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  • 1. 18 Week Commissioning Pathway Persistent/Atypical Headache (Version 1.0) Supplementary Information Patient Information 1.1.1 Description: Visual disturbance, nausea and/or vomiting, photophobia, neck symptoms 1.1.2 Metric (Incidence & Prevalence): Migraine – 12% and Chronic daily headache 4% of general population. Ref: Dowson AJ & Cady RK ‘Rapid Reference to Migraine’, London, UK: Mosby, 2002. Other headaches (such as sinister, cluster and headaches associated with the elderly) are less prevalent. Arrow to Primary Assessment Oval 1.3.1 Red Flags: RED FLAGS Age <5 or >50 yrs, new onset headache (history <6 months), very acute headache, atypical or isolated symptoms or abnormal (focal) neurological exam, papilloedema, symptoms – rash non-resolving neuro deficit, vomiting, pain or tenderness (including scalp tenderness), accident or head injury, infection, hypertension, personality changes, history of cancer. Primary Assessment Information 18 Week Clock Events: See Clock symbols and references next to the relevant section of the pathway. Only applies ‘if referred or likely to be referred to a Consultant led service’ regardless of setting. Clock starts on receipt of referral. See updated 18 week clock rules published December 2006 (paragraph 8). Clinical Guidelines: www.mipca.org.uk for various MIPCA guidelines; www.bash.org.uk for BASH guidelines. Primary Assessment (e.g. Primary Care) Oval 2.2.1 History: Answer Yes to any of the following – Does the headache interfere with daily activities? Has the pattern of headache changed recently? Are the headaches frequent? Are headache treatments ineffective? Identify potential red flag symptoms for referral: Age <5 or >50 yrs, new onset headache (history <6 months), very acute headache, atypical or isolated symptoms or abnormal (focal) neurological exam, papilloedema, symptoms – rash, non-resolving neuro deficit, vomiting, pain or tenderness (including scalp tenderness = suspected cranial arteritis), accident or head injury, infection, hypertension, personality changes, history of cancer. Arrow to Primary Assessment Diagnostics 2.5 Diagnostic Thresholds: Presence of clinically meaningful headache 2.6 Decision Aids: International Headache Society (HIS) criteria; inclusive questionnaires (e.g. Diagnostic Screening Questionnaire (DSQ); exclusive questionnaires (e.g. ID Migraine for migraine) Issue 1 – April 2008 Notes on using the 18 Week Pathway This supplementary information should be used in conjunction with the 18 Week Pathway and contains important additional information.
  • 2. 18 Week Commissioning Pathway Persistent/Atypical Headache (Version 1.0) Supplementary Information Primary Assessment Diagnostics (with agreed diagnostics thresholds) 2.7.2 ESR/CRP: Do urgently if cranial arteritis suspected: ESR – Erythrocyte sedimentation rate; CRP – C Reactive Protein. Cranial arteritis – risk of blindness (particularly onset headaches >60 years). Arrow to Primary Assessment and Definitive Treatments 2.8.2 Decision Aids: Toolbox of specific disability, QOL and outcome questionnaires. Primary Assessment Definitive Treatments (with agreed treatment thresholds) 2.9.1 Reassurance, Information & Self-Help: Provision of oral advice, leaflets; websites; patient support organisations (Migraine Action Association for all headaches & organisation for the understanding of cluster headaches; any local expert patient programme); lifestyle strategies (e.g. trigger avoidance, stress reduction) and behavioural/ physical therapies (e.g. relaxation, exercise). 2.9.2 Watchful Waiting: Headache diary and impact questionnaires, medication review 2.9.3 Physical/Psychological Treatment: TTH – Episodic tension-type headache. 2.9.4 Medication: Mild-to-moderate migraine – treat with analgesic plus oral triptan as rescue. Moderate-to- severe migraine – treat with oral triptan, plus oral, nasal spray or subcutaneous triptan as rescue. Additional preventative therapy for certain migraine patients. Chronic – preventive drugs. Arrow to Specialist Assessment Oval 2.11.1 Red Flags: RED FLAGS Age <5 or >50 yrs, new onset, headache (history <6 months), very acute headache, atypical or isolated symptoms or abnormal (focal) neurological exam, papilloedema, symptoms – rash, non-resolving neuro deficit, vomiting, pain or tenderness, accident or head injury, infection, hypertension, personality changes, history of cancer. 2.11.3 Decision Aids: Refer or seek advice for ineffective management of benign headaches, chronic migraine/ TTH with medication overuse, other chronic headaches (Hemicrania continua; NDPH; Primary stabbing; Hypnic; Cluster; Chronic paroxysmal hemicrania; SUNCT) and TTH with significant comorbidities to Specialist service. Issue 1 – April 2008 Notes on using the 18 Week Pathway This supplementary information should be used in conjunction with the 18 Week Pathway and contains important additional information.
  • 3. 18 Week Commissioning Pathway Persistent/Atypical Headache (Version 1.0) Supplementary Information Specialist Assessment Information 18 Week Clock Events: See Clock symbols and references next to the relevant section of the pathway. Clock stops only if treatment is expected to be the definitive treatment and no further treatment x is planned. The clock stops when treatment commences. See updated 18 week Clock rules published in December 2006. Clinical Guidelines: Scanning and other investigations. The need for investigations in patients with headache evidence-based recommendations from the Migraine in Primary Care Advisors (MIPCA) for the GP and GP with Special Interest in Headache (GPSIH) – article in draft for submission. Workforce and Equipment: DH Guidelines for GPSI in headaches, 2003 & GPSI competency framework by MIPCA and RCGP (submitted for publication). DH Guidelines for appointment of GPSI in delivery of clinical services: headache, April 2003; MIPCA – Migraine in Primary Care Advisors; RCGP – Royal College of General Practitioners. Arrow to Specialist Assessment Diagnostics 3.5 Decision Aids: Locally agreed protocols if Tier 2 in primary care setting. Specialist Assessment Diagnostics (with agreed diagnostics thresholds) 3.6.2 CT/MRI scans: Brain tumour, subarachnoid haemorrhage, Chronic subdural haematoma, Meningitis, plus BIH (benign intracranial hypertension), papilloedema. Debate needed on imaging thresholds, but includes high anxiety patients who are not reassured, also what appropriate for CT vs MRI – views?? Most chronic headaches are primary, and do not require any imaging. Red Flags are: 1. New onset >50 years 2. Increasing frequency and severity 3. Headache that wakens patient 4. Associated unexplained neurological symptoms, e.g. dizziness, in coordination, tingling, numbness 5. History of malignancy Framework for Primary Care Access to Imaging Arrow to Subspecialist Assessment Oval 3.10.1 Red Flags: RED FLAGS Age <5 or >50 yrs, new onset, headache (history <6 months), very acute headache, atypical or isolated symptoms or abnormal (focal) neurological exam, papilloedema, symptoms – rash, non-resolving neuro deficit, vomiting, pain or tenderness, accident or head injury, infection, hypertension, personality changes, history of cancer. Issue 1 – April 2008 Notes on using the 18 Week Pathway This supplementary information should be used in conjunction with the 18 Week Pathway and contains important additional information.
  • 4. 18 Week Commissioning Pathway Persistent/Atypical Headache (Version 1.0) Supplementary Information Subspecialist Assessment Information 18 Week Clock Events: See Clock symbols and references next to the relevant section of the pathway. Clock stops only if treatment is expected to be the definitive treatment and no further treatment is planned. The clock stops when treatment commences. See updated 18 week Clock x rules published December 2006. Specialist Assessment Diagnostics (with agreed diagnostics thresholds) 4.6.2 CT/MRI: Brain tumour, subarachnoid haemorrhage, Chronic subdural haematoma, Meningitis, plus BIH (benign intracranial hypertension), papilloedema. Debate needed on imaging thresholds, but includes high anxiety patients who are not reassured, also what appropriate for CT vs MRI – views?? Issue 1 – April 2008 Notes on using the 18 Week Pathway This supplementary information should be used in conjunction with the 18 Week Pathway and contains important additional information.