Migraine and Medication-Overuse Headache: A Care Staff Guide for Ireland

This guide covers Ireland. For the UK equivalent, see our guide: Migraine and Medication Overuse Headache: A Care Staff Guide.

Care staff need to know the difference between a migraine, a headache that needs a GP, and a headache that needs an ambulance, and to understand why frequent painkiller use can make headaches worse. This guide summarises the HSE migraine pages (last reviewed 16 August 2024, next review shown as due 16 August 2027) and explains where the sources are silent. It gives no treatment advice beyond what the HSE says, and medicines decisions stay with the prescriber; our guide to medication management training for healthcare staff in Ireland covers the practical side of giving medicines safely.

What migraine is and how it looks

The HSE describes migraine as a common condition that affects the brain and nervous system. The main symptom is an intense headache, usually on one side of the head, that is a moderate or severe throbbing sensation, gets worse with movement and can stop a person doing everyday things. Sometimes it affects both sides, the face or the neck. Other symptoms include nausea and vomiting, sweating, poor concentration, feeling very hot or very cold, tummy pain and diarrhoea, dizziness, tiredness, and sensitivity to movement, light, sound or smell. Not everyone has all of these, and some people have the symptoms without a headache.

The HSE says an attack can last from 4 hours to 3 days, and tiredness can continue for up to a week afterwards. Attacks often develop in four stages, though not everyone has all of them and the stages can overlap:

• Prodromal stage: changes in mood, energy, behaviour and appetite, hours or days before an attack.
• Aura: affects about 1 in 3 people with migraine, before the head pain. It can include visual problems such as flashing lights, zig-zag patterns or blind spots, numbness or pins and needles, dizziness, difficulty speaking and, rarely, loss of consciousness. The HSE says aura can develop over about 5 minutes and last up to an hour.
• Headache stage: pulsating or throbbing pain, often with nausea or vomiting, lasting 4 to 72 hours.
• Resolution stage: symptoms fade, and tiredness may last a few days.

Aura matters for care staff because some of its features, such as speech difficulty and numbness, overlap with signs the HSE lists as emergencies. Our suggestion: if you are unsure whether a symptom is aura or an emergency sign, treat it as the emergency and follow the escalation rules below.

Red-flag headaches: when to call 112 or 999

The HSE migraine pages say to call 112 or 999 and ask for an ambulance if the person has:

• paralysis or weakness in one or both arms, or on one side of the face
• slurred or garbled speech
• a sudden, very painful headache unlike anything they have had before
• a headache with a high temperature (fever), stiff neck, confusion, seizures, double vision and a rash

The HSE notes these may signal a more serious condition. Separately, the HSE stroke page (last reviewed 28 June 2023) gives the same instruction for face drooping, inability to lift both arms and keep them there, or slurred speech. Our suggestion: do not wait to see whether painkillers work if any of these are present, stay with the person, and tell the ambulance service and your manager exactly what you saw and when it started. Our suggestion: report the event through your service's incident process.

When to contact the GP

The HSE gives two non-urgent triggers for contacting a GP: severe symptoms that do not improve with over-the-counter painkillers, and more than 5 migraine attacks in a month. On its diagnosis page the HSE adds that a GP may refer someone to a neurologist, including where migraine occurs on 15 or more days a month, where treatment is not controlling symptoms, or where new symptoms develop. The same page says there is no single test for migraine and that a GP diagnoses it mainly from symptoms and their pattern. Care staff should not label headaches as migraine on their own; report what you see and let the clinician decide.

The HSE recommends keeping a migraine diary for at least 4 weeks, recording dates, timing, what the person was doing when symptoms began, symptoms, duration, menstrual timing, and the medicines used and how well they worked. Support staff can often help a person to keep this, if the person agrees and your service allows it.

Medicines safety and medication-overuse headache

The HSE treatment page says over-the-counter painkillers such as paracetamol, aspirin or ibuprofen can help, that painkillers containing codeine should be avoided, and that the painkiller should be taken at the first sign of an attack. It advises that aspirin should not be given to children under 16 without GP advice, and that aspirin and ibuprofen should be avoided with a history of stomach, liver or kidney problems or stomach ulcers. These are general statements about the public information. Whether a particular person may take a particular medicine is for their prescriber or pharmacist, and staff should follow the person's medicines record and the service's procedures.

On medication-overuse headache, the HSE says taking painkillers often and over a long time can cause it, and that it is also called painkiller headache or rebound headache. The HSE pages give two different limits in different places. The diagnosis page says to avoid taking painkillers on more than 10 days every month in the long term, while the overview page says to try not to use the maximum dosage of painkillers more than 2 days a week. The treatment page does not give a number but says to contact the GP if painkillers are needed often or stop working. Because the figures differ and depend on the medicine, our suggestion is to count and record how often a person asks for headache medicines and to pass that record to the GP rather than applying either number yourself.

The HSE also says triptans, which a GP may recommend if other painkillers fail, can themselves cause medication-overuse headache if too many are taken. It lists anti-sickness medicines, combination medicines and preventive medicines such as topiramate, propranolol and amitriptyline as options that a GP may prescribe, with warnings. It says, for example, that topiramate can reduce the effectiveness of hormonal contraceptives and can harm an unborn baby. Those are prescriber decisions, so care staff should give them exactly as prescribed and report side effects, and never change, stop or share them.

Triggers and complications

The HSE says triggers do not cause migraine but can make an attack more likely in someone who already has it. It lists the menstrual cycle, stress and strong emotions, disrupted sleep or shift work, neck and shoulder tension, skipped meals, dehydration, alcohol, caffeine, bright or flickering lights, loud noises, strong smells and weather changes. It also notes that some sleeping tablets, the combined contraceptive pill, other oestrogen-containing contraceptives and hormone replacement therapy may trigger attacks. The HSE complications page says people with migraine with aura are about twice as likely to have an ischaemic stroke as people without migraine, although the absolute risk remains small, and it advises having blood pressure and pulse checked, eating well, being active and not smoking. It also lists depression and anxiety disorder among conditions linked to migraine, describes the added risk as very small, and says that anyone with migraine and mental health difficulties should talk to their GP. The Irish College of General Practitioners (ICGP) published a 49-page Migraine Quick Reference Guide for GPs in 2019, written by M. Kearney, M. Ruttledge and E. Tomkins; it is aimed at general practice, so this post does not summarise its clinical content.

A practical approach for care staff

Our suggestions, not requirements, for services supporting people with recurrent headache:

• Check the care plan: look for a diagnosis, known triggers, and prescriber instructions for what to give and when.
• Record accurately: time of onset, symptoms, any aura, what was given, and the effect.
• Escalate clearly: emergency signs go to 112 or 999; the other concerns above go to the GP.
• Look beyond the headache: if a person with communication difficulties repeatedly shows signs of pain or you suspect their needs are being missed, think about your safeguarding duties, outlined in our guide to safeguarding vulnerable adults training in Ireland.
• Keep records inspection-ready: medicines and incident records are part of how services show good practice; see our guide to HIQA inspections and staff training in Ireland.

Learnsignal's offices are off Baggot Street in Dublin, and we offer in-person training from there. For current details, see our CPD pages.

Frequently asked questions

What headache symptoms mean I should call an ambulance?

The HSE says to call 112 or 999 for paralysis or weakness in an arm or one side of the face, slurred or garbled speech, a sudden very painful headache unlike any before, or headache with fever, stiff neck, confusion, seizures, double vision and a rash.

Can painkillers make headaches worse?

Yes. The HSE says taking painkillers often and over a long time can cause medication-overuse headache. Report how often headache medicines are used to the GP.

Should care staff give codeine-containing painkillers for migraine?

The HSE says codeine-containing painkillers should be avoided for migraine. Whatever is given must be what the prescriber or pharmacist has approved for that person, so check the medicines record.

When should a person with migraine see a GP?

The HSE says to contact a GP for severe symptoms that do not improve with over-the-counter painkillers, or for more than 5 attacks in a month.

When staff recognise red flags quickly and record headache medicines accurately, people get the right help sooner.