Event 1: Margaret Meets with Her Pharmacist

Margaret presents to the pharmacy seeking  a recommendation for treating persistent headaches that she has been experiencing. 

The pharmacist notes that the patient has been visiting the pharmacy routinely for the past 2 months.

Margaret Meets with the Pharmacist

Based on the patient’s history, we discover that Napuli:

  • Reports a “dull” and “throbbing” headache for the past 2 months after falling in gymnastics class
  • Rates her pain a 2-3 out of 10, sometimes reaches a 5
  • Received a CT scan at time of injury that revealed no skull or jaw fractures
  • Receives minimal relief from current medication including acetaminophen, naproxen, ibuprofen, and codeine
  • Is self-medicating with mother’s prescription migraine medication 

Pharmacist's Concerns

OTC Analgesics

  • Pharmacist noticed that the patient was purchasing OTC analgesics very frequently.
  • Overuse of OTC Analgesics of concern when patient is using OTC analgesics for > 15 days per month
  • Patient questioned to determine the amount of acetaminophen, naproxen, ibuprofen, and aspirin she is taking daily and weekly.

Medication Overuse Headache

Definitions for Diagnostic Criteria:

  • Headache present on >15 days per month 
  • Regular overuse for >3 months of one or more
  • Acute/symptomatic treatment drugs 
  • Headache developed or worsened during medication overuse

Definition of Medication Overuse Depends on Drug Class  

  • Ergotamine, triptans, opioids, or combination analgesic preparations 
  • >10 days per month on a regular basis for >3 months  
  • Simple analgesics or any combination of acute headache treatments
  • >15 days per month on a regular basis for >3 months


Olesen J, Bousser MG, Diener HC, et al.  New appendix  criteria open for a broader concept of chronic migraine. Cephalalgia 2006; 26: 742-746.

Although the definition  specifies medication use for >3 months, the pharmacist is being proactive in identifying a potential problem of medication overuse at 2 months.

Pharmacist Recommendation

At the pharmacist’s recommendation,  Margaret and her mother visit Margaret’s primary care physician.

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