10.4 Migraine & Common Analgesics

10.4 Migraine & Common Analgesics

Quick Answer: Treat migraine early with appropriate simple analgesics/NSAIDs, add a triptan when indicated (including careful S3 supply assessment), and use antiemetics for nausea. Prevent medication-overuse headache by limiting frequent acute drug days. Know prophylaxis candidates at high level. Watch combination analgesics and codeine (post-rescheduling controls). Never give aspirin to children/teenagers with viral illness — Reye syndrome risk.

This section blends primary-care migraine management with everyday analgesic safety — classic Intern Written territory for 3.2 (implement) and 5.x primary care judgement integrated into therapeutics.

Migraine — recognise and differentiate (high-level)

Migraine is a primary headache disorder with recurrent attacks that may include moderate–severe pain, nausea/vomiting, photophobia/phonophobia, and sometimes aura (transient neurological symptoms). Red flags requiring urgent medical assessment include sudden “thunderclap” onset, neurological deficit unlike usual aura, fever/meningism, new headache in concerning ages/contexts, progressive daily headache, or headache after head injury — do not manage these as simple migraine at the counter.

Pharmacy goals in typical migraine:

• Confirm it is consistent with the person’s known migraine pattern (or refer if first/worst/different).
• Treat early in the attack.
• Address nausea so oral medicines can work.
• Reduce attack frequency through lifestyle and, when needed, prophylaxis referral.
• Avoid analgesic overuse.

Acute migraine treatment

Simple analgesics and NSAIDs

For many mild–moderate attacks, soluble aspirin, ibuprofen, or paracetamol (alone or in evidence-based combinations where appropriate) taken early can help. Choose based on comorbidities (ulcer, CKD, CV disease, asthma, pregnancy). Avoid overuse patterns.

Triptans

Triptans (e.g. sumatriptan, rizatriptan, zolmitriptan, eletriptan, naratriptan) are 5-HT1B/1D agonists used for acute migraine when simple analgesia is insufficient. They are not for hemiplegic/basilar-type syndromes or for people with significant cardiovascular disease — contraindications matter.

S3 (Pharmacist Only) sumatriptan supply (where available under current scheduling and professional protocols) requires structured assessment concepts:

If any exclusion or uncertainty applies, do not supply S3 — refer to a medical practitioner.

Antiemetics

Nausea impairs absorption and quality of life. Agents such as metoclopramide or prochlorperazine (status and counselling per schedule/product) are used in acute care pathways. Watch extrapyramidal reactions (especially in young people with metoclopramide), sedation, and interactions. Domperidone has cardiac rhythm cautions in some contexts — check AMH.

Non-oral routes

If vomiting is prominent, consider non-oral options (wafers, nasal sprays, injections in medical settings) rather than repeating oral doses that will not stay down.

Medication-overuse headache (MOH)

Medication-overuse headache occurs when acute headache medicines are used too frequently, perpetuating a chronic daily or near-daily headache pattern. Risk is classically discussed with:

• Triptans (e.g. on ≥10 days/month patterns in teaching thresholds)
• Combination analgesics / opioids
• Simple analgesics used on most days (e.g. ≥15 days/month teaching thresholds)

Exact day-count thresholds are clinical teaching guides — the exam concept is that more acute medicine is not always better. Management involves medical review, education, and often withdrawal/reduction of the overused agent plus preventive strategies. Pharmacists should flag frequent repeat purchases and high triptan consumption for GP review.

Migraine prophylaxis — candidates (high-level)

Consider discussing prophylaxis (via GP/specialist) when attacks are frequent, disabling, poorly responsive to acute therapy, or associated with overuse risk. Examples of agents used in Australian practice (individualised; comorbidities decide choice):

• Beta-blockers (e.g. propranolol, metoprolol) — avoid/caution in asthma, watch for bradycardia/fatigue
• Amitriptyline — sedation, anticholinergic effects; useful if migraine + sleep/tension features
• Topiramate — cognitive slowing, paraesthesia, weight loss, teratogenicity counselling, hydration/renal stone awareness
• Candesartan — sometimes used; monitor blood pressure/renal issues
• CGRP monoclonal antibodies / gepants — specialist/PBS pathway concepts; not casual OTC
• Botulinum toxin for chronic migraine in specialist pathways

Lifestyle foundations: regular sleep, meals, hydration, trigger awareness, limit alcohol, manage stress, review hormonal triggers with the prescriber when relevant.

Common analgesic combinations

Combination products (paracetamol + ibuprofen; paracetamol + codeine historically; aspirin + codeine; migraine “cocktails”) can improve acute efficacy but:

• Increase risk of exceeding paracetamol maxima when patients take multiple products.
• Add opioid harms when codeine is included.
• May accelerate medication-overuse if used frequently.

Always map the total daily load of each component. Prefer single-agent clarity when counselling complex patients.

Codeine-containing products — Australian post-rescheduling context

Australia up-scheduled codeine so that previously OTC codeine combination analgesics are no longer available without prescription (codeine became prescription-only). Exam implications:

• Do not counsel as if low-dose codeine combos are freely available S2/S3 options.
• Codeine is a prodrug converted by CYP2D6 to morphine — ultra-rapid metabolisers risk toxicity; poor metabolisers get little analgesia.
• Harms include constipation, sedation, dependence, and overdose risk in combinations.
• For cough or pain requests seeking “the old chemist codeine packs,” offer evidence-based alternatives, assess for misuse, and refer for medical review when appropriate.

Aspirin in children and Reye syndrome

Reye syndrome is a rare but serious condition with acute encephalopathy and hepatic injury, associated with aspirin use in children and teenagers during viral illnesses (notably influenza and varicella). Practical rule for community pharmacy:

• Do not recommend aspirin for analgesic/antipyretic use in children/adolescents with viral illness.
• Prefer paracetamol or ibuprofen (age/weight-appropriate products) when antipyresis/analgesia is needed and suitable.
• Low-dose aspirin for specific medical indications (e.g. Kawasaki disease) is specialist-directed — not casual OTC use.

Integrated primary-care analgesic counselling

Whether for migraine or general pain, structure counselling as:

1. What is the pain likely to be, and are there red flags?
2. Which medicine matches the mechanism and patient risks?
3. How much and how often, including absolute maxima and duration caps?
4. What else — non-drug care, antiemetic need, prophylaxis referral, MOH prevention?
5. When to return/ escalate — lack of response, neurological change, overuse pattern, adverse effects.

Intern Written excellence here is not memorising every triptan half-life; it is demonstrating safe supply judgement, schedule awareness, and public-health sense about overuse and paediatric aspirin.