Transcript Clinical case scenarios (slide set)

Headaches
Clinical case scenarios
for group discussion
Support for education and learning
2nd Edition – January 2016
What this presentation covers
•
Introduction to clinical case scenarios
•
Background
•
NICE Pathway
•
The cases
•
NICE Evidence
•
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Clinical case scenarios
Each scenario includes details of the patient’s initial presentation.
The clinical decisions about diagnosis and management are then
examined using a question and answer approach.
Relevant recommendations from the NICE guideline
are quoted in the notes and additional information and detail from the
full guideline is added to answers.
These clinical case scenarios form part of a package of education and
learning materials which include an Academic detailing aid and
Diagnosis poster to support CG150, Headaches.
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Background: Headaches
Headaches are one of the most common neurological problems
presented to GPs and neurologists.
Most common primary headache disorders are tension-type headache,
migraine and cluster headache.
Improved recognition of primary headaches will help the generalist
clinician to manage headaches more effectively, allow better targeting
of treatment and potentially improve quality of life and reduce
unnecessary investigations for people with headache.
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NICE Pathways
The NICE Headaches Pathway
shows all the recommendations
in the Headaches guideline.
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Learning objectives
The learning objectives for these clinical case scenarios are to improve
knowledge on:
• how to manage acute migraine.
• best practice for migraine prophylaxis (including migraine
prophylaxis for women and girls of childbearing potential).
• treating cluster headaches, including the key points about
ordering home and ambulatory oxygen.
• where to find information for patients on acute
migraine, migraine prophylaxis and cluster headaches.
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Case scenario 1
Joseph, acute migraine
(paediatric)
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Presentation
Joseph is a 14-year-old boy. He attends your clinic accompanied by his
mum, Claire. He presents with a 2-month history of headaches that he
describes as “banging” and that make his head “very very sore”. He
says that in the past 2 months he has had 6 of these headaches. He
also says that light hurts his eyes when he has the headaches. He
does not feel nauseous or vomit during the headaches.
Claire tells you that when Joseph has the headaches he is unable to go
to school and that the headaches last from 2 to 4 hours. She gives
Joseph paracetamol and if that doesn’t work she also gives him
ibuprofen. Joseph reports that this combination of medication helps but
that it still hurts a lot until the headache eventually goes completely.
Joseph and Claire ask if Joseph’s headaches are migraines and
if there is anything more he can take to ease the pain and
reduce the amount of time he is taking off school.
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1.1 Question
Based on the history provided, and using the diagnosis poster as a
quick reference to recommendations in section 1.1 and 1.2 of the
guideline, you diagnose migraine without aura.
Claire asks what this means for Joseph.
How would you answer this?
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1.1 Answer
You would explain the diagnosis to Claire and Joseph and reassure
them that a serious underlying cause is unlikely, based on Joseph’s
history and your examination of him, which showed no abnormalities.
You would tell them that migraines are a well-recognised problem
although what causes them is not known for certain. You would
reassure Claire and Joseph that you appreciate the large impact the
headaches are having on Joseph’s life. You would give them written
information about migraine in a format suitable for both, and include
information about support organisations (see information in notes).
Given that Joseph is likely to have recurrent migraines that will need
treatment, you would explain the risk of medication overuse headache.
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1.2 Question
For acute management of Joseph’s migraine, you would tell Joseph
and Claire that Joseph could have nasal sumatriptan, to take along with
a non steroidal anti-inflammatory or paracetamol.
However, Claire is concerned about Joseph taking 2 drugs and asks if
there is an option for him to take just 1 drug.
How would you answer this?
At the time of publication of these cases (January 2016), only nasal sumatriptan had a UK
marketing authorisation for this indication in people aged 12 to 18 years
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1.2 Answer
You would tell Claire and Joseph that adding nasal sumatriptan, to
paracetamol or a non steroidal anti-inflammatory would be the most
effective option for relieving his migraines, but that Joseph could try
taking just nasal sumatriptan to see whether it works better than
paracetamol or ibuprofen. You would explain that the triptan would
come as a nasal spray because it is not usually prescribed in tablet or
capsule form for people aged under 18.
You would tell Claire and Joseph that the other option would be
monotherapy with either paracetamol or NSAID and you would ensure
that the dose was optimised.
However, since Joseph has already tried both of these drugs
and they didn’t work well enough, triptan would be a
suitable option for him to try next.
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1.3 Question
Claire asks what they should do if the nasal triptan doesn’t work and
whether there are there alternative medications.
a) How would you answer this?
b) What tool could you use to help assess the effectiveness of the
nasal triptan?
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1.3 Answer
a) You would explain that Joseph should try the sumatriptan nasal
spray for at least 3 headaches because it isn’t possible to tell
whether it’s working based on just 1 headache. If it still doesn’t work
well enough then they should return to you and you would offer
combination therapy with nasal sumatriptan, and a non steroidal
anti-inflammatory. You explain that it is a case of finding out which
type of treatment works best for Joseph.
b) You could give Joseph a headache diary containing prompts for him
to record the frequency, duration and severity of his headaches as
well as his response to the triptan. You would explain to Joseph and
Claire that keeping the diary will help them to learn more about his
migraines (See next slide).
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1.3 Answer (headache diary)
Headache diaries are more accurate than recall and allow patterns of
events to be more clearly seen. They also play an important role in
acknowledging the impact of headache. Keeping the diary will help the
patient to learn more about their migraines, for example whether they
occur in patterns and whether they are triggered by anything in
particular. The diary will also enable them to record any changes in
how often the migraines happen, how painful they are, how well the
treatments for them are working and any side effects from the
treatments.
You would use this information in the standard review you carry out
after starting or changing treatment.
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1.4 Question
Claire and Joseph thank you for your help and leave. As you are
reflecting on Joseph's case, you think about other treatment
options that might be suitable for Joseph if the triptan nasal spray
doesn’t work well enough for him.
What other treatment options would be available?
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1.4 Answer
You could try combination of the nasal sumatriptan with paracetamol.
Alternatively you might then consider trying a different formulation of
nasal triptan, triptan tablets or melts, but you would prefer not to
prescribe these for Joseph because they are usually only given to
people aged 18 and over.
In addition to different formulations of nasal triptan, or triptan tablets or
melts, you might consider adding an anti-emetic to Joseph’s treatment,
taking into account the risk of side effects and Joseph and Claire’s
preferences.
At the time of publication of these cases (January 2016), only nasal sumatriptan had a UK
marketing authorisation for this indication in people aged 12 to 18 years
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Case scenario 2
Anaka, migraine prophylaxis
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Presentation
Anaka is a 28-year-old woman who was diagnosed with migraine
with aura 6 months ago. She has, on average, 1 migraine attack
per week, for which she takes triptan, an NSAID and an antiemetic.
Because Anaka has migraine about 4 times per month, she is
unlikely to develop medication overuse headache. You are
therefore happy with her current treatment plan.
However, during an attack, she is unable to work or continue her
normal daily activities. She also worries a lot about when the next
attack is going to happen and their frequency causes her to take
a lot of time off work.
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2.1 Question
You note from Anaka's records that other than the medication
mentioned above she is not taking any other forms of medication.
You want to confirm that she is not a taking combined hormonal
contraceptive for contraception purposes. Why is this?
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2.1 Answer
There is an increased risk of ischaemic stroke in people with migraine
with aura. This risk is increased in women using combined hormonal
contraception.
Anaka confirms that she currently uses contraception but not a
combined hormonal contraceptive.
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2.2 Question
Anaka asks if there is anything that can be done to reduce the
frequency of her migraine attacks.
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2.2 Answer
You would tell Anaka about the option of prophylactic treatment.
Explain that prophylactic treatments prevent, rather than cure, a
condition, and that for migraines they aim to reduce the frequency,
severity and duration of the attacks.
You explain the risks and benefits of prophylactic treatment – ensuring
she understands her risk of migraine recurrence and severity, with and
without prophylaxis, and her risk of adverse effects.
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2.3 Question
The NICE guideline recommends offering topiramate or propranolol
and considering amitryptiline for the prophylactic treatment of migraine.
When discussing the most suitable prophylaxis for Anaka what
important information do you need to tell her about topiramate?
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2.3 Answer
Given that Anaka is of child bearing potential, it is important for her to
be aware that topiramate is associated with a risk of fetal
malformations.
Additionally, as Anaka has confirmed that she is currently using
contraception, she needs to be aware that there is potential for
topiramate to impair the effectiveness of hormonal contraceptives.
With Anaka's consent you arrange an appointment for her with the
contraceptive service so she can talk about the options for suitable
contraception if she were to take topiramate.
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2.4 Question
Following consultation with the contraceptive service, Anaka
decides that she does not want to use any of the contraceptives
that were recommended as suitable and reliable for use with
topiramate. You therefore suggest propranolol for migraine
prophylaxis.
a) How would you assess the effectiveness of the propranolol?
b) When would you review the need to continue this prophylaxis?
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2.4 (a) Answer
a) You would provide Anaka with a headache diary that contains
prompts to record the frequency, duration and severity of her
headaches as well as her response to the propranolol. Headache
diaries are more accurate than relying on a person’s memory, and allow
patterns of events to be more clearly seen. Diaries also play an
important role in acknowledging the impact of headaches.
You would advise Anaka to complete the diary in order to: understand
any patterns or triggers that may cause her symptoms; be more alert to
changes in the regularity or severity of her attacks; and learn the
effectiveness of any new medications she takes. It will also help inform
the standard review process, to assess the treatment’s effectiveness
and the presence of side effects after starting or changing a treatment
plan.
See next slide for answer 2.4 (b)
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2.4 (b) Answer
b) Continuing treatment when it is no longer needed puts the person at
risk of having side effects and drug interactions.
Experts agree that many people can stop prophylaxis after 6 months of
treatment and continue to benefit from the prophylactic treatment.
Therefore, you would review Anaka’s need to continue prophylactic
treatment at 6 months.
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2.5 Question
Anaka asks if there is anything else she can do or take, such as a
natural remedy, which could help reduce her migraine intensity. How
would you address this?
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2.5 Answer
You would tell Anaka that taking riboflavin (400 mg once a day) may
help to reduce her migraine frequency and intensity. You would tell her
that products containing riboflavin can be purchased from pharmacies
and health food stores.
You could also tell Anaka that if propranolol is unsuitable or ineffective
you will consider offering her a course of acupuncture.
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2.6 Question
Anaka tells you that her mum also takes treatment to prevent
migraines, but that she takes amitriptyline.
Anaka says amitriptyline works for her mum and asks why she has not
been offered it.
How would you answer this question?
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2.6 Answer
You would tell her that, following a review, NICE (a national
organisation that advises the NHS about the effective use of drugs)
recommends:
• offering prophylaxis with topiramate or propranalol
• considering treatment with amitriptyline
depending on the person’s clinical needs and their preferences.
You discuss the risks and benefits of amitriptyline so she can
consider treatment with this medicine as an alternative to topiramate
or propranolol.
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2.7 Question
If Anaka wants to become pregnant in the future, but still needs
migraine prophylaxis, what should you do?
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2.7 Answer
Migraine without aura often improves during pregnancy. However,
migraine with aura is more likely to continue throughout pregnancy.
If Anna becomes pregnant you should therefore assess whether she
needs prophylaxis during her pregnancy. If she does, then you would
seek specialist advice.
This could be advice over the telephone to avoid delaying a
prescription that would otherwise require a referral.
You would also review and discuss her use of triptan, NSAIDs and antiemetics, because of the risks associated with these medications
during pregnancy.
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2.8 Question
Anaka asks you if there is any reading she can do to learn more about
her condition.
a) In your discussion with Anaka, what information and support would
you provide as a minimum?
b) What further information would you provide to Anaka?
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2.8 Answer
a) As a minimum, you would explain to Anaka about her diagnosis and
reassure her that other pathology has been excluded. You would
reassure Anaka that this type of headache is a well-recognised
problem and that you understand that it is having a big impact on
her life.
b) You would provide Anaka with information (in a format suitable for
her) about headache disorders, including information about support
groups (see supporting information in notes).
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Case scenario 3
Malcolm, cluster headache
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Presentation
Malcolm is a 31-year-old man. He has a history of severe headaches,
which he says cause him the worst pain he’s ever felt. When he gets these
headaches, he has pain on 1 side of his head, around his eye and along
the side of his face. He also experiences drooping or swelling of the eyelid,
watery eye and nasal congestion, on the same side as the headache.
Malcolm experienced the severe headache for the first time 2 weeks ago
for which he went to accident and emergency, where he was given a CT
scan. The CT scan was normal and you have been asked to evaluate
Malcolm.
Malcolm tells you that, since his first severe headache 2 weeks ago, he
has experienced 6 more headaches. He says that on average his severe
headaches last from 30 to 90 minutes.
Based on Malcolm's history and using the diagnosis poster as a quick
reference to recommendations in section 1.1 and 1.2 of the guideline you
diagnose him with cluster headache.
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3.1 Question
What advice and support can you offer Malcolm about his diagnosis?
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3.1 Answer
At a minimum, you would explain the diagnosis and reassure Malcolm
that other pathology has been excluded.
You would also talk about the options for management (see case
continued) and reassure him that you recognise these severe
headaches are having a big impact on him.
You would also provide Malcolm with information about cluster
headache in a format suitable for him and include information about
support organisations (see information in notes).
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3.2 Question
When you ask Malcolm about how his attacks have been since his
admission to the emergency department, he becomes upset and says
that that they are very painful.
He asks if there is any more that can be done to reduce the pain during
attacks.
What interventions could help Malcolm during an attack?
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3.2 Answer
You would offer Malcolm subcutaneous or nasal triptan.
You need to make Malcolm aware that the nasal triptan does not have
UK marketing authorisation for this indication (correct at time of
publication of these case scenarios in January 2016).
Malcolm is concerned about injecting himself; therefore, you decide to
offer him nasal triptan. You document that Malcolm has consented to
this treatment.
You highlight that, if he is not receiving adequate relief with the nasal
triptan, you will meet with Malcolm again and talk about subcutaneous
triptan.
See next slide for answer 3.2 continued
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3.2 Answer continued
You would also assess Malcolm's medical history and note that he has
no history of respiratory disease or COPD.
You would offer Malcolm home and ambulatory oxygen.
As required, you would explain that during an attack he will need to use
a non-rebreathing mask and reservoir bag, and that the oxygen will be
running at a flow rate of at least 12 litres per minute.
The home oxygen is for use if he has an attack at home. The
ambulatory oxygen is for him to take out and use if he has an attack
while he is away from home (recognising that attacks happen at
unpredictable intervals). You would explain that this will allow
him to treat his attack at the earliest opportunity.
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3.3 Question
You are prescribing Malcolm the nasal triptan. How much should you
prescribe?
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3.3 Answer
Because of the frequent nature of attacks during a bout of cluster
headaches, it is important that Malcolm has an adequate supply of
medication to reduce the pain.
You would calculate this according to his history of cluster bouts and
based on the manufacturer’s maximum daily dose.
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3.4 Question
How will you order the oxygen for Malcolm?
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3.4 Answer
To order the oxygen you must complete a home oxygen order form
(HOOF). There are sections for ambulatory oxygen and long term or
short burst oxygen.
As well as ordering the oxygen, it is important to order the nonrebreathing mask (cushioned).
It is essential that all the necessary equipment has been delivered to
Malcolm to make sure he receives the prescribed oxygen.
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3.5 Question
What prophylaxis for cluster headache could you offer Malcolm?
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3.5 Answer
In order to reduce the frequency, severity and duration of attacks, you
consider offering Malcolm verapamil.
However, because of your lack of experience in using verapamil for
cluster headache, you consult a colleague who is a GP with a special
interest in headaches or neurology (or a consultant neurologist) for
guidance in using this medication before prescribing it.
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3.6 Question
What medications would you not offer Malcolm for the acute
management of his cluster headache attacks?
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3.6 Answer
You would not offer paracetamol, NSAIDS, oral triptans, ergots or
opioids as there is no evidence to suggest that they would have any
clinical benefit in the treatment of cluster headache.
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Case scenario 4
Nisha, acute migraine (adult)
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Presentation
You are an out-of-hours GP and have been called out to visit Nisha.
Nisha is a 48-year-old woman who was diagnosed with episodic
migraine 10 years ago. She is taking topiramate for prophylaxis and
takes an NSAID and oral triptan for acute treatment.
Nisha currently has a severe migraine with aura that started 60 minutes
ago.
She took her usual oral triptan and NSAID 50 minutes ago and her
migraine has not responded. Nisha has also vomited 6 times during
this attack; once just after taking the oral medication.
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4.1 Question
What other acute migraine treatment can you offer Nisha?
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4.1 Answer
Given that the oral preparations of NSAID and triptan were not effective
for Nisha, you offer her intramuscular metoclopramide or
prochlorperazine.
You also consider offering Nisha a non-oral NSAID or triptan; however,
you decide against this because Nisha has recently taken both of
these.
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NICE Evidence
Visit NICE Evidence for the best available evidence on all aspects of
Headaches.
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NICE Evidence
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Find out more
Visit www.nice.org.uk/guidance/CG150 for:
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the guideline
Information for the public
costing statement and template
baseline assessment tool
academic detailing aid
diagnosis poster
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