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Rein in headache pain
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Rein in headache pain

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OTCs Today

Mary Warner

Most patients turn to OTC analgesics—including aspirin, acetaminophen, naproxen sodium, and ibuprofen—for relief of headache pain. Because tension headaches, migraine headaches, and sinus headaches vary in location, nature, intensity, onset, and duration, the same analgesic may not be most effective for all types of headaches.

Image of a woman with a headacheHeadaches are a common complaint among patients of all ages, with women nearly twice as likely as men to have had a severe headache or migraine in the past 3 months. Approximately 90% of headaches, including episodic and chronic tension headaches, migraine headaches with and without an aura, and sinus headaches, are amenable to self-care treatment, though in some cases, patients with chronic migraine headaches may require prescription pain relievers.

Combination products are also commonly used for headache pain relief. Caffeine is commonly used in these products as an adjunct to analgesics for tension and migraine headaches. Clinical trials have suggested that combining caffeine with analgesics may result in better efficacy; however, caffeine itself may be a trigger for migraines, and withdrawal of caffeine may result in headache. Combination products containing a decongestant and either acetaminophen or an NSAID are available for treatment of sinus headaches.

The choice of nonprescription analgesic depends on patient preferences, the presence of contraindicating conditions, concurrent prescription medications, cost, and other factors.

Headache characteristics


Tension headache

Migraine headache

Sinus headache



Usually unilateral

Face, forehead, or periorbital area


Diffuse ache, tightening, pressing, constricting

Throbbing, pulsating

Pressure behind eyes or face, dull and bilateral pain








Simultaneous with sinus symptoms


30 minutes to 7 days

4–72 hours

Days (resolves with sinus

Aggravating factors

Stress, anxiety

Physical activity, light, sound

Nasal congestion

Nonheadache symptoms

Scalp tenderness, neck pain
and muscle tension

Nausea, vomiting, aura

Nasal congestion nasal discharge

Source: APhA’s Handbook of Nonprescription Drugs.


Tension headaches

Tension (or stress-related) headaches are usually relatively mild, come on gradually, and are often accompanied by neck pain and muscle tension. They are considered chronic if they occur for 15 or more days per month or for at least 3 months; headaches are considered frequent if at least 10 headaches occur per month. Women suffer from tension headaches more than 3 times as often as men.

Tension headaches generally respond well to nonprescription analgesics, including acetaminophen and NSAIDs such as salicylates, especially when taken at the onset of the headache. Patients with chronic tension headaches may also benefit from relaxation exercises in addition to nonprescription (or prescription) medications.

Migraine headaches

Most patients who suffer from migraines describe it as intense pulsing or throbbing pain in one area of the head, often accompanied by nausea and/or vomiting, or sensitivity to both light and sound. Migraine headaches are 3 times more common in women than in men and roughly one-third of affected individuals see an aura (visual disturbances that appear as flashing lights, zig-zag lines) or a temporary loss of vision before onset. According to NIH, migraines were once believed to be linked to the dilation and constriction of blood vessels in the head, but it is now believed that migraines have a genetic cause.

Stress, fatigue, irregular sleep patterns, fasting or missing a meal, vasoactive substances in food, caffeine, alcohol, changes in hormones, changes in barometric pressure and altitude, bright lights, odors, neck pain, exercise, and smoking can all trigger a migraine headache. Some medications—including reserpine, nitrates, oral contraceptives, and postmenopausal hormones—may also trigger a migraine.

Taking an NSAID at the onset of symptoms can abort mild or moderate migraine headache, as analgesics work best in the early stages of a migraine. Patients with migraine who can predict the occurrence of the headache should take an analgesic before the event known to trigger the headache as well as throughout the duration of the headache. For patients with coexisting tension and migraine headaches, treatment of the initiating headache type can halt the mixed headache.

Sinus headaches

Sinus headaches occur when nasal congestion causes inflammation of the sinus walls caused by viral or bacterial infection or allergic rhinitis. Symptoms of sinus headaches include pain, pressure, and fullness in the cheeks, brow, or forehead and worsening pain when bending forward or lying down. Sinus headaches are often accompanied by fatigue and an achy feeling in the upper teeth.

Sinus headaches respond well to oral and nasal decongestants such as pseudoephedrine and oxymetazoline that reduce the congestion causing the headache. Nonprescription analgesics taken with the decongestant can relieve sinus headache pain while congestion is present. Patients with chronic congestion and sinus infections should be encouraged to consult a specialist as these symptoms may be a sign of structural abnormalities.

What to tell your patients

Advise patients that if nonprescription analgesics are used to treat chronic headache, their use should be limited to less than 3 days per week or 14 days per month to prevent medication overuse headache. If headaches cannot be controlled in this manner, patients should consult their physician. Patients who suffer from migraine headaches should be advised to avoid triggers and consult their physician if the headaches become frequent. Finally, advise patients who are taking prescription medications, particularly warfarin, digoxin, ACE inhibitors, and methotrexate, to obtain medical advice before taking nonprescription pain relievers as analgesics are known to interact with these medications.

For further information, please see Chapter 5 of APhA’s Handbook of Nonprescription Drugs, available in print via the bookstore on or online through Pharmacy Library. ■





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