MIGRAINE IN PRIMARY CARE ADVISORS Establishing new management guidelines for migraine in primary care

Introduction
Evaluate currently available evidence Gather evidence for new initiatives
Physical therapy Food intolerances (YORK Labs study) New therapies (e.g. Botox)

Existing MIPCA guidelines for migraine management 1995 Update 1998

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

If sufferer has already tried analgesics (OTC or prescription) unsuccessfully

Oral triptan

Intranasal or subcutaneous triptan If required

If unsuccessful Consider alternative triptan If unsuccessful Migraine

Frequent headache (i.e. 4 or more attacks per month)

Consider prophylaxis + acute treatment for breakthrough migraine attacks

If unsuccessful Chronic daily Headache (CDH)? Consider referral

Establishing new management guidelines for migraine in primary care

Objectives
Update of the existing MIPCA guidelines
Identification and screening of patients in need of care Development of new diagnostic tools and algorithms Best management practice

Utilizing evidence-based medicine wherever possible

Starting points
What is required Detailed history taking, patient education and buy-in Diagnostic screening and confirmatory differential diagnosis 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

Overall diagram for migraine management

Management individualized for each patient

Consultation

Diagnosis

Assess severity

Treatment plan

Follow-up

Specific consultation Treatment history Patient education, counselling and buy-in

Screen for headache type

Differentiate
migraine from other headaches

Attack frequency and pain severity Impact on patients life (MIDAS / HIT) Non-headache symptoms Patient factors

Establish goals Behavioural therapy Acute therapy Possible prophylactic therapy Alternative therapy?

Assess outcome of therapy

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 modify treatment if necessary

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

Careful diagnosis
Proposal: the IHS diagnostic criteria are too
complex 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 with additional questions

Four-item questionnaire
A. Consider sinister headaches 1. What is the impact of the headache on the sufferers lifestyle? (screens for migraine/chronic headaches and ATTH) 2. How many days of headache does the patient have every month? (screens for migraine and chronic headaches) B. Consider short-lasting chronic headaches

Four-item questionnaire
3. For patients with chronic daily headache, on how many days per week does the patient take analgesic medication? (screens for analgesic-dependent headaches) 4. For patients with migraine, does the patient experience reversible sensory symptoms associated with their attacks? (screens for migraine with aura and migraine without aura)

Consider sinister headache

Patient presenting with headache Q1. Headache impact

High Migraine/CDH > 15 Consider short-lasting headaches Q4. Reversible sensory symptoms Yes With aura No Without aura < 15 Migraine Q2. No. of headache days per month

low ATTH

Chronic headache

Q3. Analgesic days/week <2 >2 Analgesic dependent

Not analgesic dependent

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

MIDAS Questionnaire

HIT-6 Questionnaire

Assessment of severity
Mild-to-moderate migraine Moderate-to-severe migraine

Headaches mild-tomoderate in intensity

Non-headache symptoms not severe in intensity Impact not significant: MIDAS Grade I or II HIT Grade 1 or 2

Headaches moderate or severe in intensity

Significant non-headache symptoms, possibly severe Significant impact: MIDAS Grade III or IV HIT Grade 3 or 4

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

Individualizing care behavioural 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

Individualizing care acute medications

Acute medications should be provided for all patients Goals: to rapidly relieve the headache and other symptoms, and permit the return to normal 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

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

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

Caveats on triptan use

Most patients are effectively treated with an oral triptan
Differences between the oral triptans are small and of uncertain clinical significance

Patients with unpredictable or fast-onset attacks may benefit from ODT or nasal spray formulations Patients with severe attacks may benefit from nasal spray or subcutaneous formulations Subcutaneous sumatriptan is an effective rescue medication

Individualizing care prophylactic medications

Prophylactic medications should be provided:
For patients with frequent, high-impact migraine attacks (4/month) Where acute medications are ineffective or precluded by safety concerns For patients who overuse acute medications and/or have CDH

Goals: to reduce headache frequency by >50% However: acute medications should be provided for breakthrough attacks

Prophylactic medications: treatments

First-line medications:
Beta-blockers* (propranolol, metoprolol, timolol, nadolol) Anticonvulsants (sodium valproate) Antidepressants (amitriptyline)

Second-line medications
Serotonin antagonists* (pizotifen, methysergide, cyproheptadine)

Individualizing care alternative therapies

Recommended therapies
Feverfew Magnesium Vitamin B2 Acupuncture

However: use only registered alternative practitioners

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

Headache diaries

MIPCA HEADACHE DIARY 1 Record of headaches

MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY

N NO HEADACHE G MILD HEADACHE M MODERATE HEADACHE S - SEVERE HEADACHE

MIPCA HEADACHE DIARY 2 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

MIPCA HEADACHE DIARY 3 TREATMENTS Record here any treatments taken or any tablets of any type. How may tablets and how often did you take them?
MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY

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 attacks Does 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 weeks Has 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.

Menstrual headache diary

Date Menstrual bleeding 1 2 3 4 5 6 7 8 9 etc

Time of onset

- first symptom (specify) - headache - headache - last symptom (specify)

Time of resolution

Maximum intensity of headache (mild, moderate or severe) Other symptoms (specify)

Time lost from normal activity (hours)

Time spent at less than 50% of normal activity (hours)

Drugs taken

Contraceptive drug (if any)

Pre-menstrual symptoms or intercurrent illness (if any)

Follow-up treatment decisions

Acute medications
Patients effectively treated should continue with the original therapy Patients who fail on original therapy should be offered other therapies

Prophylactic medications
Ensure medication is provided for an adequate time period (3 months) If effective, treatment can continue for 6 months, after which it may be stopped If ineffective, another prophylactic medication may be tried

Patients refractory to repeated acute and prophylactic medications should be referred to a specialist

Implementation of guidelines
Primary care headache team
GP, practice nurse and receptionists (core team) Pharmacist Community nurses Associate team Optician members Dentist Alternative practitioners Specialist physician (additional resource)

Pharmacist Practice nurse Ancillary staff

Community nurse

Optician

Primary care physician

Specialist physician

Dentist Alternative practitioner

Patient

Primary care

Specialist care

New MIPCA algorithm Initial consultation and treatment

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

Initial consultation

Intermittent mild-to-moderate migraine

Intermittent moderate-to severe migraine

Behavioural/alternative therapies Aspirin/NSAID (large dose) Aspirin/paracetamol plus anti-emetic Paracetamol plus isometheptane Rescue

Initial treatment
Oral triptan Rescue

Nasal spray/subcutaneous triptan

New MIPCA algorithm Follow-up consultation and treatment

Initial Initial treatment treatment

Aspirin/NSAID (large dose) Aspirin/paracetamol plus anti-emetic Paracetamol plus isometheptane If unsuccessful Rescue Oral triptan

Follow-up treatment
Alternative oral triptan Nasal spray/subcutaneous triptan

Oral triptan

If unsuccessful Frequent headache (i.e. 4 attacks per month)

Migraine Consider prophylaxis + acute treatment for breakthrough migraine attacks If unsuccessful Chronic daily Headache (CDH)? Consider referral

10 Commandments
of headache

Screening/diagnosis
1. Almost all headaches are benign and should be managed in general practice. (However, monitor for sinister headaches and refer if necessary.)

Screening/diagnosis
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 should be given a default diagnosis of migraine and the diagnosis confirmed with further investigation.)

Management
3. Migraine management should be shared between doctor and patient. (The patient taking control of their management and the doctor providing education and guidance.)

Management
4. Migraine attacks are highly variable in frequency, duration, symptomatology and impact. (Therefore, provide staged care for migraine and encourage patients to treat themselves.)

Management
5. Follow-up patients, preferably with migraine diaries. (The patient should have permission to return for further management and the GP should apply a proactive policy.)

Management
6. Adapt migraine management to changes that occur in the illness and its presentation over the years. (e.g. migraine may change to chronic daily headache over time.)

Treatments
7. Acute medication should be provided to all migraine patients and taken as soon as possible after the migraine attack starts. (Triptans are the most effective acute medications for migraine. Avoid codeine and ergotamine if possible.)

Treatments
8. Prophylactic medications should be prescribed to patients who have 4 migraine attacks per month or who are resistant to acute medications. (First-line prophylactic medications are beta-blockers, sodium valproate and amitriptyline.)

Treatments
9. Monitor prophylactic therapy regularly.

Treatments
10. Ensure that the mode of administration of the medication is practical for the patients lifestyle and headache presentation.

Outputs from the project

Complete guidelines published in Current Medical Research and Opinion Summary article in Guidelines in Practice Slide set for presentation Educational items on guidelines for GPs and patients

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