MIGRAINE IN PRIMARY CARE ADVISORS Establishing new management guidelines for migraine in primary care

1. MIGRAINE IN PRIMARY CARE ADVISORS Establishing new management guidelines for migraine in primary care

2. Introduction • Evaluate currently available evidence • Gather evidence for new initiatives • Physical therapy • Food intolerances (YORK Labs study) • New therapies (e.g. Botox)

3. Existing MIPCA guidelines for migraine management1995Update 1998

4. Confirm diagnosis of migraine • Review previous treatments (including OTC) • Discuss pattern/frequency of attacks • Assess impact on the patient’s lifestyle • Initiate acute treatments for sufferers • experiencing up to 4 attacks per month Simple analgesic  anti-emetic Intranasal or subcutaneous triptan If required If sufferer has already tried analgesics (OTC or prescription) unsuccessfully Oral triptan If unsuccessful Consider alternative triptan If unsuccessful Consider prophylaxis + acute treatment for breakthrough migraine attacks Frequent headache (i.e. 4 or more attacks per month) Migraine If unsuccessful Chronic daily Headache (CDH)? Consider referral

5. Establishing new management guidelines for migraine in primary care Objectives • Update of the existing MIPCA guidelines • Identification and screening of patients in need of care • Development of new diagnostic tools and algorithms • Best management practice • Utilizing evidence-based medicine wherever possible

6. Starting points • What is required • Detailed history taking, patient education and buy-in • Diagnostic screening and confirmatory differential diagnosis • Management individualized for each patient • Prescribing only treatments that have objective evidence of favourable efficacy and tolerability • Prospective follow-up procedures to monitor the success of treatment • Specific consultations for headache and a team approach to management

7. Overall diagram for migraine management Management individualized for each patient Follow-up Treatment plan Assess severity Diagnosis Consultation • Attack frequency and pain severity • Impact on patient’s life (MIDAS / HIT) • Non-headache symptoms • Patient factors • Establish goals • Behavioural therapy • Acute therapy • Possible prophylactic therapy • Alternative therapy? Assess outcome of therapy • Specific consultation • Treatment history • Patient education, counselling and buy-in • Screen for headache type • Differentiate migraine from other headaches

8. Processes • First consultation • Screening • Patient education and buy-in • Diagnosis • Assessment of illness severity • Implementation of initial treatment plan • Follow-up consultations • Monitor success of therapy and modify treatment if necessary

9. Screening procedures: history taking, patient education and buy-in Taking a careful history is essential • Use of a headache history questionnaire is recommended • Patient education • Advice, leaflets, websites and patient organisations (Migraine Action Association) • Patient buy in • Patients to take charge of their own management • Effective communication between patient and physician

10. Careful diagnosis • Proposal: the IHS diagnostic criteria are too complex for everyday use in primary care • MIPCA has developed a simple but comprehensive scheme for the differential diagnosis of headache subtypes • Diagnosis can then be confirmed with additional questions

11. Four-item questionnaire A. Consider sinister headaches • What is the impact of the headache on the sufferer’s lifestyle? (screens for migraine/chronic headaches and ATTH) • How many days of headache does the patient have every month? (screens for migraine and chronic headaches) B. Consider short-lasting chronic headaches

12. Four-item questionnaire • For patients with chronic daily headache, on how many days per week does the patient take analgesic medication? (screens for analgesic-dependent headaches) • For patients with migraine, does the patient experience reversible sensory symptoms associated with their attacks? (screens for migraine with aura and migraine without aura)

13. Consider sinister headache Patient presenting with headache Q1. Headache impact low ATTH High Migraine/CDH Q2. No. of headache days per month > 15 < 15 Migraine Consider short-lasting headaches Chronic headache Q3. Analgesic days/week Q4. Reversible sensory symptoms <2 >2 Yes No With aura Without aura Analgesic dependent Not analgesic dependent

14. Management individualized for each patient Assess illness severity • Attack frequency and duration • Pain severity • Impact • MIDAS/HIT questionnaires • Non-headache symptoms • Patient factors • History, preference and other illnesses

15. MIDAS Questionnaire

16. HIT-6™ Questionnaire

17. Assessment of severity

18. Provision of individualized treatment plan Evidence-based medicine (Duke database) suggests: • Behavioural therapy recommended for all • Acute therapy recommended for all • Prophylactic therapy recommended for certain patients • Alternative treatments may be useful as adjunctive therapy

19. Individualizing care – behavioural and physical therapy Recommended therapies • Behavioural: • Biofeedback and relaxation • Stress reduction • Avoidance of triggers • Food intolerances under investigation by MIPCA • Physical • Cervical manipulation • Massage • Exercise

20. Individualizing care – acute medications • Acute medications should be provided for all patients • Goals: to rapidly relieve the headache and other symptoms, and permit the return to normal activities • Strategy: staged care, patients have a portfolio of medications to treat attacks of differing severities, and have access to rescue medications if the initial therapy fails

21. Staged care for migraine Migrainediagnosis Severityassessment Mild to moderate migraine Moderate to severe migraine Initial therapy Initial therapy If unsuccessful Rescue Rescue

22. Acute medications: treatments • Mild-to-moderate migraine • Initial therapies • Aspirin or NSAIDS (high doses) • Aspirin/paracetamol plus anti-emetics • Paracetamol plus isometheptene • Use if possible before headache starts • Rescue medications • Oral triptans • Use for any headache severity

23. Acute medications: treatments • Moderate-to-severe migraine • Initial therapies • Oral triptans (tablet/ODT) • Use after the headache starts, if possible when it is mild in intensity • Rescue medications • Nasal spray or subcutaneous triptans • Symptom control

24. Caveats on triptan use • Most patients are effectively treated with an oral triptan • Differences between the oral triptans are small and of uncertain clinical significance • Patients with unpredictable or fast-onset attacks may benefit from ODT or nasal spray formulations • Patients with severe attacks may benefit from nasal spray or subcutaneous formulations • Subcutaneous sumatriptan is an effective rescue medication

25. Individualizing care – prophylactic medications • Prophylactic medications should be provided: • For patients with frequent, high-impact migraine attacks (4/month) • Where acute medications are ineffective or precluded by safety concerns • For patients who overuse acute medications and/or have CDH • Goals: to reduce headache frequency by >50% • However: acute medications should be provided for breakthrough attacks

26. Prophylactic medications: treatments • First-line medications: • Beta-blockers* (propranolol, metoprolol, timolol, nadolol) • Anticonvulsants (sodium valproate) • Antidepressants (amitriptyline) • Second-line medications • Serotonin antagonists* (pizotifen, methysergide, cyproheptadine)

27. Individualizing care – alternative therapies Recommended therapies • Feverfew • Magnesium • Vitamin B2 • Acupuncture • However: use only registered alternative practitioners

28. Follow-up procedures • Instigate proactive long-term follow-up procedures • Monitor the outcome of therapy • Headache diaries (new MIPCA diary) • Impact questionnaires (MIDAS/HIT) • Make appropriate treatment decisions

29. Headache diaries

30. MIPCA HEADACHE DIARY – 1 Record of headaches N – NO HEADACHE G – MILD HEADACHE M – MODERATE HEADACHE S - SEVERE HEADACHE Record here any treatments taken or any tablets of any type. How may tablets and how often did you take them?

31. MIPCA HEADACHE DIARY – 2 TRIGGERS Mark on here stressful events, foods, smells, unusual events, poor sleep, late mornings, late nights or any other possible trigger.

32. MIPCA HEADACHE DIARY – 3 TREATMENTS Record here any treatments taken or any tablets of any type. How may tablets and how often did you take them?

33. SELF-RATING YOUR MIGRAINE MANAGEMENT Please use your headache diary to help you complete these questions. This should help you to get the best care for your migraine. Rate your relief medication Please rate after 3 or more attacks Does your medication give some degree of relief in at least 2 migraines out of 3? Y/N Are you satisfied with your relief medication? Y/N If you answered No to either question, please see your doctor. Rate your preventative medication Please rate after 6 or more weeks Has your preventative medication at least halved the number of migraines you have per month? Y/N Are you satisfied with your preventative medication? Y/N If you answered No to either question, please see your doctor. Rate the impact of your migraine Does your migraine seriously interfere with your work and/or your leisure time? Y/N Does your migraine seriously interfere with your sense of psychological well-being? Y/N Do you have any other concerns which you think you should mention to your doctor? Y/N If you answered Yes to any question, please see your doctor.

34. Menstrual headache diary

35. Follow-up treatment decisions • Acute medications • Patients effectively treated should continue with the original therapy • Patients who fail on original therapy should be offered other therapies • Prophylactic medications • Ensure medication is provided for an adequate time period (3 months) • If effective, treatment can continue for 6 months, after which it may be stopped • If ineffective, another prophylactic medication may be tried • Patients refractory to repeated acute and prophylactic medications should be referred to a specialist

36. Implementation of guidelines • Primary care headache team • GP, practice nurse and receptionists (core team) • Pharmacist • Community nurses • Optician • Dentist • Alternative practitioners • Specialist physician (additional resource) Associate team members

37. Pharmacist Practice nurse Ancillary staff Community nurse Optician Primary care physician Specialist physician Dentist Alternative practitioner Patient Specialist care Primary care

38. New MIPCA algorithmInitial consultation and treatment

39. Detailed history, patient education and buy-in • Diagnostic screening and differential diagnosis • Assess illness severity • Attack frequency and duration • Pain severity • Impact (MIDAS or HIT questionnaires) • Non-headache symptoms • Patient history and preferences Initial consultation Intermittent mild-to-moderate migraine Intermittent moderate-to severe migraine Behavioural/alternative therapies Initial treatment Aspirin/NSAID (large dose) Aspirin/paracetamol plus anti-emetic Paracetamol plus isometheptane Oral triptan Rescue Rescue Nasal spray/subcutaneous triptan

40. New MIPCA algorithmFollow-up consultation and treatment

41. Initial treatment Initial treatment Aspirin/NSAID (large dose) Aspirin/paracetamol plus anti-emetic Paracetamol plus isometheptane Oral triptan If unsuccessful Follow-up treatment Alternative oral triptan Nasal spray/subcutaneous triptan Rescue Oral triptan If unsuccessful Frequent headache (i.e. 4 attacks per month) Consider prophylaxis + acute treatment for breakthrough migraine attacks Migraine If unsuccessful Chronic daily Headache (CDH)? Consider referral

42. ‘10 Commandments’ of headache

43. Screening/diagnosis • Almost all headaches are benign and should be managed in general practice. (However, monitor for sinister headaches and refer if necessary.)

44. Screening/diagnosis • The physician should use questions / a questionnaire assessing impact on daily living for diagnostic screening and to aid management decisions. (Any episodic, high impact headache should be given a default diagnosis of migraine and the diagnosis confirmed with further investigation.)

45. Management • Migraine management should be shared between doctor and patient. (The patient taking control of their management and the doctor providing education and guidance.)

46. Management • Migraine attacks are highly variable in frequency, duration, symptomatology and impact. (Therefore, provide staged care for migraine and encourage patients to treat themselves.)

47. Management • Follow-up patients, preferably with migraine diaries. (The patient should have permission to return for further management and the GP should apply a proactive policy.)

48. Management 6. Adapt migraine management to changes that occur in the illness and its presentation over the years. (e.g. migraine may change to chronic daily headache over time.)

49. Treatments 7. Acute medication should be provided to all migraine patients and taken as soon as possible after the migraine attack starts. (Triptans are the most effective acute medications for migraine. Avoid codeine and ergotamine if possible.)

50. Treatments 8. Prophylactic medications should be prescribed to patients who have 4 migraine attacks per month or who are resistant to acute medications. (First-line prophylactic medications are beta-blockers, sodium valproate and amitriptyline.)