PERSPECTIVE
Community-based headache management Tension-type headache (TTH) – also known as ‘regular’ or ‘ordinary’ headache (1) – is extremely common. The key symptom is a tight band or pressing pain felt on both sides of the head (1). The headache pain in TTH is mild or moderate and lasts from several hours up to a few days (1). TTH usually responds well to treatment with simple over-the-counter (OTC) analgesics such as ibuprofen and paracetamol (2). These factors – in particular the ubiquity of the condition, the acute, self-limiting nature of the headache attacks and the availability of effective OTC treatment options – make TTH a condition that is amenable to self-care. Yet, the WHO has identified a large unmet need in that large numbers of people with headache do not receive effective healthcare, and awareness of headache is poor even among people who are directly affected (3).
Self-care Self-care has been defined as ‘a life-long habit and culture. It is the action individuals take for themselves and their families to stay healthy and manage minor and chronic conditions, based on their knowledge and the information available’ (4). Self-care has an increasing role in health management today. Empowering people to look after their minor ailments through self-care, so that they consult a physician only when needed, will reduce demands on the healthcare system and lighten the strain on healthcare costs. Self-care initiatives that have been successfully implemented include nicotine replacement therapy and the prevention of chronic heart disease. The concept also applies to the management of chronic conditions, where people are increasingly encouraged to become ‘expert patients’, taking control of their care and treatment. The concept of self-care is not a new one but in many countries with successful healthcare systems, the relevant skills have become eroded because people have learnt to look to the healthcare system, and in particular the general practitioner, for help. In the UK, 220,000 GP consultations per day (57 million consultations per year) are for minor ailments (5). As a result, GPs spend 20–40% of their time on minor ailments (6). To facilitate a shift towards more self-care, it will be important to re-instil the confidence in people to
act independently. In a survey of almost 1000 doctors and NHS managers in the UK, 78% agreed that doctors need to give clear and explicit advice to their patients about when to self-care and when to come to the surgery (7).
The role of pharmacy
There is increasing recognition globally that community pharmacies can have a key role in supporting this shift towards self-care. Pharmacists are among the most accessible healthcare professionals and patients can approach them for free advice without needing an appointment. Therefore, they are being called on to expand their role from drug dispenser to client counsellor and advisor (8). Pharmacies already have a strong track record in the following areas (8):
•
Public health (e.g. providing services in areas such as smoking, obesity and sexual health). • Self-care (helping patients to manage common ailments and long-term conditions). • Medicines management (e.g. helping people understand the correct use of medicines).
Educating people with headache about how to treat their headache effectively and efficiently is of considerable public health importance
They are therefore well placed to contribute to better management of painful conditions such as TTH, reduce GP workloads and expand patient choice (9). To fully apply their expertise when serving customers with headache (or other common ailments), pharmacy staff need to have excellent communication skills. In particular, they rely on their ability to question patients to obtain an accurate understanding of their needs and preferences, so they can target their advice accordingly. However, a survey in the UK found worrying inadequacies in this area (10). For the survey, 122 trained mystery shoppers visited pharmacies to purchase OTC drugs for traveller’s diarrhoea, heartburn or migraine. A panel of three pharmacists rated the advice they were given. It was unsatisfactory in 43% of visits. Counter assistants dealing with customers without involvement of a pharmacist were more likely to give poor advice than pharmacists: twothirds of visits handled solely by counter assistants were rated as unsatisfactory, compared with a quarter of visits if a pharmacist handled the interaction or was consulted. The rating indicated a failure to ask
ª 2015 John Wiley & Sons Ltd Int J Clin Pract, May 2015, 69 (Suppl. 182), 17–20 doi: 10.1111/ijcp.12653
17
18
Perspective
the right questions when advising customers, and some pharmacy staff also displayed a lack of knowledge about new OTC drugs. The expert panel concluded that pharmacists must ensure adequate training of their staff to equip them with the necessary skills and knowledge to act as client counsellors and advisors (10).
Serving customers with headache – what pharmacy staff need to know Several mnemonics have been suggested to assist pharmacists when questioning patients. The simplest acronym to use is WWHAM, which stands for Who? What? How long? Action taken? and Medicine? However, the information picked up with this approach is very limited because it does not take the complexity of clinical pictures into account. Another mnemonic that is more suited to establish the nature of a current headache complaint and to determine whether the patient has had similar episodes in the past is ASMETTHOD. This stands for A = age, S = self or someone else, M = medicines, E = exactly what do you mean, T = taken anything or seen GP, T = time/duration of symptom, H = history of symptom, O = other symptoms and D = doing anything to alleviate or worsen. Pharmacy staff also need to have a solid knowledge of common pain-related conditions and their treatment to be able to provide appropriate advice. When advising patients who present with headache, this means knowledge in the following areas:
•
Medical conditions that are associated with pain. These include acute injury (skin, muscle, bone, dental), musculoskeletal disease (arthritis), cancer, organ damage/disease (visceral), brain (headache, vascular) and nerve damage (neuropathic pain). • Red flags for serious headache (i.e. when to refer). These include: onset in a middle-aged/elderly patient; severe and abrupt onset; progressive severity or increased frequency; significant change in headache pattern; stiff neck, focal signs, reduced consciousness; and systemic signs such as fever or appearing sick. • Appropriate use of NSAIDs. Given that the headaches in episodic TTH are mild to moderate and short-lasting, simple analgesics and NSAIDs are the mainstay of the pharmacological approach (4). This approach is principally the same as for mild migraine (11). Risk factors for gastrointestinal symptoms when using NSAIDs include age above 65 years, renal or heart disease, history of ulceration, high dose, NSAID combination and concomitant use of corticosteroids or anticoagulants (used together with a proton-pump inhibitor).
It is also important for pharmacy staff to realise that self-care for TTH is a habitual process. As a result, headache sufferers often display ‘bad habits’ which can prevent them from maximising the benefits of available OTC analgesics. Examples of this inappropriate medicines use behaviour include:
•
Not taking enough analgesic or taking it at the wrong time. When self-managing headache, many people display so-called ‘safety behaviour’ – waiting until the pain becomes severe before taking an analgesic, and then administering a lower than recommended dose (12). It is important for customers to be aware that OTC analgesics for TTH should be taken at the full recommended dose as soon as the headache starts in order to optimise pain relief (12). • Buying analgesics out of habit. Many customers will stick to purchasing familiar analgesics which they’ve relied on in the past, even if the medicine in question consistently fails to deliver the level of relief required or target the source of a particular pain (13). Regular pharmacy customers prone to this type of behaviour are easy to identify through their habitual OTC purchasing patterns, others can be quickly elucidated by simple questions such as ‘is this the pain reliever you’d usually use?’ Explaining the role of muscles as the source of TTH can help patients understand the rationale for recommending one type of analgesic over another. Fast-acting and effective early pain relief is also particularly important in TTH to prevent central sensitisation and the potential chronification of headaches (14). • Using inappropriate analgesics like codeine. Customers may opt for combination products containing codeine to self-treat their TTH because of its perception as a ‘strong’ painkiller. The reality is that codeine is not recommended as a suitable analgesic for TTH in any of the leading European or British treatment guidelines (1,2,15). This is due in part to the heightened risk of medicines-overuse headache, which has been linked to the use of codeine-containing products. • Always taking OTC analgesics with food. There is a perception among the public that taking analgesics – particularly NSAIDs – with food can in some indefinable way ‘protect’ the stomach and reduce the risk of gastointestinal side effects (16). However, this has not been conclusively confirmed by any of the available clinical data (16). What is known conclusively is that dosing analgesics with food decelerates the absorption of active ingredient into the bloodstream, slowing the onset of pain relief (16). For acute pain conditions like TTH, it may therefore be more appropriate to take analgesics on an empty stomach (17). The fasteracting headache relief that results may also help eliminate the temptation for repeat or over-dosing,
ª 2015 John Wiley & Sons Ltd Int J Clin Pract, May 2015, 69 (Suppl. 182), 17–20
Perspective
because of perceived lack of efficacy, which in turn increases the risk of adverse events (16). In addition to addressing inappropriate medicinesuse behaviour, it is also important for pharmacy staff to encourage patients to think about specific activities or factors that might act as triggers for their headache, and how to modify these. For example, maintaining good posture and head alignment is important to avoid straining the muscles in the neck and shoulders, which can activate myofascial trigger points linked to TTH development (1,2,18). Skipping meals, sleeping too much or too little, inappropriate or insufficient exercise and caffeine overconsumption are also recognised triggers for TTH (1,2,18). Key preventative advice could include eating regular meals, resting sufficiently, taking up regular exercise, staying hydrated and limiting caffeine intake. Stress is also acknowledged to be one of the major trigger for TTH (1,2,18). It can be addressed by assisting customers to modifying their behaviour and lifestyle to identify and limit stress (15,16,20). Specific interventions such as meditation or relaxation exercises like yoga may also help patients cope better with daily stress and reduce the risk of TTH (1,2,18). A useful strategy for pharmacy staff to help their customers develop new healthcare behaviours is motivational interviewing. By asking open-ended, non-judgmental questions, pharmacy staff can enable their customers to work out why their behaviour is inappropriate and what they can do to change. The technique is based on the five principles of expressing empathy; developing discrepancy; avoiding arguments and rolling with resistance and supporting self-efficacy. In practice, this means using open-ended questions, affirmations, reflective listening and summaries (the OARS approach). Cooperation between pharmacists and other healthcare professionals such as GPs,
References 1 Steiner T, Paemeliere K, Jensen R et al. European principles of management of common headache disorders in primary care. J Headache Pain 2007; 8: S3–47. 2 Bendtsen L, Evers S, Linde M et al. ; EFNS. EFNS guideline on the treatment of tension-type headache - report of an EFNS task force. Eur J Neurol 2010; 17: 1318–25. 3 WHO. Atlas of Headache Disorders and Resources in the World 2011. Geneva, Switzerland: WHO, 2011. 4 World Self-medication Industry. Frequently Asked Questions. http://www.wsmi.org/faqs1.htm (accessed April 2014). 5 Pillay N, Tisman A, Kent T et al. The economic burden of minor ailments on the National Health Service (NHS) in the UK. SelfCare 2010; 1: 105–16.
19
neurologists, physiotherapists and psychotherapists, as required, may also help patients to fully address and correct inappropriate behaviours.
Conclusion According to the WHO, educating people with headache about how to treat their headaches effectively and efficiently is of considerable public health importance (5). Community pharmacies have a key role to play in this task, reflecting recent changes in their role towards providers of patient- and medicinefocused support and advice. Pharmacy staff are the health professionals most likely to have contact with people suffering from TTH, they see them every time they purchase OTC medicines to treat their headaches, and they have the expertise to review treatment and understand potential problems. To support pharmacy staff in this role, they need training in listening to the customer, asking the right questions and providing appropriate treatment advice. This will help to maximise the potential benefit of analgesics in the treatment of TTH and to reduce the burden of TTH overall.
Disclosure TM has consulted and has lectured on community pharmacy matters for a number of pharmaceutical companies (including Reckitt Benckiser). T. Maguire The Pharmacy, Belfast, UK Correspondence to: Terence Maguire, The Pharmacy, 3 Beechmount Avenue, Belfast, BT 12 7NA, UK Tel.: + 44 2890 320590 Fax: + 44 2890 327140 Email: [email protected]
6 Department of Health. Public Attitudes To Self Care: Baseline Survey. London: The Stationery Office, 2005. 7 McCarron-Nash B. Save Our NHS: Time for Action on Self Care. http://www.selfcareforum.org/ wp-content/uploads/2012/08/2-Beth-McCarronNash.pdf (accessed April 2014). 8 Department of Health and Social Security. Making It Better: A Strategy for Pharmacy in the Community, February 2004. http://www.dhsspsni.gov.uk/ makingitbetter04_sect1.pdf (accessed April 2014). 9 Gill J, Taylor D, Knaggs R. Relieving Persistent Pain, Improving Health Outcomes. UCL School of Pharmacy, January 2012. http://www.ukcpa.net/wp-con tent/uploads/2012/01/Relieving-Persistent-PainFINAL-10-01-12.pdf (accessed April 2014). 10 Which? Are Some Pharmacies Failing? June 2013. http://press.which.co.uk/wp-content/uploads/2013/ 05/Pharmacies_R31.pdf (accessed April 2014).
ª 2015 John Wiley & Sons Ltd Int J Clin Pract, May 2015, 69 (Suppl. 182), 17–20
11 Bendtsen L, Birk S, Kasch H et al. ; Danish Headache Society. Reference programme: diagnosis and treatment of headache disorders and facial pain. Danish Headache Society, 2012. J Headache Pain 2012; 13(Suppl. 1): S1–29. 12 Eccleson C. A normal psychology of everyday pain. Int J Clin Pract 2013; 67(Suppl. 178): 47–50. 13 Analgesics Usage and Attitudes Study 2005. Prepared by TNS Consumer, September 2005. 14 Bendtsen L, Fernandez-de-la-Penas C. The role of muscles in tension-type headache. Curr Pain Headache Rep 2011; 15: 451–8. 15 British Association for the Study of Headache (BASH). Guidelines for All Healthcare Professionals in the Diagnosis and Management of Migraine, Tension-type Headache, Cluster Headache, Medication Overuse Headache, 3rd edn (1st revision), 2010. www.bash.org.uk (accessed May 2014).
20
Perspective
16 Rainsford K, Bjarnason I. NSAIDs: take with food or after fasting. J Pharm Pharmacol 2011; 64: 465–9. 17 Bjarnason I. Gastrointestinal safety of NSAIDs and over-the-counter analgesics. Int J Clin Pract 2013; 67(Suppl 178): 37–42.
18 NHS Choices. Tension-type headaches. http:// www.nhs.uk/Conditions/headaches-tension-type/ Pages/Introduction.aspx (accessed June 2014).
Paper received June 2014, accepted November 2014
ª 2015 John Wiley & Sons Ltd Int J Clin Pract, May 2015, 69 (Suppl. 182), 17–20
Community-based headache management Tension-type headache (TTH) – also known as ‘regular’ or ‘ordinary’ headache (1) – is extremely common. The key symptom is a tight band or pressing pain felt on both sides of the head (1). The headache pain in TTH is mild or moderate and lasts from several hours up to a few days (1). TTH usually responds well to treatment with simple over-the-counter (OTC) analgesics such as ibuprofen and paracetamol (2). These factors – in particular the ubiquity of the condition, the acute, self-limiting nature of the headache attacks and the availability of effective OTC treatment options – make TTH a condition that is amenable to self-care. Yet, the WHO has identified a large unmet need in that large numbers of people with headache do not receive effective healthcare, and awareness of headache is poor even among people who are directly affected (3).
Self-care Self-care has been defined as ‘a life-long habit and culture. It is the action individuals take for themselves and their families to stay healthy and manage minor and chronic conditions, based on their knowledge and the information available’ (4). Self-care has an increasing role in health management today. Empowering people to look after their minor ailments through self-care, so that they consult a physician only when needed, will reduce demands on the healthcare system and lighten the strain on healthcare costs. Self-care initiatives that have been successfully implemented include nicotine replacement therapy and the prevention of chronic heart disease. The concept also applies to the management of chronic conditions, where people are increasingly encouraged to become ‘expert patients’, taking control of their care and treatment. The concept of self-care is not a new one but in many countries with successful healthcare systems, the relevant skills have become eroded because people have learnt to look to the healthcare system, and in particular the general practitioner, for help. In the UK, 220,000 GP consultations per day (57 million consultations per year) are for minor ailments (5). As a result, GPs spend 20–40% of their time on minor ailments (6). To facilitate a shift towards more self-care, it will be important to re-instil the confidence in people to
act independently. In a survey of almost 1000 doctors and NHS managers in the UK, 78% agreed that doctors need to give clear and explicit advice to their patients about when to self-care and when to come to the surgery (7).
The role of pharmacy
There is increasing recognition globally that community pharmacies can have a key role in supporting this shift towards self-care. Pharmacists are among the most accessible healthcare professionals and patients can approach them for free advice without needing an appointment. Therefore, they are being called on to expand their role from drug dispenser to client counsellor and advisor (8). Pharmacies already have a strong track record in the following areas (8):
•
Public health (e.g. providing services in areas such as smoking, obesity and sexual health). • Self-care (helping patients to manage common ailments and long-term conditions). • Medicines management (e.g. helping people understand the correct use of medicines).
Educating people with headache about how to treat their headache effectively and efficiently is of considerable public health importance
They are therefore well placed to contribute to better management of painful conditions such as TTH, reduce GP workloads and expand patient choice (9). To fully apply their expertise when serving customers with headache (or other common ailments), pharmacy staff need to have excellent communication skills. In particular, they rely on their ability to question patients to obtain an accurate understanding of their needs and preferences, so they can target their advice accordingly. However, a survey in the UK found worrying inadequacies in this area (10). For the survey, 122 trained mystery shoppers visited pharmacies to purchase OTC drugs for traveller’s diarrhoea, heartburn or migraine. A panel of three pharmacists rated the advice they were given. It was unsatisfactory in 43% of visits. Counter assistants dealing with customers without involvement of a pharmacist were more likely to give poor advice than pharmacists: twothirds of visits handled solely by counter assistants were rated as unsatisfactory, compared with a quarter of visits if a pharmacist handled the interaction or was consulted. The rating indicated a failure to ask
ª 2015 John Wiley & Sons Ltd Int J Clin Pract, May 2015, 69 (Suppl. 182), 17–20 doi: 10.1111/ijcp.12653
17
18
Perspective
the right questions when advising customers, and some pharmacy staff also displayed a lack of knowledge about new OTC drugs. The expert panel concluded that pharmacists must ensure adequate training of their staff to equip them with the necessary skills and knowledge to act as client counsellors and advisors (10).
Serving customers with headache – what pharmacy staff need to know Several mnemonics have been suggested to assist pharmacists when questioning patients. The simplest acronym to use is WWHAM, which stands for Who? What? How long? Action taken? and Medicine? However, the information picked up with this approach is very limited because it does not take the complexity of clinical pictures into account. Another mnemonic that is more suited to establish the nature of a current headache complaint and to determine whether the patient has had similar episodes in the past is ASMETTHOD. This stands for A = age, S = self or someone else, M = medicines, E = exactly what do you mean, T = taken anything or seen GP, T = time/duration of symptom, H = history of symptom, O = other symptoms and D = doing anything to alleviate or worsen. Pharmacy staff also need to have a solid knowledge of common pain-related conditions and their treatment to be able to provide appropriate advice. When advising patients who present with headache, this means knowledge in the following areas:
•
Medical conditions that are associated with pain. These include acute injury (skin, muscle, bone, dental), musculoskeletal disease (arthritis), cancer, organ damage/disease (visceral), brain (headache, vascular) and nerve damage (neuropathic pain). • Red flags for serious headache (i.e. when to refer). These include: onset in a middle-aged/elderly patient; severe and abrupt onset; progressive severity or increased frequency; significant change in headache pattern; stiff neck, focal signs, reduced consciousness; and systemic signs such as fever or appearing sick. • Appropriate use of NSAIDs. Given that the headaches in episodic TTH are mild to moderate and short-lasting, simple analgesics and NSAIDs are the mainstay of the pharmacological approach (4). This approach is principally the same as for mild migraine (11). Risk factors for gastrointestinal symptoms when using NSAIDs include age above 65 years, renal or heart disease, history of ulceration, high dose, NSAID combination and concomitant use of corticosteroids or anticoagulants (used together with a proton-pump inhibitor).
It is also important for pharmacy staff to realise that self-care for TTH is a habitual process. As a result, headache sufferers often display ‘bad habits’ which can prevent them from maximising the benefits of available OTC analgesics. Examples of this inappropriate medicines use behaviour include:
•
Not taking enough analgesic or taking it at the wrong time. When self-managing headache, many people display so-called ‘safety behaviour’ – waiting until the pain becomes severe before taking an analgesic, and then administering a lower than recommended dose (12). It is important for customers to be aware that OTC analgesics for TTH should be taken at the full recommended dose as soon as the headache starts in order to optimise pain relief (12). • Buying analgesics out of habit. Many customers will stick to purchasing familiar analgesics which they’ve relied on in the past, even if the medicine in question consistently fails to deliver the level of relief required or target the source of a particular pain (13). Regular pharmacy customers prone to this type of behaviour are easy to identify through their habitual OTC purchasing patterns, others can be quickly elucidated by simple questions such as ‘is this the pain reliever you’d usually use?’ Explaining the role of muscles as the source of TTH can help patients understand the rationale for recommending one type of analgesic over another. Fast-acting and effective early pain relief is also particularly important in TTH to prevent central sensitisation and the potential chronification of headaches (14). • Using inappropriate analgesics like codeine. Customers may opt for combination products containing codeine to self-treat their TTH because of its perception as a ‘strong’ painkiller. The reality is that codeine is not recommended as a suitable analgesic for TTH in any of the leading European or British treatment guidelines (1,2,15). This is due in part to the heightened risk of medicines-overuse headache, which has been linked to the use of codeine-containing products. • Always taking OTC analgesics with food. There is a perception among the public that taking analgesics – particularly NSAIDs – with food can in some indefinable way ‘protect’ the stomach and reduce the risk of gastointestinal side effects (16). However, this has not been conclusively confirmed by any of the available clinical data (16). What is known conclusively is that dosing analgesics with food decelerates the absorption of active ingredient into the bloodstream, slowing the onset of pain relief (16). For acute pain conditions like TTH, it may therefore be more appropriate to take analgesics on an empty stomach (17). The fasteracting headache relief that results may also help eliminate the temptation for repeat or over-dosing,
ª 2015 John Wiley & Sons Ltd Int J Clin Pract, May 2015, 69 (Suppl. 182), 17–20
Perspective
because of perceived lack of efficacy, which in turn increases the risk of adverse events (16). In addition to addressing inappropriate medicinesuse behaviour, it is also important for pharmacy staff to encourage patients to think about specific activities or factors that might act as triggers for their headache, and how to modify these. For example, maintaining good posture and head alignment is important to avoid straining the muscles in the neck and shoulders, which can activate myofascial trigger points linked to TTH development (1,2,18). Skipping meals, sleeping too much or too little, inappropriate or insufficient exercise and caffeine overconsumption are also recognised triggers for TTH (1,2,18). Key preventative advice could include eating regular meals, resting sufficiently, taking up regular exercise, staying hydrated and limiting caffeine intake. Stress is also acknowledged to be one of the major trigger for TTH (1,2,18). It can be addressed by assisting customers to modifying their behaviour and lifestyle to identify and limit stress (15,16,20). Specific interventions such as meditation or relaxation exercises like yoga may also help patients cope better with daily stress and reduce the risk of TTH (1,2,18). A useful strategy for pharmacy staff to help their customers develop new healthcare behaviours is motivational interviewing. By asking open-ended, non-judgmental questions, pharmacy staff can enable their customers to work out why their behaviour is inappropriate and what they can do to change. The technique is based on the five principles of expressing empathy; developing discrepancy; avoiding arguments and rolling with resistance and supporting self-efficacy. In practice, this means using open-ended questions, affirmations, reflective listening and summaries (the OARS approach). Cooperation between pharmacists and other healthcare professionals such as GPs,
References 1 Steiner T, Paemeliere K, Jensen R et al. European principles of management of common headache disorders in primary care. J Headache Pain 2007; 8: S3–47. 2 Bendtsen L, Evers S, Linde M et al. ; EFNS. EFNS guideline on the treatment of tension-type headache - report of an EFNS task force. Eur J Neurol 2010; 17: 1318–25. 3 WHO. Atlas of Headache Disorders and Resources in the World 2011. Geneva, Switzerland: WHO, 2011. 4 World Self-medication Industry. Frequently Asked Questions. http://www.wsmi.org/faqs1.htm (accessed April 2014). 5 Pillay N, Tisman A, Kent T et al. The economic burden of minor ailments on the National Health Service (NHS) in the UK. SelfCare 2010; 1: 105–16.
19
neurologists, physiotherapists and psychotherapists, as required, may also help patients to fully address and correct inappropriate behaviours.
Conclusion According to the WHO, educating people with headache about how to treat their headaches effectively and efficiently is of considerable public health importance (5). Community pharmacies have a key role to play in this task, reflecting recent changes in their role towards providers of patient- and medicinefocused support and advice. Pharmacy staff are the health professionals most likely to have contact with people suffering from TTH, they see them every time they purchase OTC medicines to treat their headaches, and they have the expertise to review treatment and understand potential problems. To support pharmacy staff in this role, they need training in listening to the customer, asking the right questions and providing appropriate treatment advice. This will help to maximise the potential benefit of analgesics in the treatment of TTH and to reduce the burden of TTH overall.
Disclosure TM has consulted and has lectured on community pharmacy matters for a number of pharmaceutical companies (including Reckitt Benckiser). T. Maguire The Pharmacy, Belfast, UK Correspondence to: Terence Maguire, The Pharmacy, 3 Beechmount Avenue, Belfast, BT 12 7NA, UK Tel.: + 44 2890 320590 Fax: + 44 2890 327140 Email: [email protected]
6 Department of Health. Public Attitudes To Self Care: Baseline Survey. London: The Stationery Office, 2005. 7 McCarron-Nash B. Save Our NHS: Time for Action on Self Care. http://www.selfcareforum.org/ wp-content/uploads/2012/08/2-Beth-McCarronNash.pdf (accessed April 2014). 8 Department of Health and Social Security. Making It Better: A Strategy for Pharmacy in the Community, February 2004. http://www.dhsspsni.gov.uk/ makingitbetter04_sect1.pdf (accessed April 2014). 9 Gill J, Taylor D, Knaggs R. Relieving Persistent Pain, Improving Health Outcomes. UCL School of Pharmacy, January 2012. http://www.ukcpa.net/wp-con tent/uploads/2012/01/Relieving-Persistent-PainFINAL-10-01-12.pdf (accessed April 2014). 10 Which? Are Some Pharmacies Failing? June 2013. http://press.which.co.uk/wp-content/uploads/2013/ 05/Pharmacies_R31.pdf (accessed April 2014).
ª 2015 John Wiley & Sons Ltd Int J Clin Pract, May 2015, 69 (Suppl. 182), 17–20
11 Bendtsen L, Birk S, Kasch H et al. ; Danish Headache Society. Reference programme: diagnosis and treatment of headache disorders and facial pain. Danish Headache Society, 2012. J Headache Pain 2012; 13(Suppl. 1): S1–29. 12 Eccleson C. A normal psychology of everyday pain. Int J Clin Pract 2013; 67(Suppl. 178): 47–50. 13 Analgesics Usage and Attitudes Study 2005. Prepared by TNS Consumer, September 2005. 14 Bendtsen L, Fernandez-de-la-Penas C. The role of muscles in tension-type headache. Curr Pain Headache Rep 2011; 15: 451–8. 15 British Association for the Study of Headache (BASH). Guidelines for All Healthcare Professionals in the Diagnosis and Management of Migraine, Tension-type Headache, Cluster Headache, Medication Overuse Headache, 3rd edn (1st revision), 2010. www.bash.org.uk (accessed May 2014).
20
Perspective
16 Rainsford K, Bjarnason I. NSAIDs: take with food or after fasting. J Pharm Pharmacol 2011; 64: 465–9. 17 Bjarnason I. Gastrointestinal safety of NSAIDs and over-the-counter analgesics. Int J Clin Pract 2013; 67(Suppl 178): 37–42.
18 NHS Choices. Tension-type headaches. http:// www.nhs.uk/Conditions/headaches-tension-type/ Pages/Introduction.aspx (accessed June 2014).
Paper received June 2014, accepted November 2014
ª 2015 John Wiley & Sons Ltd Int J Clin Pract, May 2015, 69 (Suppl. 182), 17–20
