Upload
shinta-d-marlina
View
220
Download
0
Embed Size (px)
Citation preview
8/13/2019 Management Guidelines
1/54
MIGRAINE IN PRIMARY CARE ADVISORS
Establishing new management guidelines for
migraine in primary care
8/13/2019 Management Guidelines
2/54
Introduction
Evaluate currently available evidence
Gather evidence for new initiatives
Physical therapy
Food intolerances (YORK Labs study)
New therapies (e.g. Botox)
8/13/2019 Management Guidelines
3/54
Existing MIPCA guidelines for
migraine management
1995Update 1998
8/13/2019 Management Guidelines
4/54
Confirm diagnosis of migraine
Review previous treatments (including OTC)
Discuss pattern/frequency of attacks
Assess impact on the patients lifestyle
Initiate acute treatments for sufferers
experiencing up to 4 attacks per month
Simple analgesic
anti-emetic
Oral triptan
If sufferer has already
tried analgesics
(OTC or prescription)
unsuccessfully
Intranasal or
subcutaneous triptan
If required
Consider
alternative triptan
Consider prophylaxis +
acute treatment for
breakthrough migraineattacks
Frequent headache
(i.e. 4 or moreattacks per month)
Consider referral
Chronic daily
Headache (CDH)?
Migraine
If unsuccessful
If unsuccessful
If unsuccessful
8/13/2019 Management Guidelines
5/54
Establishing new management
guidelines for migraine in primary care
Objectives
Update of the existing MIPCA guidelines
Identification and screening of patients in need ofcare
Development of new diagnostic tools and
algorithms
Best management practice Utilizing evidence-based medicine wherever
possible
8/13/2019 Management Guidelines
6/54
Starting points
What is required
Detailed history taking, patient education and buy-in
Diagnostic screening and confirmatory differentialdiagnosis
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
8/13/2019 Management Guidelines
7/54
DiagnosisAssess
severity
Treatment
plan
Screen for
headache type
Differentiatemigraine from
other
headaches
Attack frequency
and pain severity
Impact onpatients life
(MIDAS / HIT)
Non-headache
symptoms
Patient factors
Establish goals
Behavioural
therapyAcute therapy
Possible
prophylactic
therapy
Alternative
therapy?
Consultation
Specific
consultation
Treatment
history
Patient
education,
counselling
and buy-in
Follow-up
Assess outcome
of therapy
Management individualized
for each patient
Overall diagram for migraine
management
8/13/2019 Management Guidelines
8/54
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 modifytreatment if necessary
8/13/2019 Management Guidelines
9/54
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
8/13/2019 Management Guidelines
10/54
Careful diagnosis
Proposal:the IHS diagnostic criteria are toocomplex 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 withadditional questions
8/13/2019 Management Guidelines
11/54
Four-item questionnaire
A. Consider sinister headaches
1. What is the impact of the headache on thesufferers lifestyle?
(sc reens fo r m igraine/ch ron ic headaches
and ATTH)
2. How many days of headache does the
patient have every month?(screens for m igraine and chronicheadaches)
B. Cons ider short -last ing ch ron ic headaches
8/13/2019 Management Guidelines
12/54
Four-item questionnaire
3. For patients with chronic daily headache,on how many days per week does thepatient take analgesic medication?
(sc reens fo r analgesic -dependen theadaches)
4. For patients with migraine, does the patientexperience reversible sensory symptomsassociated with their attacks?
(sc reens fo r m igraine w ith aura and
m igraine withou t aura)
8/13/2019 Management Guidelines
13/54
Patient presenting
with headache
Migraine/CDH
low
High
Q1. Headache impact
ATTH
Q2. No. of headache
days per month
> 15 < 15
Chronic headache
Q3. Analgesic
days/week
2
Not analgesic
dependent
Analgesic
dependent
Migraine
Q4. Reversiblesensory symptoms
With aura Without aura
Yes No
Consider sinister
headache
Consider short-lasting
headaches
8/13/2019 Management Guidelines
14/54
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
8/13/2019 Management Guidelines
15/54
MIDAS
Questionnaire
8/13/2019 Management Guidelines
16/54
HIT-6
Questionnaire
8/13/2019 Management Guidelines
17/54
Assessment of severity
Mild-to-moderate migraine Moderate-to-severe
migraine
Headaches mild-to-
moderate in intensity
Headaches moderate or
severe in intensity
Non-headache symptoms
not severe in intensity
Significant non-headache
symptoms, possibly
severeImpact not significant:
MIDAS Grade I or II
HIT Grade 1 or 2
Significant impact:
MIDAS Grade III or IV
HIT Grade 3 or 4
8/13/2019 Management Guidelines
18/54
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
8/13/2019 Management Guidelines
19/54
Individualizing carebehavioural 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
8/13/2019 Management Guidelines
20/54
Individualizing careacute medications
Acute medications should be provided for all
patients
Goals:to rapidly relieve the headache and
other symptoms, and permit the return tonormal 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
8/13/2019 Management Guidelines
21/54
8/13/2019 Management Guidelines
22/54
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
8/13/2019 Management Guidelines
23/54
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
8/13/2019 Management Guidelines
24/54
Caveats on triptan use
Most patients are effectively treated with anoral triptan Differences between the oral triptans are small
and of uncertain clinical significance
Patients with unpredictable or fast-onsetattacks may benefit from ODT or nasal sprayformulations
Patients with severe attacks may benefit
from nasal spray or subcutaneousformulations
Subcutaneous sumatriptan is an effectiverescue medication
8/13/2019 Management Guidelines
25/54
Individualizing careprophylactic
medications
Prophylactic medications should beprovided: For patients with frequent, high-impact migraine
attacks (4/month) Where acute medications are ineffective orprecluded by safety concerns
For patients who overuse acute medicationsand/or have CDH
Goals:to reduce headache frequency by
>50% However: acute medications should be
provided for breakthrough attacks
8/13/2019 Management Guidelines
26/54
Prophylactic medications:
treatments
First-line medications:
Beta-blockers* (proprano lol , metop rolol ,
t imo lol , nado lol)
Anticonvulsants (sodium valproate)
Antidepressants (amitr ipty l ine)
Second-line medications
Serotonin antagonists* (pizotifen,
methysergide, cyp roheptadine)
8/13/2019 Management Guidelines
27/54
Individualizing carealternative
therapies
Recommended therapies
Feverfew
Magnesium
Vitamin B2
Acupuncture
However: use only registeredalternative practitioners
8/13/2019 Management Guidelines
28/54
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
8/13/2019 Management Guidelines
29/54
Headache diaries
8/13/2019 Management Guidelines
30/54
MIPCA HEADACHE DIARY1
Record of headachesMONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY
NNO HEADACHE
GMILD HEADACHE
MMODERATE HEADACHE
S - SEVERE HEADACHE
8/13/2019 Management Guidelines
31/54
MIPCA HEADACHE DIARY2
TRIGGERS
Mark on here stressful events, foods, smells, unusual events, poor sleep,
late mornings, late nights or any other possible trigger.
MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY
8/13/2019 Management Guidelines
32/54
MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY
MIPCA HEADACHE DIARY3
TREATMENTS
Record here any treatments taken or any tablets of any type.
How may tablets and how often did you take them?
SELF RATING YOUR MIGRAINE MANAGEMENT
8/13/2019 Management Guidelines
33/54
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 attacksDoes 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 weeksHas 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.
8/13/2019 Management Guidelines
34/54
8/13/2019 Management Guidelines
35/54
Follow-up treatment decisions
Acute medications Patients effectively treated should continue with the original
therapy
Patients who fail on original therapy should be offered othertherapies
Prophylactic medications Ensure medication is provided for an adequate time period
(3 months)
If effective, treatment can continue for 6 months, after whichit may be stopped
If ineffective, another prophylactic medication may be tried
Patients refractory to repeated acute andprophylactic medications should be referred to aspecialist
8/13/2019 Management Guidelines
36/54
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
8/13/2019 Management Guidelines
37/54
Pharmacist
Community nurse
Optician
Dentist
Alternative
practitioner
Patient
Primary care
physician
Practice
nurse
Specialist
physician
Ancillary
staff
Primary care
Specialist
care
8/13/2019 Management Guidelines
38/54
New MIPCA algorithm
Initial consultation andtreatment
8/13/2019 Management Guidelines
39/54
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
Intermittent
mild-to-moderate migraine
Intermittent
moderate-to severe migraine
Aspirin/NSAID (large dose)Aspirin/paracetamol plus anti-emetic
Paracetamol plus isometheptane
Oral triptan
Nasal spray/subcutaneous
triptan
Initial consultation
Initial treatment
Rescue
Rescue
Behavioural/alternative therapies
8/13/2019 Management Guidelines
40/54
New MIPCA algorithm
Follow-up consultation andtreatment
8/13/2019 Management Guidelines
41/54
Aspirin/NSAID (large dose)
Aspirin/paracetamol plus anti-emetic
Paracetamol plus isometheptane
Oral triptan
Initial treatment
Follow-up treatment
Oral triptan
Alternative oral triptan
Nasal spray/subcutaneous
triptan
Rescue
If unsuccessful
Consider prophylaxis +
acute treatment for
breakthrough migraine
attacks
Frequent headache
(i.e. 4 attacks per month)
Consider referralChronic daily
Headache (CDH)?
Migraine
If unsuccessful
If unsuccessful
Initial treatment
8/13/2019 Management Guidelines
42/54
10 Commandments
of headache
8/13/2019 Management Guidelines
43/54
Screening/diagnosis
1. Almost all headaches are benign and
should be managed in general
practice.
(However, mon itor for sin ister
headaches and refer if necessary.)
8/13/2019 Management Guidelines
44/54
2. 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
shou ld be given a defaul t diagnos is of
m igraine and the diagnosis con f irmedw ith further invest igat ion .)
Screening/diagnosis
8/13/2019 Management Guidelines
45/54
Management
3. Migraine management should be
shared between doctor and patient.
(The pat ient taking contro l of their
management
and
the doctor provid ing education and
guidance.)
8/13/2019 Management Guidelines
46/54
Management
4. Migraine attacks are highly variable in
frequency, duration, symptomatology
and impact.
(Therefo re, p rovide staged care fo r
m igraine and encou rage patients to
treat th emselves.)
8/13/2019 Management Guidelines
47/54
Management
5. Follow-up patients, preferably with
migraine diaries.
(The patient should have perm ission
to return for fur ther management and
the GP shou ld apply a proact ive
policy.)
8/13/2019 Management Guidelines
48/54
Management
6. Adapt migraine management to
changes that occur in the illness and
its presentation over the years.
(e.g. m igraine may change to chronic
daily headache over time.)
8/13/2019 Management Guidelines
49/54
Treatments
7. Acute medication should be provided
to all migraine patients and taken as
soon as possible after the migraine
attack starts.
(Tr iptans are the most effect ive acu te
medicat ions for m igraine. Avoid
codeine and ergo tam ine i f poss ible.)
8/13/2019 Management Guidelines
50/54
Treatments
8. Prophylactic medications should be
prescribed to patients who have 4
migraine attacks per month or who
are resistant to acute medications.
(First-l ine prophylact ic medicat ions
are beta-b lockers, sod ium valproate
and amitr ipty l ine.)
8/13/2019 Management Guidelines
51/54
Treatments
9. Monitor prophylactic therapy
regularly.
8/13/2019 Management Guidelines
52/54
Treatments
10. Ensure that the mode of
administration of the medication is
practical for the patients lifestyle
and headache presentation.
8/13/2019 Management Guidelines
53/54
Outputs from the project
Complete guidelines published in
Current Med ical Research and
Opin ion
Summary article in Guidel ines in
Practice
Slide set for presentation Educational items on guidelines for
GPs and patients
8/13/2019 Management Guidelines
54/54
The future
Educational initiatives
Wider educational programmes for headache
services in primary care
Nurses
Research
GP specialists
Pharmacists
Physical therapy
Headache diaries
New treatments
Acute and prophylactic