Migraine: what do pharmacists need to know? (transcription)

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Sandip: I’d say from the moment of getting my first migraine to feeling I have it under control, it’s probably been about 20 years, which is a mind-blowing number of years. 

Alex: Migraine is a complex long-term health condition that can involve debilitating pain and nausea, and sensitivity to light, sound and smells. Affecting around 10 million people in the UK, symptoms can severely disrupt daily life, work and social relationships, with The World Health Organization ranking migraine as the second-highest cause of disability in the world.

You just heard from Sandip. Sandip experiences migraines that, even when controlled, seriously affect his everyday life. 

Sandip: I genuinely cannot put into the words the impact it had on me…

Alex: It was that severe patient impact, experienced by so many in the UK, that prompted the Pharmaceutical Journal to undertake a piece of work to understand how pharmacists can better contribute to the care of migraine patients.

[Audio from roundtable] Before we begin, I just wanted to say thank you all so much for attending and for your support and engagement during the process so far. Caitlin and I have been working on migraine this year… [fades out]

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Alex: One component of this was an expert roundtable that we hosted in July 2025. Going into the roundtable, a detailed survey of 304 pharmacists was undertaken where we asked about current levels of knowledge and confidence and gauged interest in an expanded pharmacy role in migraine management. The roundtable report and survey results were published in the PJ and are linked in the show notes. 

This work was financially supported by Pfizer, who are kindly supporting this podcast as well.

Throughout this episode you will hear extracts recorded at the roundtable. Apologies in advance that the audio isn’t quite podcast quality.

[Audio from round table]: So, it’s quite an ambitious agenda, but bringing you all here today, we do hope we can make some really productive progress discussing how pharmacists and pharmacy teams across sectors can best support patients with migraine… Fades out.

Alex: I’m Alex Clabburn and in this learning episode of The PJ Pod, part of the November 2025 digital issue… We’re going to discuss some knowledge gaps and opportunities for pharmacy that were revealed by the roundtable and survey, as well as exploring best practice for pharmacy involvement in migraine management. 

[Audio from roundtable]: crowd noise… fade out

Alex: The conversations at the roundtable were lively and productive, and several themes emerged. One was that the symptoms of migraine are often misinterpreted by both patients and healthcare professionals. An interesting point raised was that different perceptions of headache as a symptom can affect recognition of migraine and how likely patients are to seek help with their condition.

Katy Munro: Unless somebody says the word ‘migraine’, they just say, ‘Oh no I just get the normal headaches that everybody gets’.

Alex: That was roundtable attendee Katy Munro, a senior GP headache specialist at the National Migraine Centre and secretary and council member at the British Association for the Study of Headache

Katy Munro: They just know a fever is wrong. They know a rash is wrong, but they think the headache is just something that everybody gets…

Alex: Another attendee at the roundtable was Callum Duncan. Callum is a consultant neurologist at NHS Grampian and was involved in a project that aimed to improve training and awareness of migraine in community pharmacists. We got back in touch with him to flesh out a few themes discussed at the roundtable.

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Alex: Here’s what he had to say about headache as a symptom.

Callum: So, the key thing for that is never to accept headache because headache is a symptom. It’s not a diagnosis. Tension-type headache is a diagnosis. Migraine is a diagnosis. Cluster headache is a diagnosis. Secondary headache is a diagnosis. Almost all headache that comes to us… if someone is saying, ‘I need help with my headache’, it’s almost always going to be migraine. 95% of people coming to a general practitioner with headache will have migraine. And it often gets underdiagnosed because the patient doesn’t quite appreciate what it is and maybe undersells the severity of their headache. 

Alex: While there’s a danger of migraine being underdiagnosed, if headache isn’t taken seriously, there’s another issue where patients are being over referred to secondary care because clinicians are worried about missing red-flag symptoms. This puts pressure on already stretched services and can delay patients receiving an appropriate migraine diagnosis and accessing treatment.

This point was raised at the roundtable by chief executive officer of the Migraine Trust, Rob Music. 

Rob Music: So, they’ve got patients that are presenting, and they’re more worried about red flags, such as brain tumours, rather than green flags, even if a patient is presenting with obvious migraine symptoms…

Alex: We put this point to Callum and asked how to differentiate migraine from other potentially more serious conditions.

Callum: Clearly those are really important, and it’s important to look at red flags, but the majority of patients are going to have migraine. So, if you’ve got someone who has headache that is moderately disabling, so limits activity, or severely disabling, who is feeling a bit sick, who doesn’t like light or sound and would prefer to be still, and that occurs repeatedly, that is migraine.

Alex: But what should pharmacists do if they do encounter patients with red-flag symptoms?

Callum: If you had somebody who had the worst headache ever come in to see you, that needs assessed. That would need to go to accident and emergency or a general practitioner depending on the… So, it’s thunderclap, instant, it’s very severe, that’s go to the emergency department. Yeah? If your headache is just getting worse and worse and worse and worse and worse, and the patient is keeping coming back, again, that’s something that needs to be looked into. That’s something you’d flag to general practice or, if you’re particularly concerned, to the emergency department.

Alex: It’s important to remember that for patients, the symptoms of migraine can be extremely unnerving, particularly during the period of initial onset. Sandip told me about his first experiences with the condition.

Sandip: My earliest memory of this is not really getting anything migraine-related until my early 20s. I remember I’d just finished university, and I’m pretty certain I was about 22, 23. And up until that point, I’d never even got headaches, really. And then one day, I got a headache and, it got worse and worse, and I was physically sick. You know, vomiting really, really badly. 

And that was quite unnerving because I went from not experiencing that to experiencing that. And then, unfortunately for me, as the weeks and months progressed, I started to get them once every week, and then a couple of times a month. And at peak, kind of mid-20s, I was getting on average about 14 a month. 

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And that literally isn’t just a little pain in the side of the head. I would start to feel sensitive to light. By that time, I was on some medication to stop the migraine getting worse. But if that didn’t work, I would go through a period of, maybe, 12, 13 hours of being really, really physically sick. I would just be completely exhausted at the end of it. And that was really my life for the next 20 years almost. 

Alex: So, migraines can be really debilitating, and as Sandip makes clear, patients need to learn how to live with the condition and manage symptoms over the full course of their life. But how should this long-term approach be managed?

At the roundtable, Bethany Hill, a headache and facial pain clinical nurse specialist at Guy’s & St Thomas’ NHS Foundation Trust, counselled that a layering approach to treatment is needed

Bethany Hill: With migraine, it’s a layering approach, we’ve always done that, especially from an acute treatment point of view. And you have to understand how you use your simple analgesics first. You have to understand how you use your antiemetics first, then you have to understand how to use your triptans before you can understand gepants… 

Alex: Here is Callum again to expand on how simple analgesia should be used first to manage migraine.

Callum: So, you want to use an abortive treatment, so something taken at the beginning of a headache to put it away rather than a piecemeal treatment taken regularly throughout the headaches. That’s the first point. Second is a decent dose, and so the two main ones are ibuprofen 600 mg or an alternative nonsteroidal, or aspirin 900 mg. So those would be the primary, simple analgesics that would be helpful. Paracetamol can help people, but it’s generally not wonderfully effective. Clearly, it would be the first choice in pregnancy because it’s safe in pregnancy. 

Alex: The survey of over 300 pharmacists that we ran in the run up to the roundtable, showed that some may currently be getting this wrong. Only 41% of respondents would recommend aspirin to relieve migraine symptoms, while 83% would recommend paracetamol.

41% also said they would recommend co-codamol, an opioid containing preparation which shouldn’t be used for routine migraine treatment due to significant risks of dependency formation and the availability of more effective options. Where patients do express a preference for over-the-counter products containing codeine, it’s important to explain that they are only safe if used as short-term treatments and for no more than three consecutive days. 

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Alex: If simple analgesia is insufficient, the next step would be escalating to a triptan. Triptans are a class of migraine treatments that work by mimicking serotonin, which constricts blood vessels and reduces pain.

Callum: From a pharmacy perspective, you can prescribe sumatriptan 50 mg over the counter, so that’s what will be available to you. On prescription, you can use a bigger dose, 100 mg, and 100 mg is more effective than 50 mg. And then there are seven triptans in total. There’s a nice recent systematic review which shows that eletriptan 40 mg and rizatriptan 10 mg are the more effective of all of the triptans.

So triptans are underused. People think of them as strong medications. They’re specific migraine medications.

Alex: Triptans can also be used in combination with other medicines. 

Callum: So antiemetics, chlorpromazine and metoclopramide, the license, are the ones that have the evidence for migraine. And we would suggest 10 mg to take with either your simple analgesic or with your triptan or take the antiemetic and the simple analgesic and the triptan together, and that combination will work better for someone with a more severe headache. 

NICE say that we should always combine triptans with a nonsteroidal or triptans with paracetamol. In sign, we’ve suggested you choose your treatment depending on the severity of the headache and depending on patient preference.

Alex: If a patient’s migraines aren’t controlled with simple analgesia and triptans, then the next stage is to step up to preventative treatments. 

Callum: So preventative treatments are indicated if you have four or more migraines in a month, particularly if they’re not adequately treated with your acute treatment. 

If someone’s got really bad headache that lasts for two or three days and treatment works poorly for it, if they’ve got two of those in a month, you might want to think about preventative treatment. And you definitely want to think about preventative treatment if people are having up to eight or more headaches per month because that’s when you risk medication overuse headache, and the standard preventatives do work. So, your tricyclic antidepressants — amitriptyline, nortriptyline, propranolol, candesartan — are your kind of first go-to, first-line treatments for migraine prevention. 

Alex: There’s a high degree of variation, both in the way people experience migraines, and also how they respond to medications. For the proportion of patients who don’t respond sufficiently well and have tried and failed multiple first-line options, CGRP inhibitors can also be prescribed. For more on this, you can listen to one of our previous episodes where we looked at these newer treatment options in more detail. That will be linked in the show notes.

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Alex: So, while there are a growing range of medical options that can help control or prevent migraines, finding the best approach to treatment that’s optimised for the individual can be a very slow process. It’s not uncommon for patients to struggle for many years trying to get the right balance between acute and preventative medications, finding an optimised dose or accessing an alternative, if their initial prescription isn’t sufficiently effective. Here’s Sandip again.

Sandip: The first kind of set of medication I was prescribed was something called topiramate. And that was a medication I took daily to prevent the onset of migraines. That had very little effect on me, unfortunately. I think I tried it for about nine months, but the frequency and the ferocity almost of migraines didn’t change. I was then prescribed something called sumatriptan, which wasn’t a preventative medication, but it was a medication that I take when I first feel a migraine is coming on. And that worked really well, but it only worked well if I took it as soon as I felt a niggling headache or kind of started to feel sick. If I left it too late, or sometimes the medication just didn’t work, which is quite rare, then just taking more of the medication wouldn’t do anything and I would get a full-on migraine and be sick and the rest of it. After that, I saw a neurologist who suggested I stop taking sumatriptan and gave me basically a nasal spray equivalent, and that’s the medication that I’m on right now. And that really works quickly. If I do feel a migraine coming on, nine out of ten times, it will stop the onset of it. And the only other medication I’m currently taking is candesartan.

Alex: In Sandip’s case, although he was prescribed an effective triptan quickly after first presenting to his GP, it was only many years later that he was able to optimise this with a faster-acting nasal spray formulation, but even then it took time for him to establish control of his symptoms with changes to his lifestyle and environment being key.

Sandip: So, at one point, I was using that spray maybe 12 to 15 times a month, which is way beyond the frequency that you should be using it. With the changes in lifestyle, the changes in people understanding that I am susceptible to migraines, I’m currently only needing to use it maybe once or twice a month. 

Alex: So, while Sandip has been able to regulate his use of acute medication, the frequency that he was initially using the nasal spray would have put him at risk of medication overuse headache. Where this occurs, treatment is significantly complicated and can result in patients experiencing increased levels of pain and discomfort, more frequent headaches and an overall reduction in the effectiveness of their medications. It’s important patients are routinely counselled by prescribers and pharmacists about the risks of medication overuse headache. This was something that the survey indicated may not be happening as consistently as it should.

Callum: So, medication overuse headache is primarily a complication of migraine management, and it is due to taking medication 10 or more days per month for triptans, for opioids, for ergots, and 15 or more days per month for simple analgesics. Keeping it simple, eight days per month, two days per week with two days spare would be your limit. So, ten days per month for everything. 

The really important thing though is not everybody who uses frequent medication has medication overuse headache. So, the really key thing here is if you stop the medication and the patient gets better, well, that’s medication overuse headache. If you stop it and it doesn’t get better, then that’s not. There are now treatments that we don’t think are affected by medication overuse, so we’ve got more options. But the traditional old-style preventatives are felt to be less effective if taken too much acute medication.

Alex: I asked Callum what he thought were the key messages pharmacists should be communicating to patients?

Callum: The key thing, I think, is if you’re prescribing acute treatment, tell somebody that this might happen, so that you prevent this happening in the first place. And always remember to ask about how much medication you’re taking. Patients may be circumspect about that or may not realise that over-the-counter medication is important. So, just be clear and ask people, particularly those with headache that is at least eight or more days per month. 

So, ten years ago it was, ‘You stop your tablets.’ Now it’s, ‘Please be aware that this is part of the issue. This might be a problem for you, and you want to be on preventative treatment, well, not just acute treatment. The acute treatment might be influencing the effects of the preventative treatment, and we need to think about it and make sure we’re doing it correctly’.  

Alex: If these messages aren’t well explained to patients it can lead to confusion that negatively affects the way they use acute medications.

Sandip: To be honest, when I wasn’t on any medication in the first five or six years, as I mentioned earlier, I was taking paracetamol and ibuprofen together or alternatively quite a lot. And I researched a lot of that myself. At one of the GP meetings and at one of the neuro meetings that I went to it did come up that I could be suffering from rebound headaches. So, I do recall trying to be very mindful of the medication I’m taking. It got to a point though where I was so worried about rebound headaches that I stopped taking the medication, and that led to more headaches. So, I got into really a bit of a bad situation there. But I think I’ve got it controlled now. But it definitely was something that was on my mind and something that was mentioned to me by both the GP and the neuro team.

Alex: Headache diaries are a crucial tool patients can use to record the details of their migraine attacks and reduce the risk of medication overuse headache.

Callum: So, it’s often difficult to know exactly how many headaches you’re having unless you keep a diary. And it’s a simple diary. Do you have no headache? Are you crystal clear? Do you have a mild headache? Do you have a moderate-to-severe headache? And do you have a severe headache? So moderate-to-severe and severe would be migraine. Mild headache would be a background headache. And if you’ve got 15 or more days of headache per month and 8 days of migraine, then you’d be reasonable for referral into secondary care. And it’s helpful to know how many headaches people are having when they’re referred in.

Alex: Headache diaries are also crucial for identifying migraine triggers. These are highly variable: stress, changes of sleep pattern, hormonal changes — particularly for women — or sensory stimuli, such as bright lights, strong smells or certain foods and drinks, can all trigger a migraine attack. Keeping a diary helped Sandip identify his migraine triggers, which in his case were quite specific.

Sandip: The earliest trigger that I was aware of, and this is where people thought I was just crazy, was the smell of frying onions, as strange as that sounds. So, whenever I was in a house where there was someone frying onions, that would literally trigger a full-on migraine within 15 to 20 minutes. And that was… I just couldn’t comprehend that, and I kept a diary and kind of noted dates and times and where I was and what was happening. And that always was present when I had a full-on migraine. And that’s when I realised that scent-triggered migraines was an actual thing, because up until that point, I struggled to get people to believe me because if you tell that to someone, it sounds laughable. 

Alex: Having identified scent as his primary trigger, Sandip was then able to make changes to his lifestyle and environment that reduced his exposure to strong smells. Interestingly, he found a creative, low-cost solution that reduced his risk of experiencing migraine attacks.

Sandip: From a lifestyle perspective, I always have to take Vicks everywhere I go. I’m mindful of where I go, and it could be something simple like if I’m at an airport and, everyone knows, you end up going through duty-free where they’re trying to sell you smells. I literally keep the Vicks under me and just literally almost have to run through that area. So, I’ve always got Vicks with me and that is literally a game-changer, and that’s how I balance things at the moment. If I go into an environment where there is a strong smell, there are occasions where even Vicks just won’t work, it just can’t mask the smell, and I literally just have to leave because I cannot risk staying there and getting a migraine. So, there are situations where I kind of lose out, and I feel extremely guilty for my family because they often end up losing out as well. But everyone understands, and everyone understands it’s just one of them things I have, and we just have to work together to live with it, really. 

Alex: So, what Sandip’s experience shows is that while migraine can’t yet be cured, with the right combination of medication and lifestyle adaptation, it is possible to reduce the impact that it has on people.

Whilst it was 20 years ago that Sandip first experienced migraine symptoms, it wasn’t until 2019 that this treatment was fully optimised, following a private consultation with a neurologist. 

Sandip: I mean, after my initial visit and the visit three weeks after that, I felt I was left to my own devices, really. It was me that had to instigate more and more GP meetings. There wasn’t any, ‘Come back and see us in three, four months’ or whatever. But because my symptoms kind of were really bad and really consistently bad, I made many, many GP visits, but I never could see the same doctor. I always found I had different, inconsistent advice, or certainly that’s how I felt anyway. 

Alex: For healthcare teams, this raises important questions around how patients can be effectively supported in primary care over the long term, while ensuring appropriate access to specialist support, when required. This is something that also came up at the roundtable… 

Rob Music: We know for the majority of people, they should be successfully managed in primary care, while there is some need for those who may need referral to a specialist care if required…

Alex: So, when is the right time to escalate to secondary care? I put this question to Callum.

Callum: For access to secondary care, you should really have tried three preventative treatments adequately. So that means them built up at the target dose or the most effective, tolerated dose and then for a few months afterwards. If they’ve gone through three treatments like that, then access to secondary care is appropriate. If patients have difficulty managing with acute treatment, then they could also potentially be referred into secondary care. For preventative treatment, it would be three preventative treatments. 

Alex: For migraine patients to be adequately supported, a long-term approach to management is required. Optimising treatment might require numerous adjustments to dose, switching to different triptans, adding anti-emetics or stepping up to alternative options like botox, gepants or CGRP monoclonal antibodies. Primary care teams and community pharmacists are ideally placed to lead this process, providing adequate monitoring, timely interventions and ongoing support, as patients learn how to structure their lives in a way that allows them to attain good control over their migraine attacks. 

Before we finished our conversation, Sandip wanted to share some words of advice for anyone who’s at the early stages of experiencing migraine themselves.

Sandip: Don’t leave it as long as I did. Go and speak to medical experts. Keep a diary. The diary is so crucial. What you ate, when you ate, how many hours you slept, what you got up, did you drink, do you not drink? All these kind of things are little gems when the medical team are trying to help you identify triggers or help you identify anything that can help you. These kind of conversations are good, that we are having now. Join the Migraine Trust. There’s a massive amount of information there. There’s a lot of people who are suffering and it just helps knowing you’re not alone. 

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Alex: So, while it’s clear that there’s still much more that needs to be done to provide effective support for people living with migraine there’s also a lot of cause for optimism. As Sandip’s story shows, major benefits can be unlocked simply through shortening the time it takes for people to seek help and work through the process of identifying the best treatment option for them.

Callum: So, I think the thing I’d like to say to a pharmacist audience is, ‘You can do this!’ Most headache is migraine. If you take a targeted history, you will get the correct answer. And providing good, sensible advice on acute treatment to avoid patients getting into medication overuse and recommending patients go and see their GP about adequate preventative treatment is going to make the migraine journey better. And hopefully if we do that, we’re going to prevent people getting into the more frequent and more severe migraine patterns like chronic migraine.

Alex: I think that’s a nice, positive good note to end on. I would like to thank Sandip for sharing his experience with us and all the experts who attended the roundtable.

And of course, a big thank you to Callum Duncan for guiding us through the available treatment options and approaches.

We’ll include links to relevant resources discussed in the episode, including sample headache diaries produced by the Migraine Trust in the show notes.

And finally, thanks again to Pfizer for supporting this episode. That’s it from us. Please do remember to like and follow us on whatever podcast platform you use.

Until next time, goodbye!

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