can
have a lot of impacts.
That can have a lot of impacts.
You mentioned, you know, kindof diagnosing or characterizing
the different headache types,and I think we'll get into that
a little bit more later and thatalso becomes quite an important
(04:56):
consideration as we're steppingdown this pathway, thinking
about treatments and differentrecommendations.
Speaker 1 (05:04):
Right, Because that, I mean, obviously isn't going to
inform which path you takebased on the management of what
is classified as right.
Speaker 2 (05:12):
Absolutely.
Speaker 1 (05:13):
Yeah, yeah, those numbers were mind blowing.
Like that is a lot of peoplethat suffer from headaches and
you know, you bring up a greatpoint as well in the fact that
it's not just the quality oflife of the patient that it's
impacting.
Obviously, that's important andthat's one of the things that
we want to try to affect withthe managing and as a pharmacist
(05:35):
.
But it's like you said, themissed work or the missed
productivity, or the fact thatthey maybe can't drive because
of debilitating headaches and sotherefore, 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 cankind of blossom and grow from
just a headache diagnosis thatreally affect and impact not
(05:58):
just the patient's quality oflife but everything around them.
So yeah, that's a great point.
Speaker 2 (06:03):
Absolutely.
I'll add to that I always findinteresting you know it's a
disorder that many alsoself-treat and manage over the
counter.
So even some of those numberswe may not have complete and
accurate assessments, and it maybe more prevalent than we know
Exactly.
Speaker 1 (06:19):
Yeah, because I mean, how many times do you say, oh
man, I have a splitting headacheand you just, you know, pop a
couple of pills and at home andit's, you know, not anything
that you actually get follow-upcare with or be officially
diagnosed with something?
So, yeah, well, I think it's agreat way to kind of go into it.
Let's, let's go and set thestage for what are the different
types of, or the differentclasses of classifications of,
(06:41):
headaches, just so that we cankind of know.
We don't have to go into greatdetail there, but it'll kind of
help inform the decision as tohow we're talking about the
management of them later.
Speaker 2 (06:49):
Absolutely Well.
Usually we start prettybroad-based in classifying
either as a primary or secondaryheadache.
So secondary headaches, youkind of think in secondary
nature to something else thathas caused this.
So this could be post-traumaticheadaches.
If they've had a history ofhead trauma, this could be
(07:09):
cervicogenic headaches.
This could be one of the mostcommon ones that we may
encounter, especially aspharmacists, is medication
overuse headaches resulting fromoveruse of various analgesic or
even migraine-specificmedications for acute treatment.
So those are secondaryheadaches and we'll talk a
little bit too about how totease out or know when to refer
(07:32):
on for additional evaluation andred flag symptoms.
But primary headaches the keythree that you'll see are the
tension-type headaches, migraineheadaches and cluster headaches
.
And migraine headachesspecifically, that tends to be
one of the more prevalent,certainly is one of the most
common primary headachedisorders I see come through my
(07:52):
clinic and has also been reallythe focus of a lot of medication
, drug development and research.
So, for migraines alone.
We've had, gosh in the lastdecade, nine different novel
medication approvals just formigraines alone.
So yeah, a lot of exciting timeto be a pharmacist in neurology
(08:17):
and learning about all of thesefor sure.
Speaker 1 (08:19):
Yeah, for sure, yeah, for sure.
It's sad sometimes that we geekout when you know things I
guess promoted are really kindof shown that they're impacting
a lot of people.
But yeah, you make a greatpoint because you know what
other disease state can makethat claim.
I would say very few that youknow have had that much
(08:40):
dedication to new, novelmedications being kind of
developed and studied.
So yeah, that's greatinformation to know.
Okay, so then you mentionedthat migraines were the most
common there, and this is whereI'll ask potentially a dumb
question.
I guess I kind of alwaysthought or remembered that
clusters were just multiplemigraines, but you kind of made
(09:06):
them sound like they'redifferent classifications, is
that?
Speaker 2 (09:08):
right, it is, yeah, so you know you can.
Then, many times you see all ofthese primary headache
disorders, then subclassified aseither episodic or chronic.
And so that may be where someof that thought is coming from.
But, yes, cluster headaches aretheir own separate primary
headache diagnosis.
And this is all outlined fromthe ICHD-3, or the International
(09:31):
Classification of HeadacheDisorders, the third edition.
That's what is our goldstandard for diagnosis criteria.
Speaker 1 (09:38):
Okay, great, yeah, All right.
So now that we've kind of setthe stage for primary versus
secondary and kind of what fitsinto those under those
additional subcategories, let'stalk a little bit about the
management and maybe how that's.
You know what are some recentupdates or movement in that
space, or you know what are someof the things that we need to
(09:59):
know as pharmacists.
As far as you said, multiplenew novel products out there, so
how they impacted themanagement and what we're going
to be doing from a pharmacistperspective.
Speaker 2 (10:09):
Absolutely and I think, maybe focusing on
migraine headaches specificallyfor this next part.
Speaker 1 (10:14):
Sure yes, that sounds great yes.
Speaker 2 (10:16):
I mean in general, for approaching the treatment
and management of headaches.
I think really the foundationfirst is to know there are two
arms to headache management.
So we have our acute treatments, which are those medications we
are often prescribing on anas-needed basis with the goal of
bringing acute relief, you know, ideally freedom from pain,
(10:40):
relief from headache, but atleast an ability to return to
function and a lower intensityof the headache pain, managing
acute symptoms along with that.
So with migraine we can see alot of nausea, vomiting,
sensitivity to light,sensitivity to sound and many
others.
So that's one whole arm, acutetreatment of the migraine itself
(11:00):
.
But then the other treatmentpath that we have to consider is
preventive treatment, and sothis is usually with a routine
scheduled medication which couldbe a daily basis, or we have
some of these newer medicationson a monthly or a quarterly
basis with the intent ofpreventing the migraines.
And so what we're looking forfrom this treatment arm is a
(11:24):
reduction in headache frequency,a reduction overall headache
and migraine days in a month.
So I think, going intotreatment, it's important to
know those two different sidesof the coin.
Many times I see patients comingto me and are mixing the two.
You know we're thinking some ofour preventive medicines are
(11:46):
really they're using it asneeded as acute treatments and
vice versa.
Others where we're using acutetreatments on a daily basis to
help manage the headache.
So this is a great spot wheresetting that foundation, having
good understanding to thetreatment approach to migraines
and headache disorders, isparamount.
Speaker 1 (12:04):
Yeah, and you know our podcasts are shorter in time
so we don't have enough time todig into all the different new
novel medications and which onesdo what and whatever.
That would be a whole nothercourse.
But in general, I just wantedto kind of go back Um.
The ones that you mentioned aremonthly or quarterly.
(12:25):
Are those injectables?
Is that what we're talkingabout here?
Yes, Well.
Speaker 2 (12:30):
So you know, most of the new migraine medications
we've had are through a wholenew pathway, a whole new
mechanism of action.
So these are.
They call them CGRP targetingtherapies.
So CGRP, the calcitoningene-related peptide.
The calcitonin gene-relatedpeptide Basically it's from the
research that we found and whatwe know is part of the
(12:52):
pathophysiologic process in amigraine.
So we're trying to block thatCGRP rise in activity.
And so our medications we'vehad some that are approved
specifically for acute treatment.
So those are often CGRP smallmolecules, oral tablets that you
can take, or one that's a nasalspray that you take on an
as-needed basis as an acutetreatment.
(13:14):
And then we have others thatare one that's an oral, three
that are subcutaneous injectionsand 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 andonly migraine medicine approved,
(13:35):
for both you can use it foracute treatment and can be a
preventive agent.
Speaker 1 (13:39):
Okay, great, and is the dual one?
Is that?
What formulation is that?
Speaker 2 (13:44):
It is actually an ODT , a dissolvable tablet.
Speaker 1 (13:47):
Okay, got it Okay.
Speaker 2 (13:49):
A lot of new action, yeah that's great.
Speaker 1 (13:52):
That's a great overview, and you know again.
We could spend another hourdigging 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 towhen treating and managing
(14:14):
migraine headaches?
So where are the discussions onwhat to use, when to use, how
to use that kind of thing?
Speaker 2 (14:23):
Absolutely Great question and an area of a lot of
literature and topics we coulddiscuss further too.
Speaker 1 (14:31):
Open to Pandora's box .
Speaker 2 (14:38):
The last major guidelines that we've had were
from the American Academy ofNeurology, published in 2012,
specifically for the preventionof episodic migraines.
This is where you see a lot ofour older medications that are
not necessarily FDA approved orspecifically designed for
migraine, but we know haveestablished evidence for helping
prevent migraines.
So you think of some of youranti-seizure medicines and your
(15:00):
antihypertensives, for example.
So 2012, quite a few years ago.
Speaker 1 (15:07):
Yeah.
Speaker 2 (15:07):
And starting around.
Speaker 1 (15:08):
I mean well, especially since you know that's
13 years and you said there'sbeen so many new novel products
in the last decade, like I feellike there's a missing guideline
update.
Speaker 2 (15:18):
So the AAN guideline update is in progress, but I
have not heard a release date onwhen we may expect that to be
out of circulation yet.
Speaker 1 (15:26):
Got it.
Speaker 2 (15:27):
But really to address that.
Yeah, we've had quite a fewdifferent organizations that
have put out guidelines orposition statements, consensus
statements, to try to addresswhere these new therapies may
fit into practice.
So my practice site is at theVA.
You mentioned the VA DODclinical practice guidelines.
(15:48):
We have had a guideline updatefor our population.
It was published in 2023, anupdate from 2020.
And it comments on some ofthese newer therapies as well.
The private sector or, moreglobally, we have the American
Headache Society that haspublished several position
(16:09):
statements and most recently hada publication just last year
specifically addressing how weintegrate these new CGRP
targeting therapies and evencommenting or almost advocating
for considering these options,sometimes as first line options.
Now, those are not formalguidelines.
(16:31):
It is still a position orconsensus statement, so you do
need to take that with a grainof salt, but I think it does
give some helpful perspectiveand helps to really help
consider this really vastincrease in medical literature
that we have to sort through andnavigate as clinicians to try
(16:53):
to decide where these fit inpractice right now.
Speaker 1 (16:56):
Yeah for sure.
Wow, yeah, that's a greatoverview and it sounds like your
need, or your division, of whatyou're doing there.
You all are in need of thoseupdates and those changes, so
hopefully that's coming soon.
So let's segue into what is therole of the pharmacist here.
(17:18):
You know, like, what are wepositioned to do as pharmacists
in managing headaches for ourpatients?
And you can specifically, youknow, speak to migraines, if
that's really probably themajority, I would assume, of
what we would see in practicesetting.
But let's just, I want to talkabout what exactly can
(17:38):
pharmacists do in this space.
Speaker 2 (17:40):
Yeah, absolutely Well .
I mean, just knowing thatheadaches are so prevalent, I
think it's very likely thatpharmacists will encounter
patients with different headachedisorders across multiple
practice settings, whether we'rein the community, whether we're
in the hospital, whetherambulatory care.
So you know, patient educationis very important.
(18:01):
We talked a little bit abouteducating on the treatment
approach to migraines the acuteversus preventive treatment.
One reason why I think thatbecomes so important is because
of the secondary headache that Imentioned earlier the
medication overuse headache,what was formerly known as
rebound headache.
Speaker 1 (18:20):
Many still refer to it as rebound headaches.
I was going to circle back tothat because you mentioned that
the meds cause headachesthemselves.
That was intriguing.
So yes, let's go down that path.
Yeah, for sure.
Speaker 2 (18:31):
Absolutely, and it's kind of counterintuitive for
patients.
They may have found a medicineor even an over-the-counter or a
prescription-specific migrainemedication to manage those
symptoms and it has benefits.
So why not take it on a dailybasis or why not take it for
every single migraine?
(18:51):
So medication overuse headacheand this is another specific
secondary headache that isoutlined in those diagnostic
criteria I referenced.
Essentially it's a headachethat can arise after consistent
overuse of acute treatments, andso this can be different
analgesics, whether it'sover-the-counter medications
(19:14):
like acetaminophen, ibuprofen,naproxen.
It can be some of ourprescription options and some of
our migraine-specific acutetreatments.
The triptans, like sumatriptan,risotriptan that whole class
has been associated with these.
Some of our other acutetreatments, like ergotamines and
(19:36):
then acute treatments that aregenerally not recommended
anymore for migraines arebutalbitol containing products
and opioid analgesics.
They have an even higher risk ofmedication overuse headache.
So but in general, when youlook at those different
treatments, for the most partwe're talking less than 10 doses
(19:59):
a month, and when we'restarting to exceed those numbers
.
So if you have a sumatriptanprescription for acute headache
management, acute migrainethat's why it's often limited to
a quantity of nine.
So 10 doses or more is where wesee that association with
medication overuse headache,where it can either cause the
(20:22):
secondary headache or themigraine diagnosis that they had
as their primary headache maybecan convert into chronic
migraine and it can be verydifficult to manage once we get
into this cycle and overusingthese acute treatments.
So prevention really is the keyand I think that education and
(20:44):
you know, kind of like smokingcessation, you ask about it at
every visit.
I kind of feel like that herewith medication overuse headache
, ask about it at every visit.
How often are you using it?
Try to really reiterate thosepoints and provide that
education so we don't get intothat cycle and have worsening
outcomes.
Speaker 1 (21:03):
Yeah, and I mean you know pharmacists are well
positioned, especially thosethat have access to the field
data.
You know we can see how oftenthey're filling those
medications.
You know, I would assume thetriptans now a lot of them have
been generic for a while.
A lot of them are probably veryaffordable now, and so some
patients probably say, oh well,my insurance doesn't pay for
more than nine, well, I'll justpay cash for another refill or
(21:26):
something.
So I think that would be a redflag in a sense of are you
overusing them?
Not a red flag in a sense ofyou're committing insurance
fraud or you shouldn't be doingthis, but more of a again asking
those thorough questions howoften are you actually using
these and providing theeducation and making sure that
(21:47):
they're aware that overuse ofthem can cause the rebound
headaches, right?
So that's a great position fora pharmacist to kind of jump in.
Speaker 2 (21:56):
Absolutely.
You know you mentioned redflags.
We use sometimes a mnemonic forred flag symptoms for headaches
and one of them does referencepainkiller overuse.
So we have the SNOOP criteriais what it's referred to
sometimes.
So that is one of those referon because they may need a
preventive therapy that's added,or they may need further
(22:19):
evaluation to help get a handleon their headaches.
Speaker 1 (22:22):
Right, and this may be opening up a whole different
avenue of discussion.
That would take longer.
But how do we rectify the issueof having a rebound headache?
Like are they ever able to goback to using those preventative
or to using those acutemedications?
Speaker 2 (22:39):
There's some different schools of thought.
You know, many times we'reconsidering a preventive
medication.
Many times we're considering apreventive medication, we're, at
minimum, trying to taper downor even taper off of the acute
medication that is the culpritand trying a different option.
One thing that's interesting tonote is that I mentioned the
CGRP targeting therapies, theGPANTS, that are approved for
(23:02):
acute treatment.
We have not seen thismedication class associated with
medication overuse headache,and so this could be one place
where, if you have someone youknow really struggling with this
, has tried our standard options.
We're not making much headway.
Maybe this is where we go nextwith one of these oral CGRP
(23:22):
inhibitors.
Speaker 1 (23:23):
Okay, interesting.
I would imagine that, one beingnew, that it's probably very
expensive and possibly not oftencovered and whatnot, so may run
into barriers there, but againit sounds like it would be a
down the line option.
So if they've already kind ofquote unquote, failed on
previous therapies or struggled,then maybe it would be
something that could getapproved.
(23:43):
So, yeah, no, that's a great,another great place for
pharmacists to interject in inbeing able to say, you know,
with that continuity of care,like, oh well, they've tried
this, this and this before, soyou know, maybe they're a
candidate for this.
So right.
Okay, that's very helpful andkind of setting the stage for
those rebound headaches.
Again, I feel like somethingthat is not really commonly
(24:07):
discussed.
So I think that's a great keypoint for pharmacists to educate
patients on that phenomenon andjust to make sure that patients
are aware and are not overusing.
So that's great.
What other opportunitiesbesides patient education do you
see pharmacists have in themanagement of headaches space
and these?
Speaker 2 (24:27):
updated position statements for both the
treatment arms prevention andacute treatment, and they cross
a lot of different mechanismsand a lot of different
(24:48):
specialties.
And you know, you may be seeingsomeone in clinic for blood
pressure management and you'remanaging their hypertension, but
they're also having migrainesthat have been worsening.
So maybe even just knowing whatsome of the key areas are where
we can overlap and use amedication as a dual treatment-
(25:09):
for those differentcomorbidities.
Try to minimize polypharmacy.
Certainly is an opportunitywhere I think pharmacists can
jump in and use that drugknowledge.
Speaker 1 (25:20):
Yeah, for sure, and you know we touched on I think
we didn't speak to itspecifically but adherence,
obviously, and again, theeducation on when is it
appropriate to use apreventative versus an acute,
and those kinds of things, andthen watching for the refill
data and determining, you know,are they adherent and whatnot
you mentioned earlier.
(25:40):
And this is something I want togo down this path before our
time runs out.
I swear I'm going to extendthese podcast sessions.
I say every time like our timejust comes to an end so quickly.
So one thing I wanted to godown the path of and just
briefly discuss again becauseyou mentioned it.
There are often some sideeffects from the medications
(26:01):
themselves, right, but there arealso other side effects from
the medications themselves,right, and, but there are also
other side effects that they'retreating, other than the
headache itself.
So let's talk briefly aboutthat and how the medications
play into that and whatpharmacists can maybe.
Speaker 2 (26:12):
Right, absolutely Well.
You know, I think a hugetakeaway point and this has also
been consistently reiterated inguidelines and position
statements is that headachemanagement is not a
one-size-fit-all approach.
Every patient is so unique inhow they may respond to a
different medication, how theymay tolerate a different
(26:33):
medication, so I think you haveto go into each unique situation
, each unique patient, with thatin mind and treat that one
patient.
Know that we've got this nowplethora of different options,
from both nonspecific andmigraine specific, to even a lot
of new non-pharmacologic andneuromodulation devices and
(26:54):
different options for management.
So you have to find what isgoing to meet the patient's
goals where can we minimize druginteractions, where can we
prevent those side effects, ormaybe where we can provide some
overlapping benefits.
That's really um, that reallyis what I love about my job.
It's kind of every day is alittle bit like a puzzle.
How, how can?
we make a bigger impact with onesmall adjustment yeah, yeah
(27:20):
that goes even down to thedosing you know with prevent
medicines.
This is something I tell mylearners when they're on
rotation.
All the time, when you'rethinking about an adequate trial
of preventative medicine, youneed to ask yourself did they
get to the right dose?
Were they there for the rightamount of time, Right dose,
right time?
And so sometimes that titrationneeds to go slower for some
(27:42):
patients.
Maybe we need to target a lowerdose or a little higher dose.
And did they have an adequatetrial to really give that
medicine a fair shot of working?
So I think, those are alsoquestions you can kind of ask
yourself.
If a patient is showing up andsaying, oh, I started this
topiramate and I've been takingit for two weeks, it's not doing
(28:03):
anything, we need to know thatthat's not an adequate trial,
that's not enough time to seethat benefit captured and again,
another great place for aninterjection from the pharmacy
team.
Speaker 1 (28:15):
And you know, with that continuity of care,
collaborating with the otherproviders, making sure that
they're aware, you know theyonly took this for two weeks.
That probably wasn't sufficient, you know, before you just
start jumping around to anothermedication choice.
So yeah.
Right yeah.
Speaker 2 (28:29):
Since I gave you my go-to for preventive medicine, I
guess I'll give you myone-liner for acute treatment.
I tell learners hit it hard,hit it fast.
So, that's anotherconsideration.
Sometimes, you know, you may behaving someone coming in
treating with the 325 milligramof acetaminophen.
That may not cut it for amigraine of moderate severity,
(28:50):
you know so we may need to hitit with 1000 milligrams.
So hit it hard, hit it fast.
Another key education componentis these acute treatments are
going to work best if you cantake them right away at that
first sign of a migrainepresenting or even sometimes in
that aura phase or craniomalphase so hit it hard, hit it
fast, get it in quick for bestresponse.
(29:13):
And so that's another placewhere I think we can support and
provide that education forpatients that may optimize their
medications effectiveness.
Speaker 1 (29:22):
Yeah, that's great.
That's great.
Well, I still have a lot ofthings on my list.
I'm going to just have to haveyou back for another episode.
So, briefly, we can talk justquickly.
Are there any challenges orbarriers that you've seen in
managing headaches that you wantto kind of touch on or share
(29:43):
any kind of tips or tricks about?
Speaker 2 (29:45):
Right Managing the medication overuse headaches
sometimes can be a big challengelike that perception coming in
of needing that acute treatmentand having to, you know, think
about those motivationalinterviewing techniques and that
shared decision making processto try to reframe our goals and
(30:06):
expectations, so that that maybe one challenge.
I'll just kind of reiteratethat.
Speaker 1 (30:11):
And, to be fair, it's not logical.
It's not logical right, like itdoesn't even like the fact of
the medication you're taking totreat your headache might cause
a headache like that.
So I can see where patients getreally confused or lost with
that.
So that's a great, a greatopportunity for the pharmacist
to really step in and educateand to support with that.
(30:33):
So, okay, well, with that, Iwill like to I always like to
kick it back to this, our guest,and ask you what's our game
changer here, what's ourtake-home point for our
listeners?
Speaker 2 (30:45):
Right.
I think the take-home overallis that we have to treat every
single patient individually,look at each unique case
comprehensively, look at whatare those specific goals that
we're trying to achieve and thatthe patient has, using the
shared decision-making to findthe best fit and the best
(31:06):
regimen, since every patient isso different.
Speaker 1 (31:09):
Yeah, so the game changer here is pharmacists.
You do have a role.
It's a very important role, andyou need to be sure that you
are individualizing the care foryour patients.
Yeah, that's great.
Well, allison, that's all wehave time for.
Thank you so much for joiningus.
This was great.
I learned a lot.
It's been a while since I'vetalked about headaches, yeah, so
(31:31):
this was great.
Thank you so much Great.
Speaker 2 (31:33):
Thank you so much for having me.
Speaker 1 (31:34):
Yeah, absolutely.
If you're a CE plan subscriber,be sure to claim your CE credit
for this episode of GameChangers by logging in at
CEimpactcom.
And, as always, have a greatweek and keep learning.
I can't wait to jump intoanother game-changing topic with
you all next week.
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