A National Migraine Centre Heads Up Podcast transcript
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Transcript
00:00:00 Welcome to the Heads Up podcast, brought to you by the National Migraine Centre, the only UK charity treating headache and migraine. Visit our website to book your appointment with a world-class headache doctor, wherever you are in the UK. There is no need for a referral. You can refer yourself. Our headache specialist doctors are looking forward to helping you soon.
00:00:35 Dr Katy Munro
Hello and welcome to this episode of Heads Up podcast. We’re talking today about migraine and the role of the pharmacist because I know that many people who have migraine or who even don’t recognise it but have severe recurrent headaches will obviously go into a pharmacist and ask for advice, so I thought it would be good to talk to two pharmacists who’ve taken a particular special interest in this area and they’re going to talk a bit about what their experience is and some advice for you people out there who are struggling to find your right pathway to manage your migraine.
So I’d like to introduce David Kelly and Nadeem Shah who are both pharmacists, and would you like to tell us a little bit about yourself. David, let me get you to start this bit.
00:01:27 David Kelly
Thank you, Katy. Yes, my name is David Kelly. I’m a pharmacist prescriber. I am based in northwest England in Lancashire, working general practice, which I have done for the last, oh dear, fifteen years or so, helping the surgery staff to manage the sort of wide gamut of primary care conditions. I do have a particular interest in pain management and migraine management. As a lifelong sufferer of migraine, the person who’s had migraine throughout their life, I have a particular interest in that area as well.
00:02:10 Dr Katy Munro
That’s brilliant. And, Nadeem, what about you? What’s your background and would you like to say a few words about how you’re working at the moment?
00:02:19 Nadeem Shah
Oh hi, Katy. My name is Nadeem Shah. I’m a community pharmacist, based in Morpeth, northeast of England. I’ve been working here in community alongside other interests, especially working in the advanced clinical practitioner role in out of-hour GP service. Also my role developed in the hospital specialist services like migraine and pain management. Just like David I also have experienced migraine, not so frequently, but when it does happen, it’s debilitating.
My recent involvement in service delivery in Sunderland and South Tyneside Trust has been very proactive and the front line of providing treatments and interventions in the long-term management of migraine.
00:03:14 Dr Katy Munro
Yeah. And I know that you spent a year or so learning about Botox injections and how those can help people with migraines. So we’ll come back to talking about that in in a bit more detail.
But David, can I ask you, you said that you’re a pharmacy prescriber. So when you’re seeing a patient, just describe their sort of pathway to see you, do they go and see a GP first or do they pop into your pharmacy and say I’ve got a headache, what shall I take? What shall I take and how do you take it from there?
00:03:47 David Kelly
Yeah. Well, just to clarify, I’m actually based in general practice, so I practise within the doctor’s surgery. The patient pathway to my service is usually patients who have got an existing diagnosis of migraine, they are usually not managed particularly well. And either on suboptimal or sometimes not the correct treatments. And I mean I’ve been based in the surgery where I work now for nearly ten years, so I have a really good working relationship and I’m sort of central in the multidisciplinary team, and most of the patients come through to me via a GP referral, so they’ll present to the acute service, same day service. So these migraine sufferers will relate to sort of that day when you wake up and it’s the worst migraine ever, every one feels like the worst one ever because they are truly awful and they’ll call the doctors and then the doctors will refer them through to me. They’ll get a call same day. They’ll get a call back from me on the same day where we’ll spend some time. We’ll go through their history and see what the management has been like, really. You know, I won’t just say, oh, I’ve got a person here with migraine, so I’m just going to treat that acutely. I’ll take the time to understand that patient’s history and what they’ve tried for their migraine and see where I can really make help to make an impact in their care.
00:05:45 Dr Katy Munro
Yeah. So I’m thinking you may be talking to them not just about acute medication and management of their acute attack but also when to consider preventative medication and also how to use the medications appropriately. Because I know from hearing from patients who come to clinic that some of them will say, oh, I got given that and it didn’t work so I only took it the once or, oh, I got given this preventer and I took it for two weeks and gave up. So all those sort of conversations around how to take medication are really important as well as all the lifestyle modifications as well, I’m guessing.
00:06:12 David Kelly
But I think what, yes, that’s absolutely right, Katy. And that’s the very sort of common story, undertreated, didn’t tolerate. So patients don’t bother coming back for a while, then perhaps feel a lack of confidence in what could be done to help them with their migraines. So yeah, it’s a very common story, that. There’s a sort of suboptimal treatment in place, so I’m happy to speak with these patients and just, I mean, use — there’s lots of evidence-based guidance out there on headache and migraine management, so I think what I tend to do is educate the patients on these pathways.
00:07:25 Dr Katy Munro
Yeah, yeah.
00:07:26 David Kelly
And then we can work together to what treatments might be suitable. Yes, you did try a tricyclic but you tried amitriptyline, made you feel really sedated, maybe let’s see if nortriptyline can be a bit better tolerated. So it’s just spending the time to sort of work through. A patient will come in to see a doctor and maybe get a diagnosis, get set up with the treatment plan and they sort of think, that’s it.
00:07:55 Dr Katy Munro
Yeah.
00:07:58 David Kelly
And then when that doesn’t work, the patient then tends to sort of be in a repeated cycle of just managing their acute migraines as they arise, either with simple analgesia and doing their best with it, or then coming back to the doctors when it gets really bad. But it’s a bit like a revolving door of care, really.
00:08:25 Dr Katy Munro
How long do you have to spend with each patient? What sort of length of time are your consultations?
00:08:25 David Kelly
Yeah, I’m quite lucky in that I can be flexible. You know, the doctors because of their fully booked surgeries literally have ten minutes with the patient. And therein lies the problem really for sort of helping somebody to understand their migraine and really understand the treatment options that they have. So I’m a bit more flexible with my working day. It isn’t jam-packed full of appointments. So if I need to spend twenty minutes, half an hour with somebody, when I think there’s a real need, then I’m happy to do that and then arrange follow-up appointments. So I can be quite flexible.
00:09:07 Dr Katy Munro
So the continuity of care is really helpful, I think, isn’t it, because I think patients get very disheartened. They have to go back to square one and tell this quite long story and journey and part, you know, I tried this and I tried that and then said it all over and over and they’re still maybe sitting there feeling a bit migrainous as they’re speaking.
00:09:23 David Kelly
Yeah, yeah. And I speak to some people who are desperate by the time I’ve spoken to them because they may have been years in that sort of revolving door and then end up on maybe inappropriate medication, so they’re using things like tramadol and co-codamol, which can actually feed the problem. So yeah, I think I certainly get some great satisfaction, good job, professional satisfaction from helping a patient to understand the condition and the management plans better. And patients certainly seem to appreciate it. I’ve got one patient at the moment who’s been on my radar for about a year or so. We’ve been trying to optimise a treatment and then we’ve referred her to the headache clinic and she’s just come back and yeah, she’s just been interesting because I know quite a few of the patients in the practice who are chronic or episodic migraine sufferers, so they know they can come to me for that extra layer of support. And it’s not because I’m particularly amazing. It’s just because I’ve chosen to spend time and commit to that area and make sure I have the time to give to the patients.
00:10:36 Dr Katy Munro
Yeah. It’s amazing to have that sort of service within the general practice. I think it would be something that would be wonderful if we saw that rolled out.
So Nadeem, just talk a bit about where your contact with patients has been in the past and how it’s developed. Have you been a sort of high street pharmacist where you’ve seen people just come in and say, can you give me advice or are you within a general practice?
00:11:16 David Kelly
Yeah. So I’m based in the community, away from the high street, more like a locality in where there’s no GP surgery close by. So my contact is with the regular patients, very much so on a day-to-day basis, my staff also see them. And as you know in community, painkillers are the top-line products selling in the retail sector. So we see a lot of people using painkillers and migraine usually is seen as pain management rather than the migraine management. They continuously treat it pretty much like a routine pain or headache, which we normally see that that’s where the opportunity comes. So on the other side — just like David, I’m a prescriber practising in this area on a private basis. But in the out-of-hour GP area, where I treat walk-in patients, acute patients presenting in the evenings, weekends, so we see people not being able to get clear diagnosis or not have the time to sit down like David mentioned with the clinician and presenting with symptoms and you kind of intervene in the best possible way. So that’s the other side of it.
So we normally see in my day role in the community pharmacy those patients who are already either prescribed medication or some of those who are just self-medicating over the counter, and we find that sometimes it’s an opportunity to listen to them and see what is the pattern and we personally know a lot of patients and community members, so we find that it’s quite an advantage for us to have that relationship built, give them the confidence, give them the information that do this intervention and explore this further really before starting to treat the symptoms side of it. And that’s where I find that my interest grew and with my personal experience that headache management and migraine management need to have a bit more focus and, you know, support from clinicians and that led me further into developing the secondary care-led service.
00:13:44 Dr Katy Munro
Yeah, I’m sure both of you find as I do that many people haven’t got a clear diagnosis when they’ve got very clear symptoms that add up to migraine and I think there’s a certain amount of fear in general practice about giving a definite diagnosis. So sometimes, it’s a funny thing, but sometimes people put up with headaches and don’t even go to the doctor to ask what could this be? And I spoke to somebody the other day and she’d had migraine attacks over the years that had recently worsened, and she said, well, I’ve never really been before because I only got them twice a year. And I just kind of went to bed, slept it off. So I’ve never taken anything for years, and you think, god, these are people who are very stoic, actually.
00:14:33 Nadeem Shah
Yeah.
00:14:34 Dr Katy Munro
Often putting up with symptoms that are very severe but quite intermittent and so they don’t bother getting a diagnosis. But then when they go to the doctor and I was giving a little bit of a talk to some GPs last week at a conference, you know, there is a fear about missing something like a brain tumour. And so, you know, oh, they’re reassured, oh, it’s just a normal headache or, you know, that horrible term which I always pick up on, don’t say a normal headache. Nothing is, a headache is not normal. You wouldn’t say just a normal rash.
00:15:07 Nadeem Shah
No.
00:15:09 Dr Katy Munro
And so there’s some barriers to care along the way. And first of all, people not presenting. Secondly, people not getting given a named diagnosis and then the issues around medication. So talking a bit more about the self-medicating, what do you find that people commonly self-medicate with, Nadeem?
00:15:22 Nadeem Shah
I think the way I see it, people develop habits and we are animals with habits and we try to do things in a certain way, certain days, certain activities. So they have these symptoms and they have these in their mind, certain triggers which they have developed, you know, and understanding themselves. But as I said before, they haven’t critically evaluated it. They haven’t critically validated it or taken a history and sat down with a clinician so they find themselves in this cycle of self-management where they are not diagnosed yet and with especially a lot of treatments becoming available over the counter from prescription to pharmacy category. So there is also a potential that they could be using the products not effectively to a long-term sustainable effective outcome. So they have these habits where they would use very simple remedies, paracetamol, ibuprofen, co-codamol, which is one of the worst product ever available over the counter.
00:16:44 Dr Katy Munro
David and I both nodding.
00:16:48 Nadeem Shah
Yeah, and some other complementary medicines, obviously. And there are sumatriptan and other products available, but there is a lack of clarity as a planned management and an ongoing review with the clinician which they can see they somehow feel it is a headache and it is a kind of headache. What sometimes, as you mentioned before that there are certain symptoms, they don’t really feel appreciated. So sometimes they could be tired or, you know, boggy, and not feeling well, and not realising that it is one of those migraine presentations they come through, but then there’s another different type of groups of patients, maybe perimenopausal or those areas where people don’t identify that what is happening with them every month in that time, so they could come quite late in their diagnosis or appreciating the symptoms so they label themselves with various conditions and treat with anything that they can get their hands on.
00:18:00 Dr Katy Munro
You’re right, yeah.
00:18:05 Nadeem Shah
And sometimes underdose themselves and paddling along, not effectively targeting the condition with appropriate dose.
00:18:11 Dr Katy Munro
Yeah.
00:18:11 Nadeem Shah
And there’s also on the clinician side, I think, in the pharmacy, just like in general practice, there is not as much awareness that how you can actually intervene and separate the symptoms. People don’t normally have diaries and they’re not encouraged to keep so. And I normally see when people come again, I always say that, how long it’s been and what’s been happening? I don’t remember after three days before what was happening and they just have this recollection of various symptoms.
00:18:48 Dr Katy Munro
The brain fog is real as well, isn’t it?
00:18:50 Nadeem Shah
Yeah.
00:18:53 Dr Katy Munro
You wanted to add something?
00:18:54 David Kelly
Yeah. I just wanted to pick up on a point there about the available treatments and we talked, you know, we where we all sort of frowned at co-codamol. But I think in terms of migraine-specific, over-the-counter sort of acute treatments I think that it’s not a great market out there. What do you think? I think really if we’re talking about anti-inflammatories, you need higher doses than you can buy over the counter and we don’t really want to tell people to buy a packet of medication over the counter, but to take a higher dose than is stated on the box. Although we know we can prescribe higher doses, so that’s, you know, a bit of a barrier, I think. And then the migraine specific product is the one I can think of is actually a co-codamol with an antiemetic, well, take the codeine out and it might be a bit more suitable.
00:19:52 Dr Katy Munro
Yeah, yeah.
00:19:53 David Kelly
I think that and sumatriptan is an interesting one because there’s your migraine specific treatment that is available over the counter, but I don’t think it’s widely known about. I think there are barriers within a pharmacy because you have to convince the pharmacy team of your need for it. You really do. They’re quite sort of worried because what if it’s not a migraine, you’ve got, you know, there’s a sort of fear of selling it inappropriately which I understand.
I think people with migraine trying to manage it themselves in the community and using the sort of resources to them, unless they’re lucky enough to bump into somebody like Nadeem, who’s a specialist, you know. In community, it’s — Yeah. I may be wrong, but I do sense barriers to effective treatments.
00:20:56 Dr Katy Munro
I agree, and confusion I think because some of the products that we’re talking about like co-codamol, codeine-containing products, are actually labelled as suitable for migraine where no headache specialist that I know would say, well, get some codeine, that’ll be great and then things like naproxen, which we know can be very useful for some people, you can’t get easily over the counter. People with migraine with aura somehow. I mean we find that soluble aspirin can be so helpful, easy to get hold of. But people, there’s a certain fear of simple things like aspirin and it can be life -changing for some people.
00:21:36 David Kelly
Yes. And then aspirin 900, I mean, I don’t know what the — No licenced product in the pharmacy will say take 300, so I’m very mindful of giving the patient advice that somehow contradicts what they’re reading on the box. People need to feel safe with what they’re doing.
00:22:00 Dr Katy Munro
Yeah, yeah, yeah. And I think, you know, obviously people need to check that they haven’t got conflicting medications that they’re taking and a well-informed pharmacist will be able to help them with that as well, obviously.
00:22:11 David Kelly
Correct, yes.
00:22:12 Dr Katy Munro
Going back to what you were saying, Nadeem, about people are not getting the diagnosis. Sometimes they may come in and say, oh, I’ve got chronic sinusitis. Can I have a nasal decongestant? When actually they’ve got migraine and nobody’s picked up, we see this sort of thing. And also things like neck pain, you know, we know a lot of patients have referred to pain to their neck during migraine attacks and they may be desperately, you know, slapping on the Deep Heat or buying the TENS machine or all these other things to try and manage the pain. But if they had the right diagnosis, they could manage the underlying condition much more effectively.
00:22:51 Nadeem Shah
Yeah, yeah, of course. I think the range of products is there, I just feel that the process of management is usually absent and they kind of get into the habit of keep doing the same thing and not realising that different products at different stages of this migraine acute presentation, how will they be effective? And then they escalate to overuse of medications and drug overdose. You know, and then that causes the problems in the longer term and then that’s where the specialist interest and I think with the education and the higher education system changing with the pharmacists able to prescribe the new degree programmes are inclusive of all that. There is going to be potential where the barriers like David identified that the products not available over the counter or the licenced barriers, they will be less and less in future. So the pharmacists would have that opportunity to prescribe prescription products, but the training side is very essential. I think that’s where in my model where I linked up with the specialist service aiming to deliver specialist service based in the community. That way is quite an interesting way of focusing on migraine.
00:24:23 Dr Katy Munro
Yeah.
00:24:23 David Kelly
That’s an interesting — Sorry to come in — that’s an interesting development, Nadeem, isn’t it? Because with pharmacist prescribers, I mean from I think it’s 2026, every newly qualified pharmacist will be a prescriber by default, so hopefully that will, yeah, help certainly in terms of better migraine management with good training and being able to prescribe. That will help to overcome those sorts of barriers that are there within the licensed OTC product range. Yes, we can just do a bespoke prescription for an aspirin 900 or ibuprofen 800 to help somebody with their acute management.
00:25:08 Dr Katy Munro
What about labelling? Are some of the products currently labelled “do not take this for more than ten days in a month” because I think one of the tricky things is encouraging patients to take their medication early enough in an attack, warning them not to take it on too many days in the month and to talk about prevention with them if they are beginning to have more than four or five days impacted by migraine, but also not scaring them because I’ve had patients who came and said, oh, my GP prescribed sumatriptan for me and said, well, don’t take this, it’s really, really strong, don’t take it unless you’re really desperate and of course then they’re waiting too late, missing the boat. So are there any labels or on the packet saying “don’t take this more than ten days a month” or anything like that?
00:25:55 Nadeem Shah
Yeah, I think there are general warnings and also in the pharmacy sale protocols there are limitations. We provide advice that don’t take it for longer than even three days, some of the products, don’t depend on this product. But it goes back to the same point that unless they understand how migraine gets triggered and medicine overuse is a phenomena which is not just a general advice, but actually biochemically it leads to worsening of symptoms, so they need to appreciate that and also understand how they can help themselves by effectively using the right product at the right time, good dose, not long enough to accumulate. All these issues I think as part of ongoing all the time, you know, protocols which sadly is not practise as much unless there is a dedicated mechanism or support both of patients and for community pharmacy staff.
More like an integrated care, like David is managing the service, providing service in the GP or primary care side of things. It’s a similar thing which once I think it will come to a point where the pharmacist-based clinics, pharmacy-based clinic will become part of that integrated care, where on one side you have part of the general practice and also on the other side you have the specialist services integrating in that community-based hubs, or I would say where ongoing management, all the interventions including oral treatments, injectables, Botox, steroids, all those things can safely be prescribed and administered really.
00:27:55 Dr Katy Munro
Tell me a bit more about the Botox and your experience with being in a secondary care clinic for a year I think it was, wasn’t it? Tell me about how you see Botox fitting into that.
00:28:04 Nadeem Shah
Yeah. So I did Botox for aesthetics for a little while, obviously, but that wasn’t my main interest. The applications of Botox in pain management brought me in discussion with local services. And in Sunderland Hospital I proposed a project where I would go in as a clinician and assist the service to bring down their waiting lists. For once they have been diagnosed and identified to go on the treatment under NICE guidelines, so we would take those patients on a regular basis, provide treatments which included Botox for migraine and also greater occipital nerve blocks, which was also administered. So I independently worked, linked with the service in that role, and that was quite great because I had my own experience of pharmacy and community pharmacy and that side. But here I was taking that to next level where I could discuss with their experience of medication use and all the other preventative treatments we could also prescribe, but I was already able to give them a better control of their symptoms through this noble treatments like Botox and greater occipital nerve block treatments.
00:29:46 Dr Katy Munro
Hmm.
00:29:46 Nadeem Shah
And we found after a year, we did an audit, nearly all of the patients felt that they would not mind seeing any other clinician other than the GP, you know, GPs working in the service or a doctor working, or a nurse working. Rather that they would have the treatment on time and have the symptoms managed. High level of satisfaction. I had a great experience working with the team and obviously the next project level was that how can we take this service out of the hospital into the community in a pharmacy and I think that is a work in progress, so we’ll see how things develop.
00:30:34 Dr Katy Munro
I think it’s really exciting to hear these new models of developing care, as both of you are doing really great work in different areas and I spoke to Doctor David Watson about the Scottish pharmacy project, which was a big project that they’ve done and that will be on this episode, about not just upskilling pharmacists, but also kind of flagging up awareness of migraine to the general community because I think that many people just really underestimate the impact or don’t realise that they have it and can go and get help.
00:31:14 David Kelly
Yeah, I think pharmacists can have a great role in the area of migraine management. I mean there are some lifestyle factors that patients can adopt, they’re usually avoidance, typically avoidance to sort of minimise the risk of triggering an attack. That can help, but it’s limited. I mean, migraine is typically about effective treatment. Manage your lifestyle factors and get effective treatment in place and there I think the pharmacist is well-equipped to help a patient to understand their condition.
00:32:03 Dr Katy Munro
Yeah.
00:32:04 David Kelly
Navigate treatments, avoid the risks of inappropriate treatment, which can turn into a cycle and worsen the situation and you know just efficient, sort of speedy access to services and treatments, whether that involves a referral or making sure that within primary care that treatments are focused on and optimised within a good time frame. I mean, I know of cases where a person with episodic possibly chronic migraine has waited eighteen months for a neurology referral.
00:32:46 Dr Katy Munro
Yeah.
00:32:47 David Kelly
Yes. And then when you see the neurologist at that point, that’s just the start of that process and it may take another six months to get that Botox treatment or the CGRP. So it’s a long wait for patients who are dealing with a very unpleasant condition that impacts on their day-to-day quality of life, greatly impacts.
00:33:09 Dr Katy Munro
And in that time the migraine may have progressed from episodic to chronic migraine because it hasn’t been effectively treated.
00:33:15 David Kelly
Absolutely, yes. Yes. Yeah. And there are effective treatments and there are new developments in migraine now. So there’s some more specific treatments that are perhaps have more preferable side effect profiles so you know from that perspective it’s an exciting time to be sort of within migraine and as a migraine suffer myself to know that this is an area that’s got some attention and some focus and there’s some developments in place to improve the lives of –
00:33:48 Dr Katy Munro
There’s hope, isn’t there? Huge hope.
00:33:51 David Kelly
Hope. Yes.
00:33:51 Dr Katy Munro
To find this relief. There are just a couple of other things I just wanted to flag up that I’m aware that people can do before they see a neurologist and may well come and talk to you about. So one is the anti-sickness medications which are commonly left out and some of which you can buy over the counter. One of the sort of supplements, minerals and vitamins, some of which have reasonable evidence, and certainly in real life experience, many patients find magnesium or vitamin B2 or coenzyme Q10 helpful. I’m always telling people about vitamin D because having it optimised is generally a good thing anyway, and omega-3. And then there’s these neuromodulation devices which people can buy for themselves. And a lot of people are very surprised they’ve never heard of these or whatever. So I’m guessing with your specialist knowledge, the two of you can also kind of point if they say I don’t want medication which people don’t, you can just ask more holistically around these other approaches.
00:35:04 Nadeem Shah
Yeah, I think.
00:35:05 David Kelly
Absolutely.
00:35:07 Nadeem Shah
Also, yeah, there is a whole range of support interventions available. In certain conditions, I think some people, if they are pregnant or if they feel that they don’t want to take any medication for their personal reasons or they’re fasting, in their situations they may not find that an oral product is appropriate. There is a range of interventions. And I like in my community pharmacy role, I have a kit made for migraine, for the pharmacy staff really. You know, the key things which we need to remind to patients for pharmacists and for pharmacy staff. So it’s like a very short bullet points and key things. So that we are consistent, we are clear, and we are providing up to date information, so those kind of things we can have available for our staff to refer to and leaflets. Normally everything is available online now most people are quite used to that. But we have QR codes available on the same leaflets, so people if they want to have, we say, take a picture of this and go home and discuss, come back to us if you want to explore.
And there are now new services available in Pharmacy First, commissioned services where if somebody’s unwell for various things, obviously may not fall in those categories, but you can get booked appointment with more clinical time available to discuss these things. So there are things happening on the community front and I feel that as I said before, a change in degree programme, availability of products, and the change of contracts in the community pharmacy sector, it is new opportunities coming in the next five years, things will be done quite differently.
00:37:17 Dr Katy Munro
I agree. Yeah. And just a plug for the podcast. Hopefully it’s made its way onto your information pack. A QR code to our podcast.
Yeah, I was going to say, but you know, looking forwards there are these exciting new drugs coming through, certainly some GPs in some areas of the country are already prescribing these oral anti-CGRP drugs. Not all, some are still restricted by their local formulary regulations. But because they’re safe and effective and very unlikely to interact with people’s medications. I do think they should be more easily available in pharmacist’s. Is that what you’re both thinking? That, you know, let us have them.
00:38:04 David Kelly
Yeah, I think it being available in community pharmacy as a sort of pharmacy-only medicine is quite far down the road at the moment. Just because of the way licensing works and sort of post-marketing surveillance that the MHRA and all the regulatory bodies really need to know that medicines are absolutely safe enough — hesitate to say the word absolutely safe — but sort of safe enough to be sold over the counter.
But as a new development they are quite exciting. They do have really favourable side effect profiles. They’re as effective as our other specific treatment which is triptan, you know, and really our only specific treatments for migraine today have been triptans.
00:39:04 Dr Katy Munro
Yes.
00:39:04 David Kelly
There’s no specific preventive. I mean, I’m talking about primary care. You know, there is some specific in secondary care, the Botox interventions and the injectable CGRPs, but it’s a long way for those medicines. Primary care now is starting to get access to these new medicines and yeah. I think cost is an issue, the NHS has to manage its resources. So there will be, shall we say, hurdles in place just to make sure that NHS resources are being used as cost effective as possible. But yeah, I mean there’s no reason why a patient who has gone through the mill in terms of trialling the currently available preventives, there’s no reason why they shouldn’t have access to this new sort of class of medicines. It means clinicians like myself writing to neurology just to seek some advice and sort of get a neurologist’s opinion on whether they’re OK to use or not, which is really in line with the NICE guidance on these new medicines. It’s not so much that doctors can’t prescribe them in some areas, it’s just they need to seek the advice of the specialist first, which is, you know.
00:40:42 Dr Katy Munro
Yes, yes. Which is, as you say, Nadeem—
00:40:46 David Kelly
With modern communications.
00:40:48 Dr Katy Munro
Yeah, it’s a changing world.
00:40:50 David Kelly
With modern communication systems. Yes. Yeah, I mean, here in my practice we can literally send a message, a DM, to neurology and they’ll tend to reply within a couple of days, you know.
00:41:07 Dr Katy Munro
Advice and guidance is quite a widespread way of–
00:41:09 David Kelly
Advice and guidance? Absolutely yes.
00:41:11 Dr Katy Munro
From neurologists and secondary care and just helping. But I think what you’re both highlighting is the way that contacting a pharmacist who has an understanding of managing migraine and headache can lead to all sorts of things that can help and support those patients while they’re in the longer wait to see somebody. And it may not even be that they need to go to secondary care if they have good information. That’s the thing, isn’t it? I think the lack of information is something we’re always trying to improve on from the National Migraine Centre through this podcast, through our website and factsheets and things like, and just talking about it. I say to people, you know, talk about migraine. I certainly talk about migraine a lot, as you can probably tell.
Is there anything else? I think we’ve probably covered most of the topics, but is there anything else that either of you wanted to point out or a top tip or anything like that? David, you want to go first?
00:42:14 David Kelly
Mine would be a quick sort of bullet point. You know, if I wanted to give a message to a patient who’s out there suffering with migraine, make sure you have your diagnosis on record and you understand what migraine is, what lifestyle changes or lifestyle factors you can consider. Make sure you have a good rescue treatment. There are good rescue treatments out there, so make sure you keep returning to your doctors or to your pharmacist to make sure you’ve investigated all options. Avoid medicines like opioids. Really don’t use opioids to treat migraine. Not good news. And you know, if you’re experiencing four or more migraines a month and it’s an impact on your quality of life, you know, just have the discussion with your doctor or pharmacist about maybe effective prevention strategies.
00:43:16 Dr Katy Munro
Yep. Hear, hear. Nadeem, anything to add?
00:43:18 Nadeem Shah
Yeah. I think as David’s covered most of the points. In terms of when they have the opportunity sometime randomly with a clinician sometime I find that they can’t remember exactly how they’ve been presenting symptoms. So having an app on the phone, it’s now quite easy to do it right now. There’s loads of apps available. And they can keep a good diary of their symptoms. What triggers them? What happens? How often? Intensity? What did they do about it? Treatments and any of the strategies which become handy for them. That helps underpinning the diagnosis, I think it’s one of the issues which we battle all the time. Is it a headache? Is it a migraine? What’s causing it? That helps to bring this management of migraine more in control. And in the longer term, obviously if the pharmacy staff and pharmacists are ready and consistent to provide that opportunity to take intervention to that particular patient, that’s very helpful on the sale points.
00:44:32 Dr Katy Munro
Training, training for pharmacy staff.
00:44:32 Nadeem Shah
Yeah, yeah.
00:44:36 Dr Katy Munro
Just on that point, I completely agree with you on the… So there’s also the website for the British Association of the Study of Headache, which is called BASH. So BASH.org.uk website has a number of resources for patients as well as for clinicians. And if you go on the patient page there are several different downloadable headache diaries in various formats, so I think some people like to use a quite complicated app like Migraine Buddy which asks, you know, what was the weather like or what did you piece standing on your head that day. And all this kind of detail and some people really like that.
00:45:10 Nadeem Shah
Yeah.
00:45:13 Dr Katy Munro
But as a clinician, the simple diary is actually very useful for us. So our National Migraine Centre headache diary, we want to know what was your maximum impact in that day? What medication did you take acutely and for women, did you have a period? Because I know obviously women are often finding they have worse attacks around their menstrual cycle and the other people I’d like to always mention is children.
So children are very impacted by migraine much more than is recognised and a simple traffic light system, you know with stickers or something. So red is a horrible day; amber is an OK, got through it day; and green is a great day, I was fine. You know, that can really just be a simple way of monitoring the impact of migraine on a child. And we see children as young as four in the clinic who are showing symptoms of migraine. So one of the things I do, and which pharmacists can do as well is say, you know, to a patient who’s got migraine, do you have any children? How are they? Because I think, you know, if we say, do they have travel sickness, do they have tummy pains? Have they had cyclical vomiting? Do they have dizziness? All of these can give clues to the fact that that child is actually developing the symptoms of migraine, and then we can get them early and get them better quicker.
00:46:36 Nadeem Shah
Of course, yeah.
00:46:37 Dr Katy Munro
Yeah. I’d like to thank both of you very much for your time in preparing and then coming on this podcast. It’s been really interesting. I think it’ll be very useful for our listeners. So thank you very much.
00:46:52 Dr Katy Munro
Pharmacists have an important role to play in the management of migraine, and they may be the first port of call. An innovative project in Scotland has looked at how to upscale pharmacists and also give them confidence and give the public confidence in consulting them about migraine management. I spoke to Doctor David Watson and Abigail Duthie about this programme.
So for this part of Heads Up podcast I’m going to be talking to Doctor David Watson and Abigail Duthie about the Scottish pharmacy project that they’ve been working on together on north of the border. So thank you both for joining me. This is a really good chance to hear about how pharmacy training is changing in Scotland and maybe how we can roll that out across the UK because I think we’re aware that education in migraine needs to happen throughout all aspects of society.
So do you just want to first of all, Abi, would you like to introduce yourself and say who you are, where you work and a little bit about why you got involved?
00:48:07 Abigail Duthie
Of course. Yeah. So I am a pharmacist and have been qualified for coming up for two years in December. Mainly I work in Peterhead at Buchanhaven Pharmacy but I work across a couple of the different branches as well. So I am just starting into my independent prescribing. So I’m not an independent prescriber just yet, but that’s what the plan is and that’s the course I’m enrolled on. So I should hopefully be qualified maybe next year, middle of next year sometime. So I’m hoping for that to go ahead, but that’s me as a pharmacist, so only two years qualified.
00:48:46 Dr Katy Munro
Lovely. And David, do you want to introduce yourself? You’ve been on the podcast before, of course, but do you just want to recap?
00:48:46 Dr David Watson
Sure, yes, hello. I’m David Watson. I’m a GP in Aberdeen, where I’ve been working in the practice, I’m in the Hamilton Medical Group for thirty-five years. But I also am a GP with extended role and I’ve been working at Aberdeen Royal Infirmary as part of the neurology department, with the Headache Clinic, now almost twenty years. So I’ve had a long-standing interest in headache. And as a lot of my GP colleagues will know, it straddles primary and secondary care in such a big way that I think it’s really important to have this conversation about where we manage headache and I think your pharmacy is something that is really important and I’m looking forward to maybe discussing more about that over the next few minutes.
00:49:41 Dr Katy Munro
And David, you’ve also been instrumental, I think, in helping to heads up the SIGN guidelines on management of migraine and headache.
00:49:49 Dr David Watson
That’s right. So we’ve had two SIGN guidelines, the original SIGN 107 guideline, which covered all headache, was published in 2008 and that was an enormous undertaking because it was really to try and cover all the primary headaches and touch base on secondary headaches as well, and it really was a three-year work from 2005 to 2008 to get it published.
And then we updated the guidelines in 2018 and just concentrated on the pharmacological management of migraine because obviously there’s been a significant change in how we manage migraine over that time. Some of the treatments that were used in the past, there’s really not a lot of evidence for them. And then we’ve got some of the newer targeted treatments.
And with respect to SIGN, we’re planning an update quite soon. We’ve in fact, we’ve just had approval from SIGN to do an update. And what we’ll do with that as well, we’ll touch base a little bit about the MHRA’s decision on topiramate. And you’ll be very much aligned to the valproate side of things. So we’ll update SIGN with that and we’ve got now the gepants that we have as targeted treatments against CGRP and will update SIGN on that. So hopefully maybe if we revisit this this time next year, SIGN will be up to date with all these important changes.
00:51:11 Dr Katy Munro
So of course, those medications you’ve just mentioned are the ones that clinicians tend to prescribe. But Abi, when you as a pharmacist are working, do you see a lot of patients coming in and asking about migraine? Is it something that is the bread and butter of pharmacists, do you think?
00:51:30 Abigail Duthie
I wouldn’t necessarily say — sorry. My dog’s barking in the background, we’ve just had a parcel delivered. I wouldn’t necessarily say that it’s the bread and butter that I see, like, tonnes of people coming in every single day with it, but I would say that we do see a lot daily anyway.
Mainly I think in the pharmacy that I’m at that we’ve got a big independent prescriber kind of role. So from there we pick up a lot of appointments that the doctors can’t fulfil just like sinus infections, ear infections and such. But I think more so because I’ve been more exposed to migraine just through working with David and Callum and Susan in that I’ve been more aware of that. It is a bigger role and it does need to be opened up to a lot more pharmacists because some of the patients that will come in will present with the likes of that — I’ve spoken about this before — about sinus pressures and repeated sinusitis. And then that’s when we’re, can I go and down more of the route of going, well, actually it’s probably not sinusitis that you’ve got, and it’s opening up that whole talking and speaking a bit more freely about the possibility that it is migraine.
I do think pharmacy could potentially have the potential to be the first point of call for migraine, but I think the issue with pharmacists in total is that it’s this, as soon as somebody comes in with any headache features or anything like that, it’s this nervousness of, oh my goodness, is this more sinister and I was working with a pharmacist up in Inverness and he loves the phrase that if you hear hooves, think horses not zebras. And I think that’s what more pharmacists need to be a bit more familiar with and think, it sounds like a migraine, it is a migraine, talks like a duck, walks like a duck, it’s a migraine. And I think it’s just getting over that hurdle of and I think that’s what we’re hoping is going to be the case with the project.
00:53:21 Dr Katy Munro
I think that’s really true and whenever I go and give talks to different groups of people about migraine, that fear of getting it wrong and fear of overlooking a brain tumour is something that really is foremost in a lot of people’s minds, especially if they haven’t had very much training. So let’s just say a little bit about the Scottish pharmacy project, which I know is in collaboration with the Migraine Trust. David, do you want to say how that collaboration came about?
00:53:49 Dr David Watson
Yes, so it’s a bit of a long story, but in short, Rob Music, the chief executive of the Migraine Trust, actually approached me in December of 2021 to say that there was this update of the neurological framework in Scotland and Scottish Government were offering funds in order to implement some of the work that was being done in the framework. And Rob and I had previously had discussions about education, really targeted education in primary care, and Rob had said, you know, should we apply for some funding and we can look at GP education, practice nurse education.
And I had quite a think about it and I said to Rob, I think it’s a great idea but the but for me was we were just coming out of COVID. And I think most of the practices were feeling quite overwhelmed at that point and to get buy-in for education, people need to feel under less pressure. But I said to Rob that you one of the allied professions that really has never properly been targeted in my understanding was pharmacists, mainly community pharmacists such as Abi working in the community. But we now have practice-based pharmacists as well.
And if you look at some of the epidemiological data that’s about how migraine presents, I think our understanding is probably about half of all patients with migraine don’t ever go and see a GP or visit a practice for advice. And a lot of patients self-manage and some will obviously do that really well. And they’ve probably got some very helpful pharmacists, but some won’t self-manage and maybe there’s quite a lot of codeine-containing medications and patients who maybe should be on preventive therapy.
So I said to Rob, why don’t we look at a project that would help target training for mainly in the community pharmacies, and Rob thought this was a good idea. So a funding application went into the Scottish Government, it was actually approved in April of 2022. But like a lot of Scottish Government projects, there was just funding for a year. And it was actually very difficult to try and find a manager of the project who would come and work for one year. And there was, you know, by the summertime we’d had no applications and Rob and I were getting a little bit frustrated about that.
But we then approached the neurology management in NHS Grampian and said, look, could we make this a joint project between the Migraine Trust and NHS Grampian? And after a few meetings we got a very positive response and that the Realistic Medicine team of the health board started to run with this and we basically then managed to get a project manager appointed in place by February 2023. Really since then, the project has grown arms and legs. The original manager was actually relocated to Inverness and we’ve got an overseeing manager, Katy Styles, who’s excellent, and we’ve got Susan who is our everyday project management, and she’s really excellent as well.
And really, you know, when I spoke to Rob, I had this vision of Callum Duncan, who’s my consultant neurology colleague, with Callum and I going and giving a couple of lectures to a group of pharmacists. And that would be the project. Because we’ve got the Realistic Medicine team and it’s properly project managed, we’ve had a pharmacy focus group so that we can look and see what the pharmacists themselves felt was important for them. We’ve had patient surveys and a patient focus group to find out what patients feel is important for pharmacists to offer, and that’s then led on to an online learning module for the pharmacists. We’ve had four workshops, one that was face-to-face and three virtual, and then that was followed up three months later by a virtual workshop. So it was like a Q&A where you’ve had the training, you’re three months into it, what are the issues? We did a patient webinar in January of 2024. And we had over patients on that webinar. It’s on YouTube, I think it’s been watched now well over a thousand times and the feedback from the patients has been that prior to the project maybe only about 15% thought they would engage with a pharmacist with migraine and now that that figure is significantly higher, certainly for the patients attending the webinar it was over 90% realised the value of consulting with a pharmacist and I think what we’ve tried to do with the project is give the pharmacists confidence in a) you know, at what point does this patient need signposted to their GP? You know, is the concern that there’s secondary headache, is the concern that it’s migraine but they’re getting frequent episodes that need to go on to preventer therapy. I think the pharmacists are absolutely fantastic at explaining about medication overuse headache, how to use acute treatment, especially triptans properly.
And what we’ve done is in terms of rolling it out was, the one slight thing we got slightly wrong in the first year was that we were very keen to get the whole pharmacy team. So that’s the counter staff, the assistants, as well as the pharmacists, because of course if you come into the pharmacy, it’s the counter staff you deal with first, so our online education module was quite technical for non-pharmacists. So we’ve got funding now to roll the project out, and one of the things we’re doing is that there’s a new online teaching module that’s aimed specifically at the counter staff. And we’re going to be talking on things about, to know the three ID migraine questions. You know, the last three months have you had headache that’s caused disability, nausea or light sensitivity so that they can then signpost these patients to the pharmacist. The other good thing with the funding now we’ve got funding to roll out to other health board areas. So it’s not just going to be Grampian, we’ve got Highlands and Islands, Lanarkshire down into Glasgow and we’re going to be engaging with some of the local clinicians there to deliver the teaching locally to their own teams.
And of course one of the big things that we’re going to have to work on is that the Scottish Government are very keen to have some outcome measures. So we feel that we’ve helped to upskill the pharmacists. I have to say that the focus group that we had for the pharmacists that first met, I’ve never met a more enthusiastic group in my whole life. They were just fantastic. And certainly one of the pharmacists in the focus group was just sitting in my clinic last week, he’s a practice-based pharmacist and is starting to do a migraine clinic in the practice. So whilst we’re mainly aiming at community pharmacy, to have someone working, starting a headache clinic in the practice, mainly looking at titration of preventer medicines. So I think things are moving quite fast but we’re going to have to try and work out outcome measures because I think that’s going to be quite difficult. But, you know, the Scottish Government are keen that there’s no postcode lottery in Scotland so that what’s available in one part of Scotland’s available to the rest of Scotland. So that’s a brief background to it.
01:01:51 Dr Katy Munro
So can I ask you, Abi, were you part of that focus group, that original group and what made you think, oh, I’d like to be involved with that? Had you any previous experience of headache and migraine management or did you just think, that sounds interesting?
01:02:09 Abigail Duthie
Yeah, basically that’s it. So I was in the original focus group and just as David was saying, I’d never really properly been in a focus group before. I’d obviously maybe seen wee Teams calls and stuff like that, but I think more so because it was face-to-face and it was just that there was so much ideas floating around and it was just, it was like a very good, and I don’t say this lightly, like a very good vibe about everyone. And it was just so like, everyone was speaking very freely, and it was amazing listening to David and Callum just speaking about it because it just was so explained in such a normal level without any jargon and it didn’t complicate everything and it was very open for anyone to jump in as well. And it was really, really good and I was like, this is a team that I would really like to be on board with.
And I’ve suffered with migraines for years as well, and I think, see, when you’ve got almost a personal connection to it, it makes you more invested in it as well. So I think that even just being on board, I’ve been able to manage my own migraines myself a lot better than what it was before. And I think just having that confidence in working with them and the team, like they’re just fab, it’s such a good group to work with and nothing’s ever a stupid question and their wisdom and their knowledge is amazing and it does just sometimes, I’m like, when I’ve been with them, listening to them as well, I’m sometimes a bit floored. I’m like, oh, god, it’s just so well-put across as well. That’s just perfect, like that aims at such an understandable knowledge level that you don’t need to upscale it and add in all this jargon. And it just comes across very nice. So that’s where I jumped in at was the original focus group.
01:03:50 Dr Katy Munro
How many were in that focus group originally, roughly?
01:03:56 Abigail Duthie
It wasn’t a massive focus group. I think. What would you say, David?
01:03:59 Dr David Watson
So maybe about eight to ten from memory, yeah.
01:04:02 Abigail Duthie
That’s why I was thinking, maybe.
01:04:05 Dr Katy Munro
You don’t need too many, do you, too many people on a focus group like that? But that’s really interesting to hear. And I wasn’t sure whether to ask you if you have migraine yourself, but of course an awful lot of us who work in this area do have migraine. That’s how we get our way to these kind of roles or interests, and it’s an exciting time to be working in migraine because of the new drugs that David mentioned earlier on and you know, getting information to all levels of society. As one of the things we know is that many people who have recurrent bad headaches that make them feel sick and they don’t like the light, they don’t recognise those as migraine. They think it’s just the normal headache that everybody gets and I’m always saying to people, not everybody gets headaches. You need to get a diagnosis. It’s so important. So the first thing is generally to kind of get the word out there that migraine is very common, one in seven people getting it, and then go and find somebody who knows about migraine and ask them if your headaches are that.
01:05:11 Dr David Watson
Katy, sorry to interrupt you. I was just going to say that that was one of the magic things of having this Realistic Medicine team that we actually had a public advertising campaign. So we had radio adverts, we had adverts on buses, we had adverts at sports venues with basically what you were saying – are you one of the one in seven? There was a QR code so people could just scan that and that linked them into an updated website with a webpage we have with migraine information which has links to a number of resources. For example, the podcast that we’re doing now is one of the resources we’ve linked to. And I think it’s been really interesting because I’ve seen patients come through at the headache clinic and they say, oh, so nice to meet you, the webinar was great, and so I think you’re right, it’s about recognising that, we have an inbuilt joke, don’t we, in the headache world about normal headache. What is normal headache? And if you’re a family of migraineurs who go to bed and shut the curtains, that’s just the family’s normal headache. But actually we need to help these people, so that the public advertising campaign I think was one of the successes of this programme.
01:06:26 Dr Katy Munro
I always say to people, you would never say to a doctor, oh, I’ve just got the normal rashes that everybody gets because everybody knows that having a rash is a symptom of something. And headache of course can be caused by other things, not just migraine. But it’s a common symptom of migraine as well as all the other things that migraine can bring.
So when you had done the focus group, Abi, did you then start connecting with? I mean, was the project rolled out to all of the Grampian pharmacists? Did everybody who was a pharmacist get notified about it? How did you recruit people to be on the project?
01:07:09 Abigail Duthie
Actually, to be honest, I can’t even really remember. I think I just had emailed someone and was like, oh, I really found this interesting. Or I think maybe was it Katy that had maybe emailed me? I really can’t remember, but I basically just ran with it. In my opinion I was like, if you need any involvement from me, I’m more than happy to be involved and I think that’s just really kind of how it came about, but I can’t remember specifically because I think it was maybe a year and a bit ago that I became involved. So yeah, I can’t even remember what I had for my supper yesterday. So let alone — I got hooked in and hook, line and sinker, I just ran with it, yeah.
01:07:51 Dr David Watson
Katy, it was again back to the success of actually having a project team and I think if it had just been me and Callum Duncan giving a couple of lectures, we would not have got to where we are just now, so having proper funding. And the Grampian Realistic Medicine team are very much on your evidence-based medicine, keeping things straightforward, keeping the message on something that people can understand, so they managed to recruit the pharmacists in Grampian. And by the time we’d finished the four-hour teaching sessions, I think 37% of all pharmacists in Grampian had done the training. So one in three pharmacists had done the training. So we thought that was a very good capture because most of the people like Abi are, you know, they’re working full time. So this is something they have to give up and things to be part of. And the online educational model probably takes about an hour and half as well, so it’s quite a bit of a commitment to be involved.
What we are hoping to do is to liaise with the two pharmacy schools in Scotland so that we’re going to offer the educational materials to the undergraduate pharmacists and training as well. And I think that Robert Gordon University in Aberdeen are I think quite open to this and they’ve had discussions with Clyde in Glasgow, I think there’s ongoing discussions, but in a sense we’ve got this online teaching model.
There’s a Scottish educational framework called TURAS, so anyone in health and social care in Scotland has access to, and there’s lots and lots of different training materials, Our perspective of putting this out that you know from our perspective, the more people who get involved, the better. So in fact you are signposting my medical students, my junior doctors, my FY2s, etcetera, to the training posts as well.
But again, what I would say if someone is thinking of trying to replicate this kind of educational model somewhere else in the UK, firstly we’d be incredibly supportive of that, but secondly I think you really need to have a project team. Because as doctors, we’re very good at pitching up and giving a lecture, holding a workshop or producing slides and things. But it’s the day-to-day, contacting people, organising when the meeting will be, finding out what the need is and I think that was a really, really good thing having the focus groups so that, you know, so Cal and I could have pitched this at a level that would just not have been appropriate–
01:10:35 Dr Katy Munro
Yeah, yeah.
01:10:36 Dr David Watson
— for the pharmacists, so it was very much, what are your needs, what do you want to know about, what can we help you with? So I think having the focus group was important. But likewise the patient focus group was really important as well. So that when we did the public webinar. And again, what was the information that patients with migraine or families of patients with migraine or people who just want to learn more, what information did they find useful? So I think having the project team is absolutely key to this.
01:11:06 Dr Katy Munro
I think there is a thirst for information out there and as you know, David Kernick and I did the Edinburgh Fringe and we had an open Q&A for people to come and ask us whatever they wanted to ask us and so we had a whole range of people asking us broadly similar questions actually because I think there is this thirst for knowledge. People with migraine generally want to understand what it is, why they’ve got it, what they can do for themselves and manage themselves. Empowering the patient is one of the things I’m quite passionate about really. I’m coming up to Scotland, to the Scottish Headache Conference later in the year to see you all and speak about migraine again, because I there’s such a need for education out there.
So I know, David, you kindly and Rob Music did a piece for my BASH website. So BASH is the British Association for the Study of Headache and I’m trying to encourage more pharmacists to join, Abi, hint hint. But there’s a piece that you wrote for our members which was summarising, you know, the results, albeit you were saying about outcome measures, but the confidence of people managing migraine or advising their customers, I guess, about migraine had really improved. That’s what you found, wasn’t it, David?
01:12:34 Dr David Watson
Absolutely so, so slightly qualitative for the feedback from the pharmacists was fantastic and feeling much more able to advise both in terms of at what point you should signpost to a GP. But what can I actually do? So just some really, again it’s kind of bread and butter to people who work in the headache world, but if you’re not in the headache world, you know, things like avoiding opiates for example, doses of ibuprofen and aspirin, how to take a triptan, when will a triptan work. And I think the pharmacists have engaged with that massively and I think they found it really helpful.
The other thing that we covered in in the sessions was just about how you ask questions to patients with migraine? So if you said to, you know, a mum with three kids under five, so when you get your migraines, you go and lie down, she’s just going to look as if you’re daft. But say, are you glad when your husband gets home? Or asking about noise and light sensitivity. You know, does light bother you when you get your migraine? No. So why have you got your sunglasses on sort of thing? So it’s just giving the pharmacist a little bit of those tools of how, very often pharmacists, but I include medical students, just get given a checklist. These are the questions to ask, but there’s no degree of subtlety on how you ask the question, how you tease that information out. And I think we’ve had the feedback that’s been really helpful just to help shape how you ask questions to patients.
01:14:09 Dr Katy Munro
That question about how many days do you have a crystal-clear head in a month as well is so revealing, isn’t it, when you say to people how many days in the month are you absolutely fine with no symptoms at all and they go, oh well, I can’t remember, because they’ve told you they’ve got three really bad attacks, but they haven’t counted all the other days where they’re pushing through and mums also are having to go out to work themselves as well, sometimes looking after elderly parents or other relatives and juggling all these things and so stopping when you have a migraine attack only happens if it’s a really bad one.
1:14:49 Dr David Watson
That’s right.
01:14:52 Dr Katy Munro
And sometimes quotes. You know, I don’t know who it was originally said this. You know, people think that those with migraine are faking illness, whereas actually they’re often faking being well.
01:15:04 Dr David Watson
That’s right.
01:15:05 Dr Katy Munro
All the rest of the time people are pushing through. Sometimes, quote, I don’t know who originally said this, those with migraine are ‘faking illness’, you know, they’re often faking being well. They just can’t stop doing what they have to do.
So Abi, when people come in now and your little ears prick up because they’re saying something about sinuses or headaches or whatever, or even dizziness possibly with vestibular migraine, what are your top tips here? Is there anything that you think right, I need to tell this patient X, Y and Z?
01:15:32 Abigail Duthie
Yes. So I’ve kind of got almost like a bit of a checklist going on in my head of, right, I need to just double check this and I need to check this. So I need to kind of figure out what they’ve already tried, so I need to see if they’ve tried any NSAIDs or anything, because my first port of call is, let’s try an aspirin. We’ll do like a triple whammy almost, so an aspirin, a triptan, a prochlor or something like that to see if that’ll kind of help anything. So I need to first get an idea of is this a recurring attack, have they had anything similarly to this before? Have they tried anything just yet? What have they tried already at home, more so based on their symptoms. Because I remember it was just how David was saying there just now just has given us as pharmacists more information to use to help as well.
So like before, I never even really realised that you can get migraines that go into your necks, which sounds so silly, but it makes so perfect sense, but just having that information and then also that we were always taught that migraine was always one-sided. It was always a one-sided headache and just having that more information of, well, it’s not always going to be that, it can be either side, it can be all over. It can go into your neck, it can go into your jaw. It’s all that kind of piecing everything together that helps a bigger picture.
So the patient would come in. I’ll give you an example of a girl that had came in. So she came in. She had sunglasses on and she was saying that this was the worst headache she’d ever had in her life. And she was probably, like, mid-twenties. She was of similar age to myself, mid-twenties. She hadn’t taken anything for it because she normally gets these kind of headaches., they just kind of go away on their own. But it’d been a couple of days into this headache that she wasn’t getting anywhere with it, she didn’t know what to try and take at all. So I had taken her into a consultation room. I’d asked her, I was like, have you been sick with this headache, is light bothering you, is sound bothering you?
But it’s more the tools of that, just as David was saying that, like, are you finding that you’ve to go into a dark room to calm yourself down? Does that help in any way, or do you find that you can’t really listen to your phone or you can’t really listen to the TV, is the sound bothering you? Are you feeling a wee bit sick or do you feel like you could be sick? Just the way that you’re phrasing the questions to patients. But yeah, that girl also, she had been sick, she was like, I can’t even bear the lights in the chemist just now, she says, I look so weird with having my sunglasses on, but it’s the only thing that’s keeping my head at bay. And then I’d asked her if she’d had anything to take, if she’d taken anything, she said no. So we had asked her if she’d had any food in her stomach to make sure that she was OK to take some of the aspirin. She says that she’s just kept down a bit of toast from then. So we started her off on some aspirin, gave her some prochlor and started her off on a triptan. And I remember asking because obviously your triptans are better taken at the start of your migraine before any other symptoms have appeared, but at that point in a pharmacy, that’s all that you’ve got, so you can only really provide them with that. So that’s what we started off on. I actually phoned her a couple of days after just to see if that had helped. And she’s like, yeah, it was amazing. She was like, I just went home. I kind of went to my bed and slept it off. But she was like, it did just make the world of a difference.
01:19:09 Dr Katy Munro
That’s good.
01:19:10 Abigail Duthie
It is. I counselled her on it as well and I’d said, it does sound like you’re experiencing a bit of a migraine, have you got any family history of migraine, have you ever been diagnosed with it before? She’s like, no. I’ve just always had these unbearable headaches, but they usually just go away on their own. She says that’s the only reason is, it hadn’t shifted, and that’s what brought me in.
And I think it’s just given us as pharmacists tools and resources, because I think it’s very easy to think, oh my goodness, we’re dealing with these drugs. But at the end of the day, I think when you come down to it you’re realising that if these drugs don’t work, it’s not going to kill a patient. And I think that’s the fear of pharmacists that we’ve got. So trial it and see what happens. If it works, fantastic, that’s what we’re aiming for. But it doesn’t, we can go back to the drawing board, there’s other resources that we can use and go from there. Or is it a case of maybe then getting a GP involved or maybe seeing what’s happening? But yeah, I’ve got like a wee checklist that I go through in my head, which is the questions that was developed for the training, which really helps as well, so.
01:20:06 Dr Katy Munro
You’ve given her the gift of a diagnosis.
01:20:09 Abigail Duthie
Exactly.
01:20:18 Dr Katy Munro
Yeah, that’s so rewarding, isn’t it? One of the things you mentioned was prochlor, which is pharmacy shortening for prochlorperazine. That is an over-the-counter anti-sickness medication, sometimes marketed under the name of Buccastem.
And the other things you mentioned. So aspirin, soluble aspirin we usually recommend, don’t we. Ibuprofen, not together obviously, because these might fight a bit. Paracetamol, again, you can get that as a soluble preparation. And the triptan, the only triptan available over the counter at the moment is sumatriptan, am I right?
01:20:45 Abigail Duthie
That’s correct. Yeah. 50 milligrams. Yeah.
01:20:48 Dr Katy Munro
But people can go and speak to a pharmacist and buy that over the counter and it can be, if they’ve never tried it before it can be really, really helpful. Imigran is the brand name I think, I don’t know if there’s other brands now. But the one thing I do find sometimes about Imigran or sumatriptan is that it makes people drowsy and they kind of say, well, it got rid of the headache but then I had to go to sleep for a few hours and that’s when I say to them, now you need to go and see your doctor and get one of the prescription triptans.
01:21:11 Abigail Duthie
Yeah.
01:21:22 Dr Katy Munro
Yeah, but they can do a huge amount with that selection of over-the-counter medications, can’t they?
01:21:28 Abigail Duthie
Yeah, exactly.
01:21:29 Dr Katy Munro
Which you’ve given a fantastic example of, so that’s brilliant. Talking about job satisfaction, it’s really nice to hear. And it’s also really lovely that you followed her up.
01:21:35 Abigail Duthie
Yeah, exactly.
01:21:46 Dr Katy Munro
Yeah, I think good for you as well, isn’t it, to feel that feedback.
00:21:49 Abigail Duthie
Exactly. I think that’s I think more so maybe because I’m a new pharmacist, I don’t know. But I think because I’m still in this realm of that, I want to try and help as much people as I can. I do prefer getting feedback and I think that’s one of the things that pharmacists are still kind of a bit closed off from GPs because we don’t get access to any patient records or notes, so a lot of the time, if I’ve even seen a weird rash that I’ve referred a patient for… Even, like on Saturday I had a lady that I suspected a DVT, I would keep their number and phone them the next day to see how they got on just to see for my own knowledge as well than anything like that because it then filters more into, OK, well, I’ll know for next time that because the lady on Saturday, she had just had a knee operation, so she was on anticoagulants for it anyway, but she was black and blue down her whole leg, and her calf was solid. And because I couldn’t tell if it was red or not, I was like, I don’t know. And it was warm to touch as well. And I was very a massive question mark over her, and so I phoned her later on that day because I’d referred her to the out-of-hours doctor and she says no, no, everything was fine but she was like the doctor said that you were right to refer because there was a big question mark and you really couldn’t tell because it was massively swollen to the other one. And I said that’s right. That’s the only reassurance I need. But yeah, I do have a tendency to phone patients and annoy them. I’ll ask them first. It’s not on my own whim, but I will ask them to say, are you OK if I maybe phone you in a couple of hours or next day just to see how you get on? But yeah.
01:23:19 Dr Katy Munro
And David, are there any plans for this to come south of the border? I’m thinking Wales, I’m thinking Cornwall, where we know that there’s a bit of a lack of headache specialist clinics. Any chance of that spreading over the UK generally, Northern Ireland, etcetera?
01:23:38 Dr David Watson
That’s a fantastic question. So I think in terms of Scottish Government funding, the funding in terms of the project in Scotland, but obviously we have a model here that seems to be working. I think as we’ve rolled this out to the rest of Scotland, I think that we’ll have to have some outward measure of effectiveness. So we know qualitatively that there’s been good feedback from patients and pharmacists. Quantitatively, we’re going to try and work what measures can be used. One measure that’s being worked on at the moment is about ED attendance, so has since the project changes, that’s changed the nature of patients attending ED with migraine. So working on that.
01:24:27 Dr Katy Munro
I mean and casualty is the worst place for somebody with a migraine, isn’t it?
01:24:31 Dr David Watson
Oh, absolutely. Because they’ll sit there for hours and hours. Hours. Yeah, yeah.
01:24:33 Dr Katy Munro
Yeah, they can’t get anything. Well, you can in cafes, in the hospitals, I guess. But the sensory environment of ED is too intense for most people with migraine.
01:24:39 Dr David Watson
Yeah. And very often that with they might see a junior doctor who thinks, they’d better scan them, but don’t actually get any management of their migraine.
So I’ve had some inquiries from Wales. Certainly someone’s had a bit of an inquiry up about it. And I’ve had an inquiry from southern England as well. So just to egg it up slightly. We have a poster on the project first year that’s been accepted for MTIS, the Migraine Trust International Symposium. So that’s going to be in September, so Callum and I will be at a poster on the Friday afternoon, but we’ve been given a two-minute chance just to talk about it. So if anyone’s listening to the podcast, but I think this podcast will probably come out after MTIS, but I’m hoping that we get some interest when we’re at MTIS. And I know that our two project managers are very happy to speak and share information. Certainly we have no ownership over this in terms of, you will want to share what we’ve done, very happy if people want to learn from what we’ve done. So I think yes because I think as you say, there’s large parts of the UK where just patients are really struggling to get help with migraine partially because of the pressures we’re under.
01:26:19 Dr Katy Munro
Yeah, yeah.
01:26:20 Dr David Watson
And obviously we only have specialist headache services in certain parts of the UK. And I think one of our things is there is some evidence out there that if you manage migraine appropriately from day one, you’re less likely to get medication overuse headache and less likely to go into chronic migraine if patients are managed. So what I would hope is that over time, we can maybe see that that there’s a) the appropriate use of acute treatment and the b) of signposting patients to primary care.
But the other thing of that is, as Abi was saying, she’s doing her prescribing course. So more and more community pharmacists are prescribers. So in theory, if you’re a prescribing pharmacist, you can prescribe anything on, certainly in Scotland, on your health board’s formulary. So I have this vision of the future where there might be pharmacists in the community who can prescribe preventive therapies and even some of the targeted treatments as well, because we know that some of the treatments like atogepant and rimegepant are well-tolerated medications that are relatively straightforward to use and, you know, we start medicines in primary care that are far more difficult, that need monitoring or have significant side effects. So I think over time as more pharmacists become prescribing pharmacists, I’m hoping that having the prescribing hat on, but also the migraine knowledge hat, we might hopefully get more management of migraine in primary care and in the community.
01:28:05 Dr Katy Munro
That’s fantastic. Yeah, I think it absolutely needs to go that way. So thank you both very much. Anything else you wanted to add, Abi?
01:28:15 Abigail Duthie
No, I just kind of wanted to echo a bit more with what David was saying that I do think that given enough time, I do think there probably, hopefully, fingers crossed, will be more migraines controlled in community pharmacy with prescribing. I know that that’s something that I’ve had a special interest just with being with on the project that I’m hoping that that would be something that I would be able to do. There is obviously a lot of red tape for bringing it more into community, just because it’s not really something that’s ever really been done before, but I don’t see why not. It’s my problem, but I have to have my degree before going and doing it because I can’t obviously just set up now and just wait until I’ve passed, but I think we’re going to be very fortunate because come 2025, all the pharmacy students, I know in Scotland, I’m not too sure about down in England, but all the Scottish students are going to be coming out as prescribers. They’ll still have to do their pre-registration year, so I think it’ll be 2026 or yeah, it’ll be 2025. they’ll graduate and then they’ll do their pre-registration year. So by 2026 they’ll be out, let loose with their prescribing pads. So it’s now going to be incorporated into their actual course. Whereas I’m one of the unfortunate ones that have to do the groups and follow up, it’s not–
01:29:33 Dr Katy Munro
It’s at postgrad. So that’s wonderful. That is great news. And I’m very encouraging and it’s really just up to everybody who’s interested in migraine headache to keep talking about it loudly and spreading that information, isn’t it? So thank you both so much for coming and helping us do that here on the podcast. And we’ve had over 250,000 downloads now of our podcast, which I was very happy to see the other day.
01:29:59 Dr David Watson
Brilliant. Fab.
01:30:01 Dr Katy Munro
And hopefully we can make a lot of noise about migraines. I think we have to get a little bit political and make sure that we’re telling all the governments of the four countries to be thinking about migraine a bit more. So watch this space, I think. All right, thank you so much.
01:30:18 Dr David Watson
Katy, thank you very much for having us talk. That’s been fantastic. Thank you.
01:30:22 Abigail Duthie
Yeah. Thank you so much and thanks for having a pharmacist on because I think it gives more pharmacists a bit of encouragement as well because it is something that we should be dealing with by all means as well.
01:30:32 Dr Katy Munro
Yeah, yeah. Hear, hear.
01:30:36 From all of us at the National Migraine Centre, we would like to wish you a very happy festive season. Thank you for listening and don’t forget to keep an eye out for Series 6 coming in the New Year. We can’t wait to share more with you then. See you soon.
This transcript is based on a past episode of the Heads Up podcast and reflects information available at the time of broadcast – some facts may have changed or new treatments become available since.
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