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  • 1. Guidelines for all doctors in the diagnosis and management of Migraine and Tension-Type Headache Writing Committee: T.J. Steiner E.A. MacGregor P.T.G. Davies 2004
  • 2. Headache in the UK
    • Affects nearly everyone occasionally
    • Is a problem for around 40% of people
    • Is one of the most frequent causes of consultation in both general practice and neurological clinics
    • Represents an immense socioeconomic burden
  • 3. Migraine in the UK
    • Affects 12-15% of the population
    • Affects 3X more women than men
    • Most troublesome late teens to early 50s
    • Also occurs in children and the elderly
  • 4. Migraine in the UK
    • An estimated 187,000 attacks every day
    • Almost 90,000 people absent from work or school as a result
    • Annual cost through lost work and impaired effectiveness may be £1.5 billion
    • Despite these statistics migraine seems to be under-diagnosed and under-treated
  • 5. Tension-type H eadache (TTH)
    • Affects up to 80% of people
    • Often referred to as a ‘normal’ or ‘ordinary’ headache by patients
    • Most do not consult a doctor
    • High prevalence results in a similar economic burden to migraine via lost work or reduced working effectiveness
    • 2-3% of adults have chronic TTH (i.e. TTH >15 days per month)
    • Chronic TTH can result in substantial disability and work absence
  • 6. British Association for the Study of Headache (BASH)
    • Management Guidelines
    • Intended for all doctors who manage headache - in general practice or specialist clinics
    • Provide management strategies supported by specialists in the field
    • Should be incorporated by healthcare commissioners into any agreement for provision of service
  • 7. British Association for the Study of Headache (BASH)
    • Headache management requires a flexible and individualized approach
    • BASH Guidelines can be tailored to individual clinical circumstances
  • 8. The International Headache Society Classification
    • The International Headache Society (IHS) classifies headache disorders under primary and secondary conditions
  • 9.
    • Migraine
      • Without aura
      • With Aura
    • Tension-type Headache
      • Episodic
      • Chronic
    • Cluster Headache and other trigeminal autonomic cephalalgias
    IHS Classification Primary Headaches
  • 10. IHS Classification Secondary Headaches
    • Headache attributed to
      • Head and/or neck trauma
      • Vascular disorders
      • Non-vascular intracranial disorders
      • A substance or its withdrawal
      • Infection
      • Disorder of homeostasis
      • Disorder of cranium neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or cranial structures
      • Psychiatric disorder
    • Cranial neuralgias an d central causes of pain
    • Headache unspecified/not classified
  • 11. Patient history The key to diagnosis
    • History is all-important
      • No diagnostic tests for primary headache
    • Patient diaries can help identify patterns of attacks and aid diagnosis*
    • Different headache types are not mutually exclusive
    • Take a separate history for each headache type
    • In children, migraine and tension-type headache may be less distinct than in adults
    * Assuming a condition requiring urgent attention has already been ruled out
  • 12. Headache history Key questions
    • TIME - Onset, frequency, patterns, duration?
    • CHARACTER - Site, intensity, nature of pain?
    • CAUSES - Predisposing, triggering, aggravating, relieving factors? - Family history?
    • RESPONSE - Patient’s actions and limitations during an attack? - Medications used?
    • INTERVALS - How does the patient feel between attacks? - Concerns, anxieties and fears about attacks?
  • 13. Migraine Diagnostic Pointers
    • Typically
    • Recurrent episodic headaches with moderate or severe pain
    • May be unilateral and/or throbbing
    • Last from 4 hours up to 3 days
    • Associated with gastrointestinal and visual symptoms
    • Activity is limited and dark/quiet is preferred
    • Free from symptoms between attacks
  • 14. IHS diagnostic criteria Migraine without aura*
    • An idiopathic recurring headache with:
    • A. At least 5 attacks fulfilling B-D B. Attacks last 4-72 hours C. At least 2 of the following - Unilateral location - Pulsating quality - Moderate or severe pain intensity - Aggravated by routine physical activity D. At least one of the following during an attack - Nausea and/or vomiting - Photophobia and phonophobia E. Not attributed to another disorder
    * In children, attacks may be shorter; also more commonly bilateral and GI disturbance is more prominent
  • 15. Diagnosis Migraine with aura
    • Aura precedes headache
    • Symptoms of migraine aura:
      • Transient hemianopic disturbances prior to headache, lasting 10-30 minutes (occasionally up to 1 hour)
      • A spreading scintillating scotoma (patients may draw a jagged crescent)
      • Other reversible focal neurological disturbances e.g. unilateral paraesthesiae of hand, arm or face
    • Visual blurring and ‘spots’ are not diagnostic
    • Patients may have attacks of migraine with aura and migraine without aura at different times
  • 16.  
  • 17. ‘ Diagnosis’ by treatment
    • Can be tempting to use the specific anti-migraine drugs as a diagnostic test
    • This approach is likely to mislead
      • Low sensitivity
        • ‘ Triptans’ are at best effective in only three quarters of attacks
      • Low specificity
        • TTH in migraineurs can respond to triptans
  • 18. Tension-type Headache (TTH)
    • TTH
      • Replaces ‘tension headache’ and ‘muscle contraction headache’
      • Typically generalized ‘vice like’ or ‘a tight band’
      • No nausea or photophobia
  • 19. Tension-type Headache (TTH)
    • Occasional TTH is seldom disabling (unlike chronic TTH)
    • Both TTH and migraine are aggravated by stress (so can be hard to differentiate)
    • Headache more often than once a week may be a mixture of TTH and migraine
    • Successful management is dependent on recognition and management of each separate headache type
  • 20. Chronic Daily Headache ( CDH )
    • CDH
      • A descriptive, not diagnostic, term
      • Headache occurs on more days than not (>50% of the time) over weeks or longer
      • Affects up to 4% of the population
      • Accounts for up to 40% of referrals to special headache clinics
      • Costs the UK economy up to £1 billion per year in lost working time yet is very poorly characterized
    • Headaches occurring every day are generally not migraine (but may co-exist with migraine)
    • CDH includes chronic TTH & Chronic Migraine
  • 21. Medication Overuse Headache (MOH)
    • Affects an estimated 1 in 50 people
    • First noted with phenacetin and ergotamine
    • Typically results from overuse of OTC analgesics
    • A related syndrome occurs with ‘triptans’
    • Accurate diagnosis is difficult in the presence of MOH
    • A detailed medication history is essential
  • 22. Cluster Headache (CH)
    • Formerly known as migrainous neuralgia
    • Generally affects men (ratio 6:1), often smokers, in their 20s or older
    • Typically occurs in bouts for 6-12 weeks every one or two years
    • Attacks typically occur at night, waking the patient 1 to 2 hours after falling asleep, lasting 30 to 60 minutes
    • Pain is intense, probably as severe as renal colic, and strictly unilateral
  • 23. Physical examination of headache patients
    • Physical examination can reassure patients
    • Optic fundi should always be examined
    • Blood pressure measurement is recommended
    • Examine head and neck for muscle tenderness, especially in tension-type headache
    • Examine jaw and bite
    • Some paediatricians recommend head circumference measurement for children, plotted on a centile chart
  • 24. Serious cause of headache 1
    • Intracranial tumours
      • Rarely produce headache until quite large
      • Epilepsy is a cardinal symptom
      • Loss of consciousness should be viewed very seriously
      • Focal neurological signs are generally present
      • Diagnosis harder in neurological ‘silent areas’ of the frontal lobes
    • Meningitis
      • Usually accompanied by fever and neck stiffness
      • Headache may be generalized or frontal (perhaps radiating to the neck)
      • Nausea and disturbed consciousness may accompany headache later
  • 25. Serious cause of headache 2
    • Subarachnoid haemorrhage (SAH)
      • Usually, sudden onset of very severe ‘explosive’ headache
      • Neck stiffness – may take hours to develop
      • Classical signs and symptoms may be absent in the elderly
      • Sometimes confused with migraine ‘thunderclap’ headache
      • Serious consequences of missing SAH call for a low threshold of suspicion
    • Temporal arteritis (TA)
      • Suspect if new headache in patients over 50 years
      • Headache accompanied by marked scalp tenderness
      • Headache persistent but often worse at night
      • Jaw claudication is highly suggestive of TA
  • 26. Serious cause of headache 3
    • Primary angle-closure glaucoma
      • Rare before middle age
      • Headache and eye pain can be dramatic or episodic and mild
    • Idiopathic intracranial hypertension
      • Formerly termed benign intracranial hypertension or pseudotumor cerebri
      • Rare cause, usually in obese young women
      • History may suggest raised intracranial pressure
      • Papilloedema is diagnostic in adults
      • Diagnosis confirmed by CSF pressure measurement
    • Carbon monoxide (CO) poisoning
      • Headache is a symptom of sub-acute toxicity
      • Uncommon but potentially fatal
  • 27. Migraine Management Overview
    • Aim for effective control of symptoms
      • A cure is unrealistic
    • Under-treatment is not cost-effective
      • Results in unnecessary pain and disability
      • Repeat consultations are expensive
    • Migraine typically varies with time
      • Needs may change
  • 28. Migraine Management Overview
    • Four elements to effective migraine management in adults
      • Correct and timely diagnosis
      • Explanation and reassurance
      • Identification and avoidance of pre-disposing/trigger factors
      • Drug or non-drug intervention
    • Children
      • Often respond to conservative migraine management
      • If this fails, most can be managed as adults
  • 29. Migraine Predisposing Factors
    • Predisposing factors are different from precipitating/trigger factors
    • Five main predisposing factors are recognized
      • Stress
      • Depression/anxiety
      • Menstruation
      • Menopause
      • Head or neck trauma
  • 30. Migraine Trigger Factors
    • Trigger factors are seen in occasional patients and include
      • Relaxation after stress: weekends/holidays
      • Change in habit: sleep, travel etc.
      • Bright lights/loud noise
      • Diet: alcohol, cheese, citrus fruits, possibly chocolate (but evidence is inconclusive); missed or delayed meals
      • Strenuous unaccustomed exercise
      • Menstruation
    • A trigger diary kept by patients can be useful unless causes introspection
  • 31. Migraine Acute Drugs
    • Five step treatment ‘ladder’
    • Failure on three occasions is the minimum criterion for moving to the next step
  • 32. Migraine Acute Drugs 1
    • Step 1: Oral analgesics ± Antiemetic
    • a) Simple analgesics, preferably soluble
      • Aspirin or paracetamol or ibuprofen
      • NOT codeine or dihydrocodeine
    • b) As above or prescription-only NSAID
    • plus prokinetic antiemetic
    • (metoclopramide or domperidone)
        • Contraindications:
        • Aspirin not recommended for children under 16
        • Metoclopramide not recommended for children or adolescents
  • 33. Migraine Acute Drugs 2
    • Step 2: Parenteral Analgesic ± Antiemetic
    • Diclofenac suppositories
    • Plus
    • Domperidone suppositories
          • Contraindications:
          • Peptic ulcer or lower bowel disease
          • Diarrhoea
          • Patient non-acceptance
  • 34. Migraine Acute Drugs 3(i)
    • Step 3: Triptans
    • Marked inter-patient variation in response – see which suits the patient best
    • Ineffective if taken before onset of headache
    • Some experts suggest adding metoclopramide or domperidone
    • Symptoms often relapse within 48 hours
        • Contraindications:
        • Uncontrolled hypertension
        • Risk factors for CHD or CVD
        • Children under 12 years
  • 35. Migraine Acute Drugs 3(ii)
    • Step 3: Ergotamine
    • Toxicity and misuse are potential drawbacks
          • Contraindications:
          • Ergotamine is not an option if triptans are contraindicated and should not be taken concomitantly with a triptan
          • Beta-blocker therapy
          • Not advised for children
  • 36. Migraine Acute Drugs 4
    • Step 4: Combinations
    • Steps 1+3 may be helpful, followed by Steps 2+3
    • Self-injected diclofenac may be tried
  • 37. Migraine Emergency Treatment
    • Emergency treatment at home
    • NOT pethidine
    • Intramuscular diclofenac
      • and/or
    • Intramuscular chlorpromazine
      • Antiemetic and sedative
  • 38. Migraine Repeated Relapse
    • Consider naratriptan, eletriptan or frovatriptan
    • Ergotamine
      • Prolonged duration of action
    • Diclofenac or tolfenamic acid may be used
      • Pre-emptively if relapse is anticipated
  • 39. Migraine Prophylactic Drugs
    • Prophylactic therapy is used (in addition to acute therapy) to reduce the number of attacks when acute therapy alone gives inadequate symptom control
    • Criteria for choice of prophylactic drug based on
      • Evidence of efficacy
      • Comorbidity and effect of drug
      • Contraindications, including risk of pregnancy
      • Frequency of dosing: once daily dosing is preferable
  • 40. Migraine Prophylactic Drugs 1
    • First-line
      • Beta-blockers (atenolol,metoprolol, prop r anolol, bisoprolol) if not contra-indicated
      • Amitriptyline – when migraine co-exists with
        • TTH
        • Another chronic pain condition
        • Disturbed sleep
        • Depression
  • 41. Migraine Prophylactic Drugs 2
    • Second-line
      • Sodium valproate
      • Topiramate
    • Evidence for sodium valproate is reasonable and clinical usage is extensive
    • Evidence for topiramate is very good but clinical usage is as yet limited
  • 42. Migraine Prophylactic Drugs 3
    • Third-line
      • Gabapentin
      • Methysergide
      • Beta-blockers and amitriptyline (in combination)
  • 43. Migraine Prophylactic drugs 4
    • Other options (limited efficacy)
      • Pizotifen
      • Verapamil
      • SSRIs
  • 44. Migraine Menstrual attacks
    • Perimenstrual prophylaxis
      • Non-hormonal
        • Mefenamic acid - first-line in migraine occurring with menorrhagia and/or dysmenorrhoea
      • Oestrogen
        • If the women has an intact uterus and is menstruating regularly, no progestogens are necessary
    • Combined oral contraceptives
      • Migraine without aura in pill-free interval may resolve with a more oestrogen-dominant pill
      • Not recommended for women with migraine with aura
  • 45. Migraine HRT
    • Migraine and hormone replacement therapy
    • The menopause itself commonly exacerbates migraine
    • Symptoms can be relieved with HRT
    • No evidence that risk of stroke is elevated or reduced by use of HRT in women with migraine
    • Some women on HRT find migraine worsens
      • Often solved by reducing dose and/or changing to non-oral formulation
  • 46. Migraine Non-drug Intervention
    • Improving physical fitness
    • Physiotherapy (but no evidence)
    • Acupuncture
    • Psychological therapy
      • Relaxation
      • Stress reduction
      • Coping strategies
      • Biofeedback
  • 47. Tension-type Headache (TTH) Management
    • Infrequent episodic TTH (<2 days/week)
    • Reassurance
    • Symptomatic treatment
      • Aspirin, paracetamol or ibuprofen
      • Codeine and dihydrocodeine should be avoided
  • 48.
    • Chronic TTH
    • Symptomatic treatment may give short-term relief but is inappropriate long-term
    • Consider a course of naproxen
      • May break the cycle
      • May stop overuse of analgesics
    • Amitriptyline is the prophylactic of choice
    Tension-type Headache (TTH) Management
  • 49. Tension-type Headache (TTH) Management
    • Non-drug interventions
    • Regular exercise
    • Physiotherapy
    • Stress-coping strategies
    • Acupuncture
  • 50. Co-existing Headaches Management
    • Restrict symptomatic medication
      • Max 2 days per week
    • Prophylaxis for migraine coexisting with episodic TTH
      • Amitriptyline
      • Sodium valproate
  • 51. BASH Guidelines Effects of Implementation
    • Improve diagnosis
    • Increase the number of patient with migraine using triptans
    • Reduce misuse of medication, including triptans
    • Reduce the need for specialist referral
    • Improve the overall effectiveness of headache management
    • Reduce inappropriate treatment
    • Improved treatment for each patient
    • Improve outcome
    • Reduce iatrogenic illness
    • Reduce disability
  • 52. BASH Guidelines Effects of Implementation
    • Initially increases the no. of consultations per patient
    • BUT
    • Reduces the overall number of consultations
    • Raises expectations, especially amongst those with migraine, leading to more patients consulting
    • BUT
    • Reduces the overall burden of illness, with savings elsewhere
  • 53. Audit Judging Effectiveness
    • Aims of Audit
      • To measure direct treatment costs
        • Consultations, referrals and prescriptions
      • To measure headache burden
        • Before and after implementation of BASH guidelines
    • Migraine Disability Assessment (MIDAS) may be useful in the audit process
      • A self-administered questionnaire
      • Measures the adverse effect of headache on work and social activities over the preceding 3 months