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Title: Self-medication of regular headache: a community pharmacy-based survey
Authors: E. Mehuys, K. Paemeleire, T. Van Hees, T. Christiaens, L.M. Van Bortel, I. Van
Tongelen, L. De Bolle, J.-P. Remon, K. Boussery
In: European Journal of Neurology 19 (8), 1093-1099, 2012
To refer to or to cite this work, please use the citation to the published version:
E. Mehuys, K. Paemeleire, T. Van Hees, T. Christiaens, L.M. Van Bortel, I. Van Tongelen, L. De
Bolle, J.-P. Remon, K. Boussery (2012). Self-medication of regular headache: a community
pharmacy-based survey. European Journal of Neurology 19 (8), 1093-1099.
DOI: 10.1111/j.1468-1331.2012.03681.x
1
Self-medication of regular headache: a community pharmacy-
based survey
Els Mehuys
1
(MSPharm PhD), Koen Paemeleire
2
(MD PhD), Thierry Van Hees
3
(MSPharm
PhD), Thierry Christiaens
4
(MD PhD), Luc M Van Bortel
5
(MD PhD), Inge Van Tongelen
1
(MSPharm), Leen De Bolle
1
(MSPharm PhD), Jean-Paul Remon
1
(MSPharm PhD) and Koen
Boussery
1
(MSPharm PhD).
1
Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University,
Harelbekestraat, B-9000 Ghent, Belgium.
2
Department of Neurology, Ghent University Hospital, De Pintelaan 185, B-9000 Ghent,
Belgium.
3
Department of Clinical Pharmacy, University of Liège, Avenue de l’Hôpital 1, B-4000 Liège,
Belgium.
4
Department of Family Medicine and Primary Health Care, Faculty of Medicine and Health
Sciences, Ghent University, De Pintelaan 185, B-9000 Ghent, Belgium.
5
Heymans Institute of Pharmacology, Faculty of Medicine and Health Sciences, Ghent
University, De Pintelaan 185, B-9000 Ghent, Belgium.
Corresponding author:
E Mehuys, Pharmaceutical Care Unit, Ghent University, Harelbekestraat 72, B-9000 Ghent,
Belgium. Tel: +32 92648043. Fax: +32 92228236. E-mail: els.mehuys@ugent.be
Total word count: 4120 words
Running Title: Self-medication of regular headache
Keywords: Headache, self-medication, medication overuse, community pharmacy.
2
ABSTRACT
Background: This observational community pharmacy-based study aimed to investigate headache
characteristics and medication use of persons with regular headache presenting for self-medication.
Methods: Participants (n=1205) completed (i) a questionnaire to assess current headache medication
and previous physician diagnosis, (ii) the ID Migraine Screener (ID-M) and (iii) the MIDAS
questionnaire.
Results: Forty-four % of the study population (n=528) did not have a physician diagnosis of their
headache, and 225 of them (225/528, 42.6%) were found to be ID-M positive. The most commonly
used acute headache drugs were paracetamol (used by 62% of the study population), NSAIDs (39%)
and combination analgesics (36%). Only 12% of patients physician-diagnosed with migraine used
prophylactic migraine medication, and 25% used triptans. About 24% of our sample (n=292)
chronically overused acute medication, which was combination analgesic overuse (n=166), simple
analgesic overuse (n=130), triptan overuse (n=19), ergot overuse (n=6) and opioid overuse (n=5).
Only 14.5% was ever advised to limit intake frequency of acute headache treatments.
Conclusions: This study identified underdiagnosis of migraine, low use of migraine prophylaxis and
triptans, and high prevalence of medication overuse among subjects seeking self-medication for
regular headache. Community pharmacists have a strategic position in education and referral of
these self-medicating headache patients.
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INTRODUCTION
Headache is a common reason for self-treatment with over-the-counter (OTC) medication. However,
overuse of acute headache medication through inappropriate self-medication can cause medication-
overuse headache (MOH). Medication-overuse and subsequent MOH is an increasing problem
worldwide. Epidemiological data suggest that the prevalence of MOH is at least 1% of adults in the
general population, and up to 30-50% in patients attending tertiary headache centers (1, 2).
Diagnosis is not always evident, especially because patients often self-treat without consulting a
physician.
Community pharmacists could play an important role in early detection and prevention of MOH, by
monitoring self-medication of headache and educating patients about the maximum intake
frequency of acute treatments. Before effective pharmacy programs can be designed, observational
data on the headache characteristics and the drug utilization of individuals seeking self-medication
for headache are required. To date, literature on this topic is scarce. We found only one paper,
describing a small observational study (22 participants) that assessed the degree of headache-related
disability and treatment views of persons purchasing OTC headache products at community
pharmacies (3). The other pharmacy-based studies published so far did not focus on self-medicating
customers, but were: a descriptive study on headaches, drug consumption and life habits of migraine
patients (4), the development and validation of a pharmacy migraine questionnaire to assess
eligibility for triptan use (5), and an intervention trial evaluating the effects of pharmaceutical care
for migraine and headache patients (6).
The present observational community pharmacy-based study aimed to investigate the headache
characteristics and the medication use of persons with regular headache, defined for this study as
headache occurring at least once per month, presenting for self-medication. These data should allow
us to formulate recommendations for improved primary care management of headache. The work
was reported in preliminary form at the 15
th
European Federation of Neurological Societies (EFNS)
Congress, Budapest, September 2011.
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METHODS
Study design
This observational study was carried out from December 2009 till May 2010 in 152 randomly selected
community pharmacies in Belgium. Approval for the study was granted by the Ethics Committees of
Ghent University Hospital (for Flanders) and CHU Liege (for Wallonia), and all patients gave written
informed consent.
Participants
Pharmacy customers purchasing an OTC analgesic (OTC analgesics available in Belgium: paracetamol,
acetylsalicylic acid, ibuprofen 200-400 mg, naproxen 200 mg, and caffeine-containing combination
analgesics) were approached consecutively and asked whether they bought the OTC analgesic for
headache. In case of a positive answer, they were invited to participate in the study when fulfilling
the following inclusion criteria: being aged ≥18 years, purchasing the headache medication for
themselves, and suffering from headache ≥1x/month. From each of the pharmacies, ten patients
were planned to be recruited.
Data collection
Persons who agreed to participate filled out a self-administered questionnaire, collecting the
following information: age, gender, physician diagnosis of headache (if available), current acute and
preventive headache medication (prescription and non-prescription) with frequency of use during
the prior 3 months, and whether they were ever advised to limit intake of acute headache
medication. A medication overuser was defined as a person overusing acute headache medication in
terms of treatment days per month (≥10 days/month for ergotamine, triptans, opioids, and
combination analgesics; ≥15 days/month for paracetamol, ASA, and NSAIDs) during the previous 3
months, according to the revised criteria of the International Classification of Headache Disorders
Second Edition (ICHD-IIR) for MOH (7).