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Managing Migraine at WorkManaging Migraine at Work

Occupational Physician and General Practitioner

Formerly with H.S.A now with Civil Service

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Principles of Occ HealthPrinciples of Occ Health Effect of Work on Health – GTN (TNT), Effect of Work on Health – GTN (TNT),

CO,H2S, N2, PesticidesCO,H2S, N2, Pesticides Effect of Health Conditions on Ability to Effect of Health Conditions on Ability to

Work - Fitness to Drive, operate machineryWork - Fitness to Drive, operate machinery Reasonable AccommodationReasonable Accommodation Murphy’s Law – Murphy’s Law –

whatever can go wrong whatever can go wrong will!will!

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Causes of Causes of Headaches at Headaches at WorkWork

TNT exposure/withdrawalTNT exposure/withdrawal Pizza FreezingPizza Freezing Carbon Monoxide Poisoning – forklift trucks in Carbon Monoxide Poisoning – forklift trucks in

factory and headachesfactory and headaches

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Is Migraine Special?Is Migraine Special? Brain cannot feel pain – but a Brain Stimulation can Brain cannot feel pain – but a Brain Stimulation can

cause migraine. Neural pathways and transmitters cause migraine. Neural pathways and transmitters may alter blood flow ie Sensitive brains!may alter blood flow ie Sensitive brains!

Muscles, Tension Headache – Lactic acid build up Muscles, Tension Headache – Lactic acid build up (Masseter muscles and helmut constriction)(Masseter muscles and helmut constriction)

Symptoms cause withdrawal and inactivity, Symptoms cause withdrawal and inactivity, Lecturer who would do routine tasks when she got Lecturer who would do routine tasks when she got migraines rather than free/associative thinking.migraines rather than free/associative thinking.

Pain, depression and photophobia, ?Anger, Pain, depression and photophobia, ?Anger, distraction and accidentsdistraction and accidents

Nausea, vomiting, photophobia, asymmetrical Nausea, vomiting, photophobia, asymmetrical throbbing headache often preceded by Aura (visual throbbing headache often preceded by Aura (visual disturbance)disturbance)

Tingling, sweating, fatique, Pale Tingling, sweating, fatique, Pale

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Migraine & WorkMigraine & Work Migraine Work and Productivity loss Questionnaire Migraine Work and Productivity loss Questionnaire

(MWPLQ)(MWPLQ) Rizatriptan beneficial for reducing absence from

work and work efficiancy Commuting particularly difficult when headache

present on waking. Bright lights, noise, fumes, odours, poor

ventilation, ringing phones, voices and moving - all made things worse.

Mental dullness – composing letter difficult compared to opening post

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Interventions at WorkInterventions at Work Wishing to be alone leads to interpersonal Wishing to be alone leads to interpersonal

difficulties at work.difficulties at work. LWDE – lost work day equivalent, Spanish postal LWDE – lost work day equivalent, Spanish postal

workers councelled and access to Triptanworkers councelled and access to Triptan 0.48 days lost before intervention down to 0.2 0.48 days lost before intervention down to 0.2

days per migraine attack after intervention.days per migraine attack after intervention. The most disabled 20% The most disabled 20%

of the participants of the participants accounted for 77% of accounted for 77% of Lost Work Day EquvalentsLost Work Day Equvalents

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SymptomsSymptoms Last from 4-72 hrsLast from 4-72 hrs Prodrome, AuraProdrome, Aura Unilateral, pulsating, worse with activity Unilateral, pulsating, worse with activity

(Routine Movement), photo/phono (Routine Movement), photo/phono phobia, Nausea and vomitingphobia, Nausea and vomiting

Post migraine, mental dullness and lack of Post migraine, mental dullness and lack of sharpnesssharpness

Need for more sleep,Need for more sleep,

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DisabilityDisability Impairment must cause a loss of function Impairment must cause a loss of function

(not hypertension)(not hypertension) Usually persisting / permanentUsually persisting / permanent Substantial loss of Activity of Daily living – Substantial loss of Activity of Daily living –

we rarely feel 100%we rarely feel 100% Prevents participationPrevents participation

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Causes of MigrainesCauses of Migraines Alcohol, Stress/Anxiety, caffeine (or withdrawal), Alcohol, Stress/Anxiety, caffeine (or withdrawal),

chocolate, odours, loud noises, bright lights, chocolate, odours, loud noises, bright lights, smoking, OCP, hormonal cycle, exercise, missed smoking, OCP, hormonal cycle, exercise, missed meals.meals.

Foods: marinated, MSG, baked foods, dairy Foods: marinated, MSG, baked foods, dairy products, peanuts, products, peanuts,

Biogenic Amines such as Tyramine & Biogenic Amines such as Tyramine & Phenylethylamine in red wine, Phenylethylamine in red wine, fish, aged cheese, liver patefish, aged cheese, liver pate

Fruits: banana, citrus, figsFruits: banana, citrus, figs Nitrates in bacon, hot dogs, Nitrates in bacon, hot dogs,

cooked meatscooked meats OnionsOnions

TreatmentsTreatments

Hyperbaric O2Hyperbaric O2 Spinal manipulation, Spinal manipulation,

massage, stretchingmassage, stretching Aspirin, Paracetamol, Sumatriptan Aspirin, Paracetamol, Sumatriptan

(oral, Rectal or nasal spray), (oral, Rectal or nasal spray), Rizatriptan,Diclofenac, acupuncture Rizatriptan,Diclofenac, acupuncture (not SSRI’s and Tricyclics), (not SSRI’s and Tricyclics), AnticonvulsantsAnticonvulsants

Relaxation tx and CBTRelaxation tx and CBT

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Hopeless?Hopeless? Spectrum study showed poor response Spectrum study showed poor response

to placebo indicating pts are very to placebo indicating pts are very accurate at identifying prodromal accurate at identifying prodromal phase – they should tx themselves phase – they should tx themselves early but danger of MOU, medication early but danger of MOU, medication overuse overuse

Cognitive Impairment during attacksCognitive Impairment during attacks Pain fibres affect Pain fibres affect

limbic system (emotions).limbic system (emotions).

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ReasonableReasonable What is reasonable for an employer to What is reasonable for an employer to

do is associated with cost and therefore do is associated with cost and therefore dependant on economic considerations dependant on economic considerations (judges pay!)(judges pay!)

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Effect on Co WorkersEffect on Co Workers

Perfume – enfringement of rights of others Perfume – enfringement of rights of others to wear perfume?to wear perfume?

OSHA Office of Training and EducationOSHA Office of Training and Education 1414

Carbon MonoxideCarbon Monoxide Incomplete combustion of carbon Incomplete combustion of carbon

based fuelbased fuel Pure form it is colourless & odourlessPure form it is colourless & odourless Low dose causes headache – 10% Low dose causes headache – 10%

saturationsaturation 2 stroke engines most dangerous2 stroke engines most dangerous Carboxyhaemoglobin is bright Carboxyhaemoglobin is bright

pink in colourpink in colour Canaries have high breathing Canaries have high breathing

rates and higher metabolic rates rates and higher metabolic rates

OSHA Office of Training and EducationOSHA Office of Training and Education 1515

Carbon Monoxide (CO)Carbon Monoxide (CO) Carboxyhaemoglobin is x200 more Carboxyhaemoglobin is x200 more

affinity for oxygen than normal affinity for oxygen than normal haemoglobinhaemoglobin

Myoglobin present in Heart muscleMyoglobin present in Heart muscle Cigarettes contain Carbon monoxide Cigarettes contain Carbon monoxide

(CO)(CO) Methylene chloride organic Methylene chloride organic

solvent metablises in the solvent metablises in the body to CO body to CO