MIGRAINE IN PRIMARY CARE ADVISORS

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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
management1995Update 1998
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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
  of care
• 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
  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

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Overall diagram for migraine management
Management individualized for each patient
Follow-up
Treatment plan
Assess severity
Diagnosis
Consultation

• 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

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

• Screen for headache type
• Differentiate migraine from other headaches

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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 modify treatment
  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 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

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Four-item questionnaire

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

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Four-item questionnaire

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

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Patient presenting with headache
Consider sinister headache
Q1. Headache impact
low
ATTH
High
Migraine/CDH
Q2. No. of headache days per month
gt 15
lt 15
Migraine
Consider short-lasting headaches
Chronic headache
Q3. Analgesic days/week
Q4. Reversible sensory symptoms
lt2
gt2
Yes
No
With aura
Without aura
Analgesic dependent
Not analgesic dependent
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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
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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 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

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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

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Staged care for migraine
Migrainediagnosis
Severityassessment
Mild to moderate migraine
Moderate to severe migraine
Initial therapy
Initial therapy
If unsuccessful
Rescue
Rescue
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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 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

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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 gt50
• However acute medications should be provided for
  breakthrough attacks

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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)

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Individualizing care alternative therapies

• Recommended therapies
• Feverfew
• Magnesium
• Vitamin B2
• Acupuncture
• However use only registered alternative
  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 DIARY 1 Record of headaches
N NO HEADACHE G MILD HEADACHE M MODERATE
HEADACHE S - SEVERE HEADACHE
Record here any treatments taken or any tablets
of any type. How may tablets and how often did
you take them?
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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.
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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?
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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
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.
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Menstrual headache diary
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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 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

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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
Practice nurse
Ancillary staff
Community nurse
Optician
Primary care physician
Specialist physician
Dentist
Alternative practitioner
Patient
Specialist care
Primary care
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New MIPCA algorithmInitial consultation and
treatment
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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

Initial consultation
Intermittent mild-to-moderate migraine
Intermittent moderate-to severe migraine
Initial treatment
Behavioural/alternative therapies
Aspirin/NSAID (large dose) Aspirin/paracetamol
plus anti-emetic Paracetamol plus isometheptane
Oral triptan
Rescue
Rescue
Nasal spray/subcutaneous triptan
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New MIPCA algorithmFollow-up consultation and
treatment
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Initial treatment
Initial treatment
Aspirin/NSAID (large dose) Aspirin/paracetamol
plus anti-emetic Paracetamol plus isometheptane
Oral triptan
If unsuccessful
Follow-up treatment
Alternative oral triptan Nasal spray/subcutaneous
triptan
Rescue
Oral triptan
If unsuccessful
Consider prophylaxis acute treatment for
breakthrough migraine attacks
Frequent headache (i.e. ?4 attacks per month)
Migraine
If unsuccessful
Chronic daily Headache (CDH)?
Consider referral
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10 Commandments of headache
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Screening/diagnosis

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

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Screening/diagnosis

• 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.)

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Management

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

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Management

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

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Management

• 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.)

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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.)

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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.
• (Triptans are the most effective acute
  medications for migraine. Avoid codeine and
  ergotamine if possible.)

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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-line prophylactic medications are
  beta-blockers, sodium valproate and
  amitriptyline.)

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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 Medical
  Research and Opinion
• Summary article in Guidelines 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