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Bash Guidelines Slides

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