Survey of Pharmacy Students’ Awareness of Medication Overuse Headache

Abstract

Medication overuse headache (MOH) is a condition in which excessive analgesic use induces headache. Recent studies have reported that simple advice significantly reduces the number of days patients use analgesics and the frequency of headaches. Pharmacists are expected to support patient self-medication and contribute to the prevention and treatment of MOH. This study was conducted at Doshisha Women’s College of Liberal Arts and Osaka Medical and Pharmaceutical University with the aim of clarifying the current state of pharmacy students’ awareness of MOH and related issues. The survey consisted of 28 items, including true or false, open-ended, and multiple-choice questions on MOH. Of the 341 students who responded, 49.9% had heard of the term MOH, and 84.5% recognized the importance of pharmacists in preventing and mitigating MOH. The correct answer rate for the true or false questions was 78.3%, but only 16.4% of the students responded that their current understanding of MOH allows them to provide care to patients, and only 7.9% reported having learned about ways to support patients with MOH. These findings indicate that the knowledge about MOH is not yet fully connected to patient support. Therefore, opportunities to learn about the practical aspects of pharmacist involvement in MOH management on campus may be limited. In the future, universities may consider providing more structured opportunities for pharmacy students to learn the practical aspects of pharmacist-led patient support.

INTRODUCTION

Medication overuse headache (MOH) is a disease in which headaches are induced by excessive use of analgesics^1,2) and its global prevalence is reported to be approximately 1–2%.^3–5) At present, there is no established treatment, but previous studies have reported that by receiving simple advice on MOH from a doctor, the average number of days that MOH patients take analgesics was significantly reduced from 22 to 6 d per month,⁶⁾ indicating that advice from medical professionals is effective in treating MOH.^6–8)

Many MOH patients purchase over-the-counter analgesics at pharmacies and treat their headaches themselves.^9,10) The easy sale of analgesics at pharmacies is thought to be one of the causes of MOH,¹¹⁾ and it is important for pharmacists to carefully support self-medication.¹²⁾

Previous studies have investigated MOH among medical professionals, but there are few studies that have investigated the awareness of MOH among students. Therefore, we investigated pharmacy students’ awareness of MOH. As future supporters of patients using over-the-counter analgesics, clarifying their awareness provides a basis for improving pharmacy education.

MATERIALS AND METHODS

Survey Method

Participants were recruited verbally or by e-mail from all the students enrolled in the pharmacy programs at Doshisha Women’s College of Liberal Arts and Osaka Medical and Pharmaceutical University, regardless of their year of study. A questionnaire survey was conducted using Microsoft Forms. The questionnaire consisted of true or false questions about knowledge of MOH,^10,13,14) awareness of MOH, prevention and improvement of MOH, and the role of pharmacists (Table 1). It was pre-tested on a small group of students to confirm its clarity and feasibility. Their feedback helped refine the final version. The survey was conducted from October 1 to November 30, 2023.

Table 1. Contents of the Questionnaire

Multiple-choice questions
Q1. Do you agree to cooperate with this survey and have the results published in a paper or other publication?
a. I agree
Q2. Which faculty are you in?
a. Faculty of Pharmacy  b. Other (　　)
Q3. What year are you in?
a. 1st year  b. 2nd year  c. 3rd year
d. 4th year  e. 5th year  f. 6th year  g. Other
Q4. What is your gender?
a. Male  b. Female  c. Prefer not to answer
Q5. How often do you have headaches?
a. Almost every day  b. Approximately once a week  c. Approximately once every 2 weeks   d. Approximately once a month   e. Approximately once every 3 months   f. Approximately once every 6 months  g. Almost never
Q6. Do you feel that headaches are a common illness?
a. Ye   b. No
Q7. Have you ever heard of the term “MOH”? If you selected “a. Yes,” please also answer Q8 and Q9.
a. Yes  b. No
Q8. How much do you know about “MOH”?
a. I can explain what it is to some extent.  b. I have heard of the term.  c. Other (  )
Q9. Where did you learn about MOH? (multiple answers possible)
a. At university  b. At a hospital or pharmacy  c. From friends or family  d. Because a friend or family member had this condition   e. I had this condition  f. Television  g. The Internet  h. Books and magazines  i. Because a family member is a medical professional   j. Other (  )
True or False questions
Q10. MOH does not interfere much with my daily life.
a. 〇  b. ×
Q11. Are there any headaches other than those associated with micturition that can cause MOH?
a. 〇  b. ×
Q12. Over-the-counter painkillers (those containing caffeine or several types of pain-relieving ingredients) may be the cause of MOH.
a. 〇  b. ×
Q13. MOH can often be improved with just appropriate advice from medical professionals.
a. 〇  b. ×
Q14. MOH is the least common type of chronic daily headache.
a. 〇  b. ×
Q15. A chronic daily headache is a headache that develops on 7 or more days per month for 3 or more months.
a. 〇  b. ×
Q16. Improvement was observed in approximately 70% of the cases within 1–6 months of the discontinuation of the causative drug.
a. 〇  b. ×
Q17. There is almost no chance of MOH recurrence.
a. 〇  b. ×
Q18. MOH is said to be related to depression.
a. 〇  b. ×
Q19. The continuous use of over-the-counter medications containing anhydrous caffeine can cause headaches as a symptom of toxicity or withdrawal.
a. 〇  b. ×
Multiple-choice/open-ended questions
Q20. Please choose the image that you think is closest to the image you currently associate with the term “MOH.” (multiple possible answers)
a. Anyone can develop MOH.  b. MOH develops in only certain people.  c. MOH is related to narcotics.   d. Only few patients have this condition.  e. Many patients have MOH.  f. MOH can be cured quickly.   g. MOH takes a long time to cure.  h. MOH is a common disease  i. Other (  )
Q21. Do you think the presence of pharmacists is important for preventing and improving “MOH”?
If you selected “a. Very important” or “b. Somewhat important,” please also answer Q22.
a. Very important  b. Somewhat important  c. Not very important  d. Not important at all  e. Do not know
Q22. Why do you think the presence of pharmacists is important in preventing and improving “MOH”? (open-ended question)
Q23. Do you think you can provide adequate care to patients with your current knowledge of MOH?
a. Yes  b. No
Q24. Have you ever learned how to help patients with MOH? a. Yes b. No
Q25. What knowledge do you think pharmacists need to support patients with MOH? (open-ended questions)
Q26. From the time you enrolled until now, have you had any classes on “headaches”?
If you selected “a. Yes,” please also answer Q27.
a. Yes  b. No
Q27. In what subject did you learn about “headaches”? (open-ended question)
Q28. After taking the survey, did you want to know more about “MOH”?
a. Yes  b. No

Analysis Method

Student responses to the questionnaire were compiled and analyzed for inter-item and intergrade comparisons. It was assumed that individuals familiar with headaches would be more likely to know the term MOH. The χ² test was used to determine the associations for questions 6 and 7. The statistical significance level was set at 5%.

Ethical Considerations

The study was conducted with the approval of the Ethics Committee for “Research on Human Subjects” at Doshisha Women’s College of Liberal Arts (Approval Number: 2023-8). Consent was obtained electronically after the participants read the study purpose and confidentiality statement. All survey participants agreed to participate in the study, which was conducted with due consideration given to personal information.

RESULTS

Questionnaire Respondents

Survey responses were received from 341 participants, of whom 324 were women. The response rate was 13.0% (Table 2).

Table 2. Number of Respondents

Grade	Total	Women
First year	112	111
Second year	76	74
Third year	66	57
Fourth year	53	48
Fifth year	18	18
Sixth year	16	16
Other	0	0
Total	341	324

Response rate: 13.0%

Awareness of MOH among Pharmacy Students

Regarding the frequency of headaches, 83 students (24.3%) answered “almost never,” but 309 students (90.6%) felt that headaches were a familiar condition. Overall, 170 students (49.9%) had heard of the term MOH, and awareness of the condition was higher among students in the third to sixth years than among those in their first and second years (Tables 3 and 4). Furthermore, there was no significant difference in the relationship between “familiarity with headaches” and “awareness of MOH” (Table 5).

Table 3. Pharmacy Students’ Views on Headaches and MOH

	Number of people	(%)
Q5. How frequent are your headaches?
Almost every day	13	(3.8)
Approximately once a week	43	(12.6)
Approximately once every 2 weeks	60	(17.6)
Approximately once a month	75	(22.0)
Approximately once every 3 months	35	(10.3)
Approximately once every 6 months	32	(9.4)
Almost never	83	(24.3)
Q6. Do you feel that headaches are a common illness?
Yes	309	(90.6)
No	32	(9.4)
Q7. Have you ever heard of the term MOH?
Yes	170	(49.9)
No	171	(50.1)
Q8. How much do you know about MOH?
I can explain what it is to some extent	58	(34.1)
I have heard the term	111	(65.3)
Other	2	(1.2)
Q9. Where did you learn about MOH?
At university	82	(48.2)
At a hospital or pharmacy	18	(10.6)
From friends or family	21	(12.4)
Because a friend or family member had this condition	1	(0.6)
Because I had this condition	1	(0.6)
Television	48	(28.2)
The Internet	57	(33.5)
Books and magazines	7	(4.1)
Because a family member is a medical professional	6	(3.5)
Other	4	(2.4)
Q20. Please choose the image that you think is closest to the image you currently associate with the term “MOH.”
It can develop in anyone	291	(85.3)
MOH develops in only certain people	28	(8.2)
It is related to narcotics	67	(19.6)
There are few patients with this condition	28	(8.2)
Many patients have MOH	127	(37.2)
MOH can be cured quickly	15	(4.4)
MOH takes a long time to cure	153	(44.9)
It is something close to home	129	(37.8)
Other	3	(0.9)
Q21. Do you think the presence of pharmacists is important to prevent and improve “MOH”?
Very important	204	(59.8)
Somewhat important	84	(24.6)
Not very important	9	(2.6)
Not important at all	0	(0.0)
Do not know	44	(12.9)
Q23. Do you think you can provide adequate care to patients with your current knowledge of MOH?
Yes	56	(16.4)
No	285	(83.6)
Q24. Have you ever learned how to help patients with MOH?
Yes	27	(7.9)
No	314	(92.1)
Q26. From the time you enrolled until now, have you had any classes on “headaches”?
Yes	164	(48.1)
No	177	(51.9)
Q28. After taking the survey, did you want to know more about “MOH”?
Yes	321	(94.1)
No	20	(5.9)

Table 4. Comparison between Grades

Question	First year	Second year	Third year	Fourth year	Fifth year	Sixth year
Students who believe that the role of pharmacists is important in preventing and improving MOH※	87 (77.7)	64 (84.2)	59 (89.4)	47 (88.6)	16 (88.9)	15 (93.8)
Students who have heard the term MOH	49 (43.8)	27 (35.5)	30 (45.5)	38 (71.7)	12 (66.7)	14 (87.5)
Students who have learned how to support patients with MOH	3 (2.7)	1 (1.3)	7 (10.6)	15 (28.3)	1 (5.6)	0 (0.0)
Students who answered that their current knowledge of MOH allows them to provide care to affected patients	17 (15.2)	12 (15.8)	10 (15.2)	15 (28.3)	0 (0.0)	2 (12.5)

Data are presented as the number of valid responses (%). ^※ For this question, only the number of students who selected “very important” or “somewhat important” is presented in this table.

Table 5. Relationship between “Familiarity with Headaches” and “Awareness of MOH”

	Do you think headaches are a common illness?
		Yes	No
Have you heard of “MOH”?	Yes	154	16	p = 0.986
	No	155	16

p > 0.05: no statistically significant difference.

The average correct answer rate for true or false questions regarding knowledge was 78.3%. However, of those who had heard of the term MOH, only 111 (65.3%) answered that they had “heard the term,” and only 58 people (34.1%) answered that they “can explain it to some extent” (Tables 3 and 6). The largest number of participants, 82 (48.2%), answered that they had learned about MOH at university (Table 3).

Table 6. True or False Questions and Correct Answer Rate

Question	Correct answer	Correct answer rate (%)
MOH does not interfere much with my daily life.	×	90.0
Are there any headaches other than those associated with micturition that can cause MOH?	○	83.3
Over-the-counter painkillers (those that contain caffeine or several types of pain-relieving ingredients) can sometimes be the cause.	○	87.1
MOH can often be improved with just appropriate advice from medical professionals.	○	71.8
MOH is the least common type of chronic daily headache.	×	80.6
Chronic daily headache is a headache that develops 7 or more days a month for 3 or more months.	×	27.0
Improvement is observed in approximately 70% of cases within 1 to 6 months after discontinuing the causative drug.	○	79.0
There is almost no chance of recurrence.	×	93.0
It is said to be related to depression.	○	83.9
Continuous use of over-the-counter medications containing anhydrous caffeine can cause headaches as a symptom of toxicity or withdrawal.	○	87.4

Average correct answer rate: 78.3%.

Pharmacy Students’ Thoughts on MOH

We surveyed students’ awareness of the importance of pharmacists’ involvement in the prevention and treatment of MOH patients. Two hundred and four students (59.8%) answered “very important,” and 84 students (24.6%) answered “somewhat important.” The higher the course grade, the more important the role of the pharmacists. Open-ended responses from students who stated that the pharmacist’s role is important in preventing and managing MOH are presented in Supplementary Materials. However, only 27 students (7.9%) answered that they “have learned about how to support patients with MOH,” and 56 students (16.4%) answered that they “can respond to patients with their current knowledge of MOH.” Most students who answered that they had learned how to support patients with MOH and that they could respond to patients were fourth-year students, and there was no correlation between these questions and course grade (Tables 3 and 4).

DISCUSSION

In this study, we surveyed pharmacy students with the aim of identifying the state of MOH awareness among them and related problems. Approximately half the students had heard of MOH, and many recognized the importance of pharmacists in its prevention and management. However, limited opportunities were available to learn patient support on campus.

Awareness of MOH

Students’ awareness of MOH increased with each academic year, indicating that lectures contributed to improved recognition. MOH was covered in required pharmacology- and therapeutics-related courses, though teaching time might be limited. This may explain the increased recognition of the term with each academic year; however, knowledge of patient support methods did not show the same trend. Therefore, providing more systematic opportunities to learn about MOH in pharmacy education may deepen understanding and provide a basis for future studies evaluating specific educational interventions and their impact on patient care.

Pharmacy Students’ Awareness of the Importance of the Role of Pharmacists in MOH Management

Most students (84.5%) recognized that the role of pharmacists is important for preventing and alleviating MOH. It is thought that students inferred the role of pharmacists from the term “drug overuse headache.” Their impressions included “they can improve MOH by using medicines appropriately” or “they can refer patients to appropriate facilities.” Additionally, because students’ awareness of the importance of pharmacists’ role in MOH management increased as they advanced in their academic year, it was thought that as their knowledge increased, they would be able to recognize the importance of pharmacists’ involvement.

Current Issues

Only 34.1% of students answered that they could explain MOH. Furthermore, at present, few students have had experience learning how to support MOH patients, and it was shown that they lack confidence to respond to patients. It was thought that by learning specific ways to support MOH patients, such as using headache diaries and improving lifestyle habits, in addition to knowledge about the disease, students would be able to gain confidence to respond to patients. Previous studies have shown that advice from medical professionals is effective in treating MOH.^6–8) It has also been shown that not only MOH but also pharmacists can improve patient outcomes by providing patient support using educational materials for hypertension and diabetes patients, even if it is just for a few minutes, in addition to regular medication instructions.¹⁵⁾ It was thought that it would be necessary to raise students’ awareness in the future about the importance and usefulness of medical professionals providing information to patients.

Limitations

This study has some limitations. First, the response rate was 13%, limiting representativeness. Second, the survey was conducted at two universities and mostly included women, limiting generalizability. Third, responses were skewed toward lower-year students, possibly affecting trends. Additionally, the survey employed the term “medication overuse headache” instead of the current Japanese terminology, possibly affecting perception.¹⁶⁾ Despite these limitations, the study offers valuable insight into students’ readiness for MOH, highlighting the need for further education.

In this survey, approximately half of the students had heard of the term MOH, and the correct answer rate for true or false questions on knowledge of MOH was relatively high. However, this knowledge may not yet be sufficiently linked to patient support. Within the limitations of this study, the findings suggest that, in addition to knowledge of the condition, pharmacy education may benefit from the inclusion of practical aspects such as the importance and usefulness of information provision to patients by medical professionals and how pharmacists can support patients. Survey results have shown that the prevalence of migraine associated with MOH in Japan is higher than in other countries,¹⁷⁾ but few patients receive adequate headache treatment,⁹⁾ and many patients may be unaware that they have MOH. MOH can develop in anyone; however, it can also be prevented. At present, headaches are underestimated worldwide,^18,19) and it is suggested that increasing pharmacy students’ awareness of MOH and pharmacist support for self-medication may help reduce the future burden of MOH.

Acknowledgments

We thank Professor Ryoichi Yano of Osaka Medical and Pharmaceutical University for his cooperation in conducting this study.

DECLARATIONS

Conflict of Interest

The authors declare no conflict of interest.

Supplementary Materials

This article contains supplementary materials.

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