Manage the surroundings. Speak quietly and lower the lights if they are currently experiencing a migraine.
Validate their experience. Acknowledge that migraines are painful and debilitating. They may feel anxious or overwhelmed.
Explore their story. “How has migraine affected your daily life and what are your concerns?”
“What are your specific symptoms and what is most bothersome?” (AUSTIN acronym can help. See "How you can you discuss migraine headache symptoms" dropdown.)
“What are your known or potential triggers?" 
"What treatments have you used for this migraine attack or past migraines? How well did it work?”
Provide information in patient-friendly language. Summarize key points they shared and provide information that can help prioritize goals and strategies during this encounter.
Involve them in treatment decisions. Provide options and resources that empower the patient to make informed decisions about their migraine management. This shared decision-making tool can engage the patient in a collaborative discussion about treatment options, including lifestyle changes and self-monitoring.

In a community pharmacy setting, there are many ways patients present with the need for improved migraine management. Consider these opportunities to approach them and explore ways to optimize their care.

• purchasing large count OTC medications like acetaminophen, ibuprofen and naproxen, as well as migraine-targeted OTC products and herbal supplements
• picking up prescriptions for acute migraine medications more frequently than the recommended limits per month
• sharing that they are missing work, school or social functions because of a migraine headache
• sharing that the frequency and or severity of migraine headaches has increased

We often find patients in the OTC aisle who are seeking relief from headaches. Migraine headache without aura accounts for 75% of all migraine headaches. In order to help patients develop a treatment plan, it’s important to know the signs and symptoms of the most common headaches and differentiate a tension-type headache (TTH) from a migraine headache without aura. (See Diagnosis Guide for screening/monitoring tools) Did you know that 75% of migraine patients also have neck pain as an associated symptom? Neck pain is often mistaken as a TTH symptom only.

An easy mnemonic to remember the signs and symptoms of a migraine without aura is AUSTIN:
Activity aggravates the headache
Unilateral location
Sensitivity to light and/or sound (and sometimes smells)
Throbbing
Intensity is moderate to severe
Nausea and/or vomiting

By contrast, a tension-type headache (TTH) has pain that is not aggravated by activity, usually bilateral, more mild to moderate in intensity, and feels more pressing and tightening (like a hat is on too tight). There is no associated nausea and they may or may not have sensitivity to light or sound. TTH symptoms are similar to medication overuse headache (MOH) and chronic daily headaches. MOH is associated with patients with 15 or more headache days / month and with > 3 months of regular overuse of acute medication.

When patients report having debilitating migraines that interfere with work, school or social activities, it can be useful to explain how migraine headaches transform over time. This is a signal to explore preventive treatment options that can help reduce the frequency and severity of migraine attacks. See additional information in the Health Screening and Monitoring Tools Section.

Using a tool like the shared decision-making tool for adults experiencing more frequent migraine attacks (i.e., 4 or more per month), can help practitioners facilitate a dialogue with the patient about what preventive treatment options would be most suitable for them. The tool supports a collaborative discussion between the provider and patient about treatment options, comparing their use, outcomes, side effects and place in therapy. The discussion should help uncover what aspects of the treatment decisions are most important to the patient; for example, convenience, cost, risks, and benefits may weigh into their preventive treatment decision. Here are some tips for using the SDM Tool.

Introduce the SDM Tool: “If you’d like, we can work together using this tool to review the options available for managing frequent migraines. I want to hear your questions and concerns and what is most important to you in choosing a care plan. How does that sound to you?”

Getting started with the SDM Tool: “This tool was designed to help explain the preventive treatment options in a way that presents their benefits, use, and side effects. As we discuss the options, please share which aspects are most important to you so we can identify your preferred approach.”

During the discussion, acknowledge concerns and preferences and identify times when information may need to be explained in another way to improve understanding. Even if a patient wants to jump to one option alone, explore why that option is important to them. What can they tell you about that option? Ask permission to generally present the other options so they can make an informed choice. The SDM Tool is still about offering patients the autonomy to make an informed treatment decision.