Transcript Management_Guidelines 272KB PPT

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 patient’s 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
Intranasal or
subcutaneous triptan
If required
Oral triptan
If unsuccessful
Consider
alternative triptan
If unsuccessful
Frequent headache
(i.e. 4 or more
attacks per month)
Migraine
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
•Specific
consultation
•Treatment
history
•Patient
education,
counselling
and buy-in
Diagnosis
•Screen for
headache type
• Differentiate
migraine from
other
headaches
Assess
severity
•Attack frequency
and pain severity
•Impact on
patient’s life
(MIDAS / HIT)
•Non-headache
symptoms
•Patient factors
Treatment
plan
•Establish goals
•Behavioural
therapy
•Acute therapy
•Possible
prophylactic
therapy
•Alternative
therapy?
Follow-up
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
sufferer’s 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
low
ATTH
High
Q2. No. of headache
days per month
Migraine/CDH
> 15
< 15
Consider short-lasting
headaches
Chronic headache
Q3. Analgesic
days/week
<2
Not analgesic
dependent
Migraine
Q4. Reversible
sensory symptoms
>2
Analgesic
dependent
Yes
With aura
No
Without aura
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
Headaches moderate or
severe in intensity
Non-headache symptoms
not severe in intensity
Significant non-headache
symptoms, possibly
severe
Impact not significant:
MIDAS Grade I or II
HIT Grade 1 or 2
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
Staged care for migraine
Migraine
diagnosis
Severity
assessment
Mild to moderate migraine
Moderate to severe migraine
Initial therapy
Initial therapy
If unsuccessful
Rescue
Rescue
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
N – NO HEADACHE
G – MILD HEADACHE
M – MODERATE HEADACHE
S - SEVERE HEADACHE
THURSDAY
FRIDAY
SATURDAY
SUNDAY
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
1
Menstrual bleeding
Time of onset
- first symptom (specify)
- headache
Time of resolution
- headache
- last symptom (specify)
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)
2
3
4
5
6
7
8
9
etc
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
Community nurse
Practice
nurse
Optician
Ancillary
staff
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
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
Initial consultation
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
Oral triptan
If unsuccessful
Oral triptan
Rescue
Follow-up treatment
Alternative oral triptan
Nasal spray/subcutaneous
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 patient’s 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