Date Published: January 23, 2019
Publisher: Public Library of Science
Author(s): Paola Brusa, Gianni Allais, Cecilia Scarinzi, Francesca Baratta, Marco Parente, Sara Rolando, Roberto Gnavi, Teresa Spadea, Giuseppe Costa, Chiara Benedetto, Massimo Mana, Mario Giaccone, Andrea Mandelli, Gian Camillo Manzoni, Gennaro Bussone, Md. Asiful Islam.
Headache disorders are considered the second leading cause of years lived with disability worldwide, and 90% of people have a headache episode at least once a year, thus representing a relevant public health priority. As the pharmacist is often the first and only point of reference for people complaining of headache, we carried out a survey in a nationwide sample of Italian pharmacies, in order to describe the distribution of migraine or non-migraine type headaches and medicines overuse among people entering pharmacies seeking for self-medication; and to evaluate the association, in particular of migraine, with socio-demographic and clinical characteristics, and with the pathway of care followed by the patients. A 14-item questionnaire, including socio-demographic and clinical factors, was administered by trained pharmacists to subjects who entered a pharmacy requesting self-medication for a headache attack. The ID Migraine™ Screener was used to classify headache sufferers in four classes. From June 2016 to January 2017, 4424 people have been interviewed. The prevalence of definite migraines was 40%, significantly higher among women and less educated people. About half of all headache sufferers and a third of migraineurs do not consider their condition as a disease and are not cared by any doctor. Among people seeking self-medication in pharmacies for acute headache attacks, the rate of definite or probable migraine is high, and a large percentage of them is not correctly diagnosed and treated. The pharmacy can be a valuable observatory for the study of headaches, and the first important step to improve the quality of care delivered to these patients.
Headache disorders are considered by The Global Burden of Disease study as the second leading cause of years lived with disability worldwide . The World Health Organization declared that headache disorders are ubiquitous, prevalent and disabling but despite this they are under-recognized, under-diagnosed and under-treated all over the world . Ninety percent of people have a headache episode at least once a year and 40% are serious or disabling headaches. Headaches cause a loss of productivity at work, a reduction in social interactions and a deterioration in the quality of life . Globally, it has a prevalence of 47% and is the most common neurological syndrome for which people turn to their family doctor while only 16% consult a neurologist . Recent epidemiological studies have shown that the phenomenon of migraine may be compared to an iceberg: the top represents correctly diagnosed cases while the submerged part is made up of those subjects that have never consulted a doctor or that, having done so, have not received a correct diagnosis [3, 4]. Furthermore, in Italy, many migraineurs make a wrong self-diagnosis assuming cervical spine pathology as the cause . This explains why the majority of migraineurs make use of self-medication, taking over the counter (OTC) analgesics to treat their headache [6,7]. The lack of a proper treatment for headache, however, can lead to an overuse of acute pain-relief medicine and to the medication overuse headache (MOH), an even more disabling chronic disorder [8,9].
The study was designed as a cross-sectional survey based on face-to-face interviews using questionnaires drawn up by experts and based on the scientific literature. Briefly, the questionnaire, reported in Fig 1, covered the following points: the socio-economic situation of the recruited subjects; the ID Migraine screener test (ID-MS) [19,20]; the frequency of attacks, the drugs usually taken and the healthcare professional, if any, responsible for the management of the subject’s headache.
The development of the study at a national level expanded the number of participating pharmacists to 610, operating in 514 community pharmacies situated in 19 out of the 20 Italian regions. Out of 610 trained pharmacists, 445 collected at least one questionnaire and participated in this survey; overall, 4424 questionnaires had been correctly completed.
In accordance with other studies  we report that women are more likely than men to suffer from headaches, particularly from migraines. In both genders, there appears to be a trend towards mainly non-occasional headaches and migraines, existing for a long time and accompanied by an important prevalence of chronic headache. Since the epidemiological data reported in the literature indicate a prevalence of chronic migraine in the general population of only 2%, must be true that the migraineurs entering a pharmacy and enrolled in this survey have a relatively severe form of migraine.
The pharmacy can be not only a valuable observatory for the study of headaches, but can also represent, through the counselling that a formed pharmacist might give, the first important step in seeking to build a good management relationship for subjects with headache, especially so for undiagnosed migraineurs; their referral in the first instance to the general practitioner and then to specialists and headache centres, may prevent the onset of chronic migraine and medication overuse headache.