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    Bash Guidelines Slides Bash Guidelines Slides Presentation Transcript

    • 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
    • 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
    • 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
    • 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
    • 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
    • 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
    • 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
    • The International Headache Society Classification
      • The International Headache Society (IHS) classifies headache disorders under primary and secondary conditions
      • Migraine
        • Without aura
        • With Aura
      • Tension-type Headache
        • Episodic
        • Chronic
      • Cluster Headache and other trigeminal autonomic cephalalgias
      IHS Classification Primary Headaches
    • 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
    • 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
    • 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?
    • 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
    • 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
    • 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
    • ‘ 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
    • Tension-type Headache (TTH)
      • TTH
        • Replaces ‘tension headache’ and ‘muscle contraction headache’
        • Typically generalized ‘vice like’ or ‘a tight band’
        • No nausea or photophobia
    • 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
    • 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
    • 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
    • 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
    • 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
    • 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
    • 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
    • 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
    • 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
    • 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
    • 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
    • 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
    • Migraine Acute Drugs
      • Five step treatment ‘ladder’
      • Failure on three occasions is the minimum criterion for moving to the next step
    • 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
    • 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
    • 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
    • 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
    • Migraine Acute Drugs 4
      • Step 4: Combinations
      • Steps 1+3 may be helpful, followed by Steps 2+3
      • Self-injected diclofenac may be tried
    • Migraine Emergency Treatment
      • Emergency treatment at home
      • NOT pethidine
      • Intramuscular diclofenac
        • and/or
      • Intramuscular chlorpromazine
        • Antiemetic and sedative
    • 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
    • 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
    • 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
    • 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
    • Migraine Prophylactic Drugs 3
      • Third-line
        • Gabapentin
        • Methysergide
        • Beta-blockers and amitriptyline (in combination)
    • Migraine Prophylactic drugs 4
      • Other options (limited efficacy)
        • Pizotifen
        • Verapamil
        • SSRIs
    • 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
    • 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
    • Migraine Non-drug Intervention
      • Improving physical fitness
      • Physiotherapy (but no evidence)
      • Acupuncture
      • Psychological therapy
        • Relaxation
        • Stress reduction
        • Coping strategies
        • Biofeedback
    • Tension-type Headache (TTH) Management
      • Infrequent episodic TTH (<2 days/week)
      • Reassurance
      • Symptomatic treatment
        • Aspirin, paracetamol or ibuprofen
        • Codeine and dihydrocodeine should be avoided
      • 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
    • Tension-type Headache (TTH) Management
      • Non-drug interventions
      • Regular exercise
      • Physiotherapy
      • Stress-coping strategies
      • Acupuncture
    • Co-existing Headaches Management
      • Restrict symptomatic medication
        • Max 2 days per week
      • Prophylaxis for migraine coexisting with episodic TTH
        • Amitriptyline
        • Sodium valproate
    • 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
    • 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
    • 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