The aim of this study was to investigate knowledge about medication overuse headache (MOH) among pharmacy staff.
The aim of this study was to investigate knowledge about medication overuse headache (MOH) among pharmacy staff.
MOH is a public health problem both in Sweden and in many other countries. Persons with MOH have limited contact with health care, and medications used are to large extent over-the-counter (OTC) medications. Therefore, pharmacists have an important role in, eg, advising these individuals about their medication use. Little is, however, known about the actual level of knowledge about MOH among pharmacy staff, which determines the quality of their advice to MOH sufferers.
A total of 326 questionnaires were distributed to 44 pharmacies in Gothenburg, Sweden. The questionnaire included background questions, questions about advice on headache treatment, source of knowledge about MOH, and questions on self-perceived and actual knowledge on MOH.
The response rate was 70%. A majority of the pharmacy staff (90.6%) considered themselves to have knowledge about MOH to some or a greater extent. Almost half had learned about MOH through their university/vocational education. Only 8.6% knew that all 5 headache medications listed in the questionnaire can cause development of MOH, but 40% responded correctly on which treatment advice one can give a person with MOH. Actual knowledge on treatment advice differed significantly between groups of self-perceived knowledge.
The knowledge on MOH is insufficient among pharmacy staff, but with the proper knowledge, pharmacy staff is well positioned to effect both primary and secondary prevention of MOH. We suggest not only increasing educational efforts about MOH within pharmacy programs but also continuing education at the pharmacies for all staff. Further, it is also important to increase knowledge among pharmacy customers.
medication overuse headache
non-steroidal anti-inflammatory drugs
Medication overuse headache (MOH) is a public health problem both in Sweden and in many other countries. It develops in individuals with primary headache who overuse acute headache medication (analgesics, non-steroidal anti-inflammatory drugs [NSAIDs], triptans, opioids, and ergotamine), and it is the third most common headache disorder after tension-type headache (TTH) and migraine. Women are more prone to developing MOH than men, and the prevalence is highest in the productive age of 40–50 years. Further, low socioeconomic status has been found to be related to a higher prevalence of MOH. Recommended treatment for MOH is abrupt withdrawal or tapering down, ie, a discontinuation of acute medication or a reduction to <10 days per month.
A previous Swedish study found that many of those with MOH have limited contact with health care, and medications used are to a large extent over-the-counter (OTC) medications. Pharmacists may therefore have an important role in advising these individuals about their medication use, the importance of withdrawal, and non-pharmacological treatment for headache. Ever since 2009, OTC medications in Sweden have been freely sold both at general stores and in pharmacies. The Swedish eHealth Agency reports that 76% of all OTC medications are sold by pharmacies and that analgesics are the most commonly sold medication.
There is some previous research on the role of pharmacy staff in advising on headache treatment. In a US survey, 85% of community pharmacists made at least one OTC suggestion related to headache every day, but pharmacists' knowledge on current migraine treatment was limited. Inadequate knowledge about migraine management among pharmacy staff was also found in a recent study from Thailand. A prospective cohort study investigated the outcomes in individuals suffering from MOH seeking pharmacists' advice and reported a lower intake of medication and frequency of headache 3 months later. Little is, however, known about the actual level of knowledge about MOH among pharmacy staff, which determines the quality of their advice to MOH sufferers.
The aim of this study was to investigate knowledge about MOH among pharmacy staff. Knowledge can be measured through both direct and indirect measures, where self-perception is regarded as an indirect measure. A previous study found that self-reports and objective tests are equally valid for measuring the knowledge levels of people who have had formal training in the domain of interest. The source of knowledge about MOH will therefore be taken into consideration in the analyses.
Specific research questions were the following:
This is a cross-sectional study based on a questionnaire administered to pharmacy staff, and this was distributed to them through visits to pharmacies.
Pharmacies situated in Gothenburg, Sweden, were selected based on a list from the Medical Products Agency. A request for participation was made to the regional managers of the six largest pharmacy companies in Gothenburg. One of the regional managers did not respond, which resulted in 53 eligible pharmacies from 5 pharmacy companies. Every pharmacy manager was asked for permission to distribute the questionnaire to their staff, through an e-mail giving information about the study. Two declined participation, 5 were excluded because of no response at all from the pharmacy manager, and an additional 2 were excluded because of too few, ie, 1 or 2, employees. After approval, all pharmacy managers were e-mailed regarding a contact person at the pharmacy and a suitable date for distribution of the questionnaire.
The study subjects included all pharmacy staff with permission to give advice to customers on OTC medication (pharmacists, dispensing pharmacists, pharmacy technicians, and other counseling staff). Pharmacists have a master of science degree (5 years of university education), and dispensing pharmacists have 2–3 years of university education. Pharmacy technicians have 1–2 years of vocational training. Other counseling staff have a few weeks' internal counseling training, conducted through educational programs implemented by the different pharmacy companies. Responsibilities differ among the different professional categories, where pharmacists and dispensing pharmacists are the only ones who have permission to dispense prescription medications.
Data were collected during the fall of 2012. A total of 326 questionnaires were distributed. The questionnaires were distributed together with response envelopes and participant information, 1 per counseling staff member at each pharmacy. The questionnaires were placed in each staff member's personal compartment at the pharmacy or given to the contact person at the pharmacy. In addition, a box for anonymous collection of completed questionnaires was left at every pharmacy in a suitable place. After 2 weeks, new questionnaires were distributed to each pharmacy as a reminder for those who had not yet responded. The questionnaires were anonymous, and no single response could be identified, nor could the pharmacy company be identified. Hence, no information was collected for non-responders. The study protocol was approved by the Regional Ethical Review Board in Gothenburg (registration number 531-11).
The questionnaire included background questions on sex, age, and professional category, number of years since graduation/completed education, and number of years working in a pharmacy. Pharmacy technicians and other counseling staff were merged into one group called “counseling staff.”
There were 8 questions about headache, 3 of which were knowledge based asking about medications that can cause MOH, individual characteristics increasing the risk of developing MOH, and treatment advice. The remaining 5 questions asked about frequency of giving advice on headache treatment, extent of perceived knowledge on MOH, the source of the knowledge, counseling for headache sufferers, and participants' preferred resource for more information on MOH. The question “Where did you learn about the disease?” was an open question, the answers to which were categorized by the authors into “university/vocational training” and “other.”
The participants were asked to indicate which category within each of the factors age, sex, and educational level has highest risk of developing MOH. The number of response categories differed for each factor. The responses were dichotomized into the correct answer (30–65 years, women, and maximum upper secondary school, respectively) and incorrect answer (all other categories).
Participants were further asked, “Which treatment advice can you give a person with MOH?” where they were given two response alternatives; they could either answer “do not know” or give an answer in their own words. All answers were categorized, and we manually counted how many had responded correctly (abrupt withdrawal or tapering down) and how many had answered incorrectly (all other answers). Many gave several different suggestions, so we ranked the different suggestions and counted only the most suitable suggestion for each person. If a person gave 2 suggestions, eg, relaxation and physician visit, he/she was considered as being in the category physician visit.
The participants were also asked to indicate “which of these medications can lead to development of MOH?” with 5 different types of medication to choose from (NSAIDs, triptans, paracetamol, opioids, and ergotamine). The responses were dichotomized into 5 medications (correct answer) and, 1–4 medications (incorrect answer).
Data were analyzed using the statistical software IBM SPSS® for Windows, version 20 (SPSS Inc., Chicago, IL, USA). Individuals with missing data for a certain variable were excluded from that particular analysis. For each category related to source of knowledge about MOH, Pearson correlations were calculated between self-perceived and actual knowledge variables (treatment advice and medications causing MOH). Comparisons between groups were performed using chi-square test or Fisher's exact test. A significance level of P < .05 was chosen.
In total, 227 questionnaires were collected at 44 pharmacies, which corresponds to a response rate of 70%. On 2 questionnaires, only background information was given; these were excluded from the analyses, resulting in 225 respondents (Table 1). The majority of the respondents were women with ≤10 years of working experience in a pharmacy.
|Working experience, yrs|
Almost half (48%) of the respondents reported that they were asked for advice on headache treatment every day, and 80% reported that they were asked for advice at least several times per week.
The majority of the pharmacy staff (90.6%) considered themselves to have knowledge about MOH to some (n = 149; 66.5%) or a greater extent (n = 54; 24.1%; Table 2). Ten percent reported that they had no knowledge about MOH at all (n = 21). There was no difference in knowledge between professional categories or between groups with different working experience.
|Variable||To a Greater Extent, n (%)||To Some Extent, n (%)||Not at All, n (%)||Total, n (%)||P Value|
|Professional category (n = 224)|
|Pharmacist||15 (23.1)||47 (72.3)||3 (4.6)||65 (100)||.133a|
|Dispensing pharmacist||31 (29.0)||66 (61.7)||10 (9.3)||107 (100)|
|Counseling staff||8 (15.4)||36 (69.2)||8 (15.4)||52 (100)|
|Working experience, years (n = 218)|
|0-10||29 (22.3)||89 (68.5)||12 (9.2)||130 (100)||.392a|
|11-20||6 (15.8)||27 (71.1)||5 (13.2)||38 (100)|
|≥21||16 (32.0)||31 (62.0)||3 (6.0)||50 (100)|
Of 189 respondents, almost half (n = 88; 46.6%) had learned about MOH through their university/vocational education. The other respondents (n = 101) had learned about it through, eg, colleagues or internal training at the pharmacy. Of those who learned through university/vocational education, more than one third (n = 31; 35.2%) perceived their knowledge to be extensive. This was significantly higher compared with those who learned about MOH in other ways (n = 21; 20.8%; P = .027).
The actual knowledge on MOH varied between different questions asked. The results on the question concerning characteristics of individuals with a higher risk of developing MOH are shown in Table 3. Among those who perceived themselves as having some or extensive knowledge about MOH, more than half marked the correct category for the factor age (n = 114; 60.3%) as well as gender (n = 137; 71%), but only one third were correct concerning educational level (n = 63; 32.8%). Those who reported no knowledge at all did not respond to these questions, nor to the question on medications causing MOH.
|Factors||Some or Extensive Knowledge, n (%)|
|Age (n = 189)|
|Correct response (30-65 years)||114 (60.3)|
|Incorrect response (Other categories)||56 (29.6)|
|Don't know||19 (10.1)|
|Gender (n = 193)|
|Correct response (Women)||137 (71.0)|
|Incorrect response (Other categories)||41 (21.2)|
|Don't know||15 (7.8)|
|Educational level (n = 192)|
|Correct response (max upper secondary school)||63 (32.8)|
|Incorrect response (Other categories)||101 (52.6)|
|Do not know||28 (14.6)|
Of 189 respondents, fewer than 10% (n = 16; 8.6%) knew that all 5 medications listed can cause development of MOH. The type of medication most frequently missed was ergotamine (n = 48). Among those who included only 1 medication in their response (n = 32), the 2 most frequent answers were NSAIDs (n = 24; 75%) and paracetamol (n = 5; 16%).
Among those who learned about MOH during their university/vocational education, 5.6% indicated that all 5 medications can cause MOH, compared with 11.6% among those who learned about MOH in other ways (P = .190).
Regarding the question about treatment advice on MOH (n = 218), 40% responded correctly, ie, that treatment should be in the form of abrupt withdrawal from or a tapering down of medications. A somewhat higher proportion (41.7%) gave other answers, eg, referral to a doctor, relaxation exercises, or regular life habits. Almost one fifth of the respondents (n = 39; 17.8%) reported that they did not know. Among those who had learned about MOH during their university/vocational education, 47.1% knew the correct advice, compared with 35.7% among those who had learned about MOH in other ways (P = .120).
The relationship between self-perceived and actual knowledge is presented in Table 4. Actual knowledge on treatment advice differed significantly between groups of self-perceived knowledge.
|Self-Perceived Knowledge||To a Greater Extent||To Some Extent||Not at All||P-Value|
|Actual knowledge, %|
|Medications causing MOH (n = 185)|
|Treatment advice on MOH (n = 218)|
The Pearson correlation analyses showed no significant correlations between self-perceived and actual knowledge for any group in relation to source of knowledge about MOH.
This is the first study investigating knowledge on MOH among pharmacy staff. Our findings reveal that about 90% of the pharmacy staff perceived themselves as having some or extensive knowledge on MOH. Almost half of respondents reported having learned about it through university or their vocational education. Concerning actual knowledge, fewer than half knew the correct treatment advice for MOH, and only 8.6% were able to identify all types of medications related to MOH development. A relationship was found between actual and self-perceived knowledge. Those who considered themselves as having extensive knowledge on MOH more often gave the correct treatment advice compared with those who reported some or no knowledge. There was, however, no correlation between actual and self-perceived knowledge in relation to source of knowledge.
A previous study concluded that self-reports and objective tests are equally valid for measuring knowledge levels among individuals who have had formal training in the domain of interest. Our results do not support that finding. The majority of the pharmacy staff in our study reported having at least some knowledge about MOH, and those with university/vocational training on MOH considered their knowledge to be extensive to a higher degree compared with those who learned about MOH in other ways. However, we consider the knowledge level among pharmacy staff to be insufficient, based on the results for the questions about treatment advice and medications causing MOH.
Regarding the treatment advice given by the respondents, many alternatives were not actually incorrect (eg, lifestyle changes and relaxation), but they were not helpful for MOHs. The only treatment with proven effect in MOH is a tapering down of or abrupt withdrawal from medications. Because many people with MOH never seek health care and may be buying the same OTC analgesics year after year, it is crucial that pharmacy staff are able to provide correct advice for this condition.
A higher proportion of those who had learned about MOH during their university education had knowledge on correct advice compared with those who gained their knowledge in other ways; however, the differences were not significant. In the latter group, it was quite common to have gained knowledge through internal training at the pharmacy. This type of training may be more, or less, structured, which may lead to variations in knowledge level. What may also be important is that this training occurred more recently in time compared with university education, which may have influenced the results.
It was quite surprising that ergotamine was the least known of the medications for its effect of causing MOH, especially as ergotamine was the first medication known to cause MOH. Initially, the disorder was even called “ergotamine-induced headache.” However, ergotamines are used to a very low extent in Sweden today. The lack of knowledge may partly be due to the fact that 40% of the respondents were <35 years of age, and a large proportion had worked less than 10 years in a pharmacy.
Asking knowledge questions to a profession may lead to problems of social desirability bias. It may be difficult to admit that you have no knowledge in a specific area of your field. It is therefore very likely that the group answering “knowledge to some extent” comprised a large variation in knowledge level on MOH, which may have influenced the results.
The majority of pharmacies in Gothenburg participated, but we had no participants from one specific pharmacy company. However, it is unlikely that this would have had an impact on the study's validity. A high response rate was obtained, and the characteristics of the participating pharmacy staff are consistent with data from previous studies in Sweden and specifically in Gothenburg.[12, 13] This makes the results of the present study generalizable to all pharmacy staff in Sweden. It is also worth noting that all professional categories were included, which also increases the generalizability of the results.
The knowledge on MOH is insufficient among pharmacy staff. When encountering pharmacy clients, they may not provide the correct advice to those overusing headache medications. Because MOH is such a common health problem, different strategies are needed to decrease both its incidence and its prevalence. With the proper knowledge, pharmacy staff is well positioned to effect both primary and secondary prevention of MOH. We suggest not only increasing educational efforts about MOH within pharmacy programs but also continuing education at the pharmacies for all staff. Besides these interventions toward students and pharmacy staff, it is also important to increase knowledge among pharmacy customers. We recommend information brochures in the analgesic section of pharmacies where customers are advised to consult a pharmacist if they use more than 10 analgesics per month. Further, information on the drug leaflets and a public awareness campaign through the media are other suggestions.
We are grateful to all pharmacy staff responding to the questionnaire.