Transcript OH and Headache Oct 2005 - The Exeter Headache Clinic

OH and Headache
Dr David PB Watson
GPwSI
Hamilton Medical Group
Aberdeen
Objectives
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Headache impact and epidemiology
Headache diagnosis
Headache management
audit and useful information
case study
Objective 1
Headache Impact and Epidemiology
Headache types
Primary headache
Secondary
headache
No underlying
medical cause:
10%
 Episodic
primary
headaches
 Chronic
primary
headaches
Underlying
medical cause:
 Tumour
 Meningitis
 Vascular
disorders
90%
 Systemic infection
 Head injury
 Drug-induced
Episodic primary headaches
Cluster
Migraine +/aura
Episodic
primary
headaches
Probable
migraine
Tension-type
headache (TTH)
Chronic primary headaches /
chronic daily headaches
New daily persistent
Hemicrania continua
Chronic daily
headache (CDH)
Chronic migraine +/medication overuse
Chronic tension
Chronic cluster
Lifetime prevalence of
primary headache
Chronic daily - all types
4%
Episodic migraine
16%
78%
Episodic TTH
(n=740)
Rasmussen et al 1991
Impact
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Episodic TTH –low (common)
Episodic Migraine – high (1 in 10)
Chronic Daily Headache - high ( 1 in 25)
Cluster – very high (1-2 in 1000)
Migraine Impact
• Meets WHO definition of disability
• Epidemiology
– 6 million people in UK
– Women 3x men
– most sufferers aged 20 to 50
Personal Impact
• 187000 migraine attacks experienced every
day
• 3/4 report disability at least sometimes
• 1/3 feel migraine controls their lives
• 47% of migraineurs experience depression
compared 17% on non migraineurs
Impact of Migraine
• UK migraine survey 1999 showed that
– 30% were unable to look after their family
– 63% were either totally or significantly
prevented from going to work
– 39% had suffered an attack whilst driving
Economics of Migraine
• 50% of migraine sufferers miss up to 26
days work a year
• 18 million working days a year lost
• lost productivity valued at almost £2 billion
a year
• sufferers function at 50% efficiency with
migraine symptoms for up to 1 week
Indirect cost of migraine
For most sufferers, migraine results in lost
productivity rather than days lost from work
Work loss 100
(%)
80
The most severely affected
sufferers (40% of the sample)
accounted for all days lost from work
60
40
Almost all sufferers reported reduced
productivity equivalent to lost work
days
20
0
0
10
20
30 40 50 60 70 80
Migraine sufferers (%)
90 100
Adapted from von Korff et al 1998
Objective 2
Headache Diagnosis
This slide kit is for educational purposes only
“Red flags”
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Single cohort (Level 3) or expert opinion (Level 4)
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new onset headache in patients who are aged over 50 29-31
abrupt onset (thunderclap) 28-30, 32, 33
focal symptoms including atypical aura greater than one hour 28, 32, 34, 35
abnormal neurological examination 28, 29, 35, 36
altered mental status 28, 30, 34
altered characteristics or associated features of headache 28, 31
headache that changes with posture 37
headache worse in the morning and during physical activity, and the valsalva
manoeuvre 28, 38
patients with risk factors for thrombosis 34, 39, 40
new onset headache in a patient with a history of HIV infection 41
jaw claudication 16
neck stiffness 30
fever 42
new onset headache in a patient with a history of cancer 9
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Abbreviated diagnostic checklist based on
IHS 2004 criteria
Migraine
Probable migraine
Tension-type
• Recurrent
• Recurrent
Essential (3) • Recurrent
• No organic disease • No organic disease • No organic disease
• Duration 4-72 h
• Duration 4-72 h
• Duration 0.5 h-7 days
Essential (2) •
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Unilateral
Pulsating
Moderate / severe
Aggravated by
movement
• Moderate / severe
+ one other
Essential (1) • Nausea / vomiting
• Photo / phonophobia
• Generalised
• Pressure / tightness
• Slight / moderate
• Photo / phonophobia
Essential (3) = all items essential for diagnosis; Essential (2) = two items from
list essential for diagnosis; Essential (1) = one item from list essential for
diagnosis
IHS 2004
What features make migraine
more likely?
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episodic severe headache that causes disability11, 23, 24
nausea16, 23
sensitivity to light during migraine headache16, 23
sensitivity to light between migraine attacks 25
aura16, 18
sensitivity to noise16
exacerbation by physical activity16
• positive family history of migraine16
• The features which give the greatest sensitivity and specificity are
disability, nausea and sensitivity to light23
– ID Migraine validation study (Level 3)
Other primary headache
• Trigeminal autonomic cephalalgias (TACs)
– Cluster headache
– Paroxysmal Hemicrania
– SUNCT
• Hemicrania continua
• New daily persistent headache
What features make TACs more
likely?
• The following features differentiate trigeminal autonomic cephalalgias
from migraine: 16, 26 (Level 4)
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Onset: rapid in TAC, gradual in migraine
Duration: TACs < 3 hours, migraine 4 - 72 hours
Frequency: multiple attacks may occur daily in TACs
Restlessness during an attack: 100% in cluster headache, 50% in
paroxysmal hemicrania
– Prominent ipsilateral autonomic features in TACs
• Features which differentiate trigeminal autonomic cephalalgias from
each other and from trigeminal neuralgia are listed in Annex 2
Diagnosis Summary
• Key question is impact
• Default diagnosis for intermittent headache
is migraine(Landmark study 90%)
• Migraine v Cluster imagine typical patient
• Chronic headache consider medication
overuse
Objective 3
Headache Management
Non-pharmacological therapies
• Behavioural treatments include:
– stress management / relaxation
training
– regular diet and sleep
– trigger identification and
avoidance
– avoidance of excessive over-thecounter medications
• Physical treatments include:
– natural remedies /
complementary medicines
– acupuncture
– transcutaneous electrical nerve
stimulation
– occlusal adjustment
– cervical manipulation
Adapted from US Headache Consortium Headache Guidelines
Acute pharmacological therapies
Drug class
Drug name
Analgesics
Aspirin 900 mg, ibuprofen 400mg
5-HT1B/1D agonists
Almotriptan, eletriptan, frovatriptan, naratriptan,
rizatriptan, sumatriptan ,zolmitriptan
(Triptans)
antiemetics
Domperidone, prochloroperazine
Avoid opioids
Management Summary
• Provide acute medication to all migraine
patients and recommend it is taken early
• Provide rescue medication
• Tailor treatment to the individual
• Prophylactic Rx if high impact
• Lifestyle management important
Objective 4
Audit
Useful Information
Ideas for Audit
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Number of Migraineurs
Assess migraine impact and lost time
Migraine awareness campaign
Medication Overuse awareness
Reassess impact and lost time
Migraine Resources
• British Association for the Study of
Headache
www.bash.org/
• Migraine Action Association
www.migraine.org.uk/
• www.sign.ac.uk
Objective 5
Case Study
Migraine and Sickness absence
• Triggers
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Long hours
Stress
Sleep disturbance
Missing meals
Travel/jet lag
Office lighting
Hormones
• Disabling headache
and ? DDA
• Reasonable
adjustments eg dark
room, lie down, flexi
time,
• No medication 100%
effective, acute
treatment side effects
Case Study
• ITU nurse aged 28 with chronic migraine
and medication overuse headache
• Issues include
– Shift work affecting sleep, diet, exercise
– Work pressures, short staffed, studying for
exam, often lack of senior staff, management
attitude to sick leave, lack of
understanding/empathy from colleagues
Any Questions?