Management Guidelines

8/13/2019 Management Guidelines

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MIGRAINE IN PRIMARY CARE ADVISORS

Establishing new management guidelines for

migraine in primary care


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Introduction

Evaluate currently available evidence

Gather evidence for new initiatives

Physical therapy

Food intolerances (YORK Labs study)

New therapies (e.g. Botox)


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Existing MIPCA guidelines for

migraine management

1995Update 1998


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Confirm diagnosis of migraine

Review previous treatments (including OTC)

Discuss pattern/frequency of attacks

Assess impact on the patients lifestyle

Initiate acute treatments for sufferers

experiencing up to 4 attacks per month

Simple analgesic

anti-emetic

Oral triptan

If sufferer has already

tried analgesics

(OTC or prescription)

unsuccessfully

Intranasal or

subcutaneous triptan

If required

Consider

alternative triptan

Consider prophylaxis +

acute treatment for

breakthrough migraineattacks

Frequent headache

(i.e. 4 or moreattacks per month)

Consider referral

Chronic daily

Headache (CDH)?

Migraine

If unsuccessful

If unsuccessful

If unsuccessful


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Establishing new management

guidelines for migraine in primary care

Objectives

Update of the existing MIPCA guidelines

Identification and screening of patients in need ofcare

Development of new diagnostic tools and

algorithms

Best management practice Utilizing evidence-based medicine wherever

possible


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Starting points

What is required

Detailed history taking, patient education and buy-in

Diagnostic screening and confirmatory differentialdiagnosis

Management individualized for each patient

Prescribing only treatments that have objective

evidence of favourable efficacy and tolerability Prospective follow-up procedures to monitor the

success of treatment

Specific consultations for headache and a team

approach to management


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DiagnosisAssess

severity

Treatment

plan

Screen for

headache type

Differentiatemigraine from

other

headaches

Attack frequency

and pain severity

Impact onpatients life

(MIDAS / HIT)

Non-headache

symptoms

Patient factors

Establish goals

Behavioural

therapyAcute therapy

Possible

prophylactic

therapy

Alternative

therapy?

Consultation

Specific

consultation

Treatment

history

Patient

education,

counselling

and buy-in

Follow-up

Assess outcome

of therapy

Management individualized

for each patient

Overall diagram for migraine

management


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Processes

First consultation

Screening

Patient education and buy-in Diagnosis

Assessment of illness severity

Implementation of initial treatment plan

Follow-up consultations

Monitor success of therapy and modifytreatment if necessary


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Screening procedures: history

taking, patient education and buy-in

Taking a careful history is essential

Use of a headache history questionnaire is

recommended Patient education

Advice, leaflets, websites and patient

organisations (Migraine Action Association)

Patient buy in Patients to take charge of their own management

Effective communication between patient and

physician


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Careful diagnosis

Proposal:the IHS diagnostic criteria are toocomplex for everyday use in primary care

MIPCA has developed a simple but

comprehensive scheme for the differential

diagnosis of headache subtypes

Diagnosis can then be confirmed withadditional questions


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Four-item questionnaire

A. Consider sinister headaches

1. What is the impact of the headache on thesufferers lifestyle?

(sc reens fo r m igraine/ch ron ic headaches

and ATTH)

2. How many days of headache does the

patient have every month?(screens for m igraine and chronicheadaches)

B. Cons ider short -last ing ch ron ic headaches


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Four-item questionnaire

3. For patients with chronic daily headache,on how many days per week does thepatient take analgesic medication?

(sc reens fo r analgesic -dependen theadaches)

4. For patients with migraine, does the patientexperience reversible sensory symptomsassociated with their attacks?

(sc reens fo r m igraine w ith aura and

m igraine withou t aura)


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Patient presenting

with headache

Migraine/CDH

low

High

Q1. Headache impact

ATTH

Q2. No. of headache

days per month

> 15 < 15

Chronic headache

Q3. Analgesic

days/week

2

Not analgesic

dependent

Analgesic

dependent

Migraine

Q4. Reversiblesensory symptoms

With aura Without aura

Yes No

Consider sinister

headache

Consider short-lasting

headaches


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Management individualized for each

patient

Assess illness severity

Attack frequency and duration

Pain severity

Impact

MIDAS/HIT questionnaires

Non-headache symptoms Patient factors

History, preference and other illnesses


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MIDAS

Questionnaire


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HIT-6

Questionnaire


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Assessment of severity

Mild-to-moderate migraine Moderate-to-severe

migraine

Headaches mild-to-

moderate in intensity

Headaches moderate or

severe in intensity

Non-headache symptoms

not severe in intensity

Significant non-headache

symptoms, possibly

severeImpact not significant:

MIDAS Grade I or II

HIT Grade 1 or 2

Significant impact:

MIDAS Grade III or IV

HIT Grade 3 or 4


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Provision of individualized treatment

plan

Evidence-based medicine (Duke database)

suggests:

Behavioural therapy recommended for all Acute therapy recommended for all

Prophylactic therapy recommended for

certain patients

Alternative treatments may be useful as

adjunctive therapy


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Individualizing carebehavioural and

physical therapy

Recommended therapies

Behavioural: Biofeedback and relaxation

Stress reduction Avoidance of triggers

Food intolerances under investigation by MIPCA

Physical

Cervical manipulation Massage

Exercise


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Individualizing careacute medications

Acute medications should be provided for all

patients

Goals:to rapidly relieve the headache and

other symptoms, and permit the return tonormal activities

Strategy:staged care, patients have a

portfolio of medications to treat attacks of

differing severities, and have access to

rescue medications if the initial therapy fails


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Acute medications: treatments

Mild-to-moderate migraine

Initial therapies

Aspirin or NSAIDS (high doses)

Aspirin/paracetamol plus anti-emetics

Paracetamol plus isometheptene

Use if possible before headache starts

Rescue medications Oral triptans

Use for any headache severity


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Acute medications: treatments

Moderate-to-severe migraine

Initial therapies

Oral triptans (tablet/ODT)

Use after the headache starts, if possible

when it is mild in intensity

Rescue medications

Nasal spray or subcutaneous triptans

Symptom control


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Caveats on triptan use

Most patients are effectively treated with anoral triptan Differences between the oral triptans are small

and of uncertain clinical significance

Patients with unpredictable or fast-onsetattacks may benefit from ODT or nasal sprayformulations

Patients with severe attacks may benefit

from nasal spray or subcutaneousformulations

Subcutaneous sumatriptan is an effectiverescue medication


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Individualizing careprophylactic

medications

Prophylactic medications should beprovided: For patients with frequent, high-impact migraine

attacks (4/month) Where acute medications are ineffective orprecluded by safety concerns

For patients who overuse acute medicationsand/or have CDH

Goals:to reduce headache frequency by

>50% However: acute medications should be

provided for breakthrough attacks


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Prophylactic medications:

treatments

First-line medications:

Beta-blockers* (proprano lol , metop rolol ,

t imo lol , nado lol)

Anticonvulsants (sodium valproate)

Antidepressants (amitr ipty l ine)

Second-line medications

Serotonin antagonists* (pizotifen,

methysergide, cyp roheptadine)


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Individualizing carealternative

therapies

Recommended therapies

Feverfew

Magnesium

Vitamin B2

Acupuncture

However: use only registeredalternative practitioners


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Follow-up procedures

Instigate proactive long-term follow-up

procedures

Monitor the outcome of therapy

Headache diaries (new MIPCA diary )

Impact questionnaires (MIDAS/HIT)

Make appropriate treatment decisions


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Headache diaries


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MIPCA HEADACHE DIARY1

Record of headachesMONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY

NNO HEADACHE

GMILD HEADACHE

MMODERATE HEADACHE

S - SEVERE HEADACHE


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TRIGGERS

Mark on here stressful events, foods, smells, unusual events, poor sleep,

late mornings, late nights or any other possible trigger.

MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY


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MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY


TREATMENTS

Record here any treatments taken or any tablets of any type.

How may tablets and how often did you take them?

SELF RATING YOUR MIGRAINE MANAGEMENT


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SELF-RATING YOUR MIGRAINE MANAGEMENT

Please use your headache diary to help you complete these questions. This should help

you to get the best care for your migraine.

Rate your relief medication

Please rate after 3 or more attacksDoes your medication give some degree of relief in at least 2 migraines out of 3? Y/N

Are you satisfied with your relief medication? Y/N

If you answered No to either question, please see your doctor.

Rate your preventative medication

Please rate after 6 or more weeksHas your preventative medication at least halved the number of migraines you have per

month? Y/N

Are you satisfied with your preventative medication? Y/N

If you answered No to either question, please see your doctor.

Rate the impact of your migraine

Does your migraine seriously interfere with your work and/or your leisure time? Y/N

Does your migraine seriously interfere with your sense of psychological well-being? Y/N

Do you have any other concerns which you think you should mention to your doctor?

Y/N

If you answered Yes to any question, please see your doctor.


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Follow-up treatment decisions

Acute medications Patients effectively treated should continue with the original

therapy

Patients who fail on original therapy should be offered othertherapies

Prophylactic medications Ensure medication is provided for an adequate time period

(3 months)

If effective, treatment can continue for 6 months, after whichit may be stopped

If ineffective, another prophylactic medication may be tried

Patients refractory to repeated acute andprophylactic medications should be referred to aspecialist


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Implementation of guidelines

Primary care headache team

GP, practice nurse and receptionists (core team)

Pharmacist Community nurses

Optician

Dentist

Alternative practitioners

Specialist physician (additional resource)

Associate team

members


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Pharmacist

Community nurse

Optician

Dentist

Alternative

practitioner

Patient

Primary care

physician

Practice

nurse

Specialist

physician

Ancillary

staff

Primary care

Specialist

care


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New MIPCA algorithm

Initial consultation andtreatment


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Detailed history, patient education and buy-in

Diagnostic screening and differential diagnosis

Assess illness severity

Attack frequency and duration

Pain severity

Impact (MIDAS or HIT questionnaires)Non-headache symptoms

Patient history and preferences

Intermittent

mild-to-moderate migraine

Intermittent

moderate-to severe migraine

Aspirin/NSAID (large dose)Aspirin/paracetamol plus anti-emetic

Paracetamol plus isometheptane

Oral triptan

Nasal spray/subcutaneous

triptan

Initial consultation

Initial treatment

Rescue

Rescue

Behavioural/alternative therapies


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New MIPCA algorithm

Follow-up consultation andtreatment


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Aspirin/NSAID (large dose)

Aspirin/paracetamol plus anti-emetic

Paracetamol plus isometheptane

Oral triptan

Initial treatment

Follow-up treatment

Oral triptan

Alternative oral triptan

Nasal spray/subcutaneous

triptan

Rescue

If unsuccessful

Consider prophylaxis +

acute treatment for

breakthrough migraine

attacks

Frequent headache

(i.e. 4 attacks per month)

Consider referralChronic daily

Headache (CDH)?

Migraine

If unsuccessful

If unsuccessful

Initial treatment


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10 Commandments

of headache


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Screening/diagnosis

1. Almost all headaches are benign and

should be managed in general

practice.

(However, mon itor for sin ister

headaches and refer if necessary.)


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2. The physician should use questions /

a questionnaire assessing impact on

daily living for diagnostic screening

and to aid management decisions.

(Any episodic, high impact headache

shou ld be given a defaul t diagnos is of

m igraine and the diagnosis con f irmedw ith further invest igat ion .)

Screening/diagnosis


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Management

3. Migraine management should be

shared between doctor and patient.

(The pat ient taking contro l of their

management

and

the doctor provid ing education and

guidance.)


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Management

4. Migraine attacks are highly variable in

frequency, duration, symptomatology

and impact.

(Therefo re, p rovide staged care fo r

m igraine and encou rage patients to

treat th emselves.)


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Management

5. Follow-up patients, preferably with

migraine diaries.

(The patient should have perm ission

to return for fur ther management and

the GP shou ld apply a proact ive

policy.)


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Management

6. Adapt migraine management to

changes that occur in the illness and

its presentation over the years.

(e.g. m igraine may change to chronic

daily headache over time.)


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Treatments

7. Acute medication should be provided

to all migraine patients and taken as

soon as possible after the migraine

attack starts.

(Tr iptans are the most effect ive acu te

medicat ions for m igraine. Avoid

codeine and ergo tam ine i f poss ible.)


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Treatments

8. Prophylactic medications should be

prescribed to patients who have 4

migraine attacks per month or who

are resistant to acute medications.

(First-l ine prophylact ic medicat ions

are beta-b lockers, sod ium valproate

and amitr ipty l ine.)


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Treatments

9. Monitor prophylactic therapy

regularly.


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Treatments

10. Ensure that the mode of

administration of the medication is

practical for the patients lifestyle

and headache presentation.


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Outputs from the project

Complete guidelines published in

Current Med ical Research and

Opin ion

Summary article in Guidel ines in

Practice

Slide set for presentation Educational items on guidelines for

GPs and patients


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The future

Educational initiatives

Wider educational programmes for headache

services in primary care

Nurses

Research

GP specialists

Pharmacists

Physical therapy

Headache diaries

New treatments

Acute and prophylactic

Management Guidelines

Documents

Transcript of Management Guidelines