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Care Expectations:Bridging the Care of Migraine from the Clinic to the ED

Kimberly Hall-Oas, MSN, APRN, FNP-BC

Christopher McLarty, D.N.P., APRN, ACNP-BC

Disclosures

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Kimberly Hall-Oas, MSN, APRN, FNP-BCAPP Advisory Board Consultant

AllerganAPP Advisory Board Consultant

Supernus

Christopher McLarty, D.N.P., APRN, ACNP-BCNo Disclosures

Objectives

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1. Review the incidence and pathophysiology of migraine headache in the United States

2. Examine historical patterns of acute treatment options in the clinic and the emergency department (ED) setting, including the use of opioids

3. Explore current evidence based individual medication recommendations for treatment in the ED to include medication efficacy, adverse events, and availability of alternative

4. Identify strategies to communicate care expectations to patients, and other providers involved in the patient’s care

“ he seemed to see something shining before him like a light, usually in part of the right eye; at the end of a moment, a violent pain supervened n the right temple,

then in all the head and neck,

….vomiting, when it became possible, was able to divert the pain and render it more moderate”

Hippocrates (c. 460-c.370 B.C.)

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Introduction and Background

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• Major Public Health IssueGlobal incidence of Headache: 50%%

• Estimated approximately 50-75% of adult population ages 18 – 65 years suffered a headache at least once in the past year… of these 30% reported migraine.

• Headache 15 or more days / month affects 1.7 – 4% of global population

Incidence and Significance

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• World Health Organization (WHO) identifies :• Migraine as 8th highest cause of global years lost to disability (YLDs)

• Headache disorders collectively are 3rd highest cause of global YLD

• WHO ranked migraine as the 4th most disabling medical condition for women

World Health Organization, Lifting the Burden. “Atlas of Headache Disorders and Resources in the World 2011.” Geneva. World Health Organization. May, 2011

Migraine is more common than Asthma and Diabetes combined…

http://www.who.int/mental_health/management/atlas_headache_disorders/en/

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Headache

§One of most common reasons for visit to primary care

§ 70-80% of adults will suffer from headache over a lifetime

§38% of children suffer headaches

§Headache accounts for 4% of all office visits

§Headache accounts for 20% of work absences7

Pathophysiology

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Headache in the ED

§ Up to 4.5 % of ED visits are for HA

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Evolution in the Acute Management of Migraines

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Key Concern…. Primary or Secondary

• PRIMARY:

• Benign”

• Secondary to brain dysfunction

• NOT associated with underlying pathology

• SECONDARY:

• Sudden, Progressive

• Associated with pathology

• May require immediate Action

Headache in the ED : Acute Treatment

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First-line treatments in ED Recommendations

IV Metoclopramide 10-20 mg SHOULD offer

IV Prochlorperazine 10 mg SHOULD offer

SC Sumatriptan SHOULD offer

IV Acetaminophen 1 gram May offer

IV Acetylsalicyclic acid 0.5-1.8 gram May offer

IV Chlorpromazine 0.1-25 mg May offer

IV Dexketoprofen 50 mg May offer

IM Dicolfenac 75 mg May offer

IV Dipyrone 1 gram May offer

IM Droperidol 2.5-8.25 mg May offer

IV Haloperidol 5 mg May offer

IV, IM Ketorolac 30-60 mg May offer

New Medications on the Horizon !

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CGRP: Calcitonin-gene-related peptide

• A New Target : both acute and chronic implications

• Four products in pipeline ( Novartis, Amgen, Alder, Lilly, Teva) • PO, Sub Q, IV

• Results are Promising

• Availability anticipated summer of 2018

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Current Evidence Based Guidelines in the Emergency Department

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Triptans Formulations Doses Max daily Notessumatriptan(Imitrex)

Tablets Nasal sprayIntra-nasal powderSC injectionsSuppositoriesTransdermal

25, 50, 100 mg5, 20 mg11 mg4, 6 mg25 mg6.5 mg

200 mg40 mg44 mg12 mg50 mg13 mg (2 patches)

Off-label: ages 6+: SC 3-6 mg; max 12 mg/24h & ages 5+: Nasal spray max 40 mg/24h

zolmitriptan(Zomig)

TabletsOral dissolvingNasal spray

2.5, 5 mg2.5, 5 mg2.5, 5 mg

10 mg10 mg10 mg

FDA labeled ages 12+ Nasal spray max 10 mg/24h

rizatriptan(Maxalt)

TabletsOral dissolving

5, 10 mg5, 10 mg

30 mg30 mg

FDA labeled ages 6-17 (5-10 mg)

naritriptan(Amerge)

Tablets 1, 2.5 mg 5 mg Only triptan NOT contraindicated with MAOI, slower onset.

almotriptan(Axert)

Tablets 12.5 mg 25 mg FDA labeled ages 12-17 (6.25, 12.5 mg)

frovatriptan(Frova)

Tablets 12.5 mg 25 mg Longest half-life: 25 hr, slow onset

eletriptan(Relpax)

Tablets 20, 40 mg 80 mg

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Dopamine Antagonists

Prochlorperazine 5–10 mg oral, syrup 5 mg/mL, injection 5 mg/mL, suppositories 25 mg, 5–10 mg IV

Metoclopramide 5–20 mg oral, syrup 5 mg/mL, injection 5 mg/mL, 5–20 mg IV

Chlorpromazine 6.25–37.5 mg every 6 h IV or 25–100 mg oral

Droperidol 0.625–2.5 mg IV every 6 to 8 h, or 1.25–2.5 mg by injection

Haloperidol 2–5 mg IV; 1, 2, or 5 mg oral

Diagnostics in the ED: the role of Imaging

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Safety First with Differential …

§“SNOOP” § Systemic Symptoms (fever, weight loss) OR

§ Secondary risk factors ( HIV, Systemic cancer)

§ Neurologic symptoms or abnormal signs

§ (confusion, impaired alertness or consciousness )

§ Onset: sudden, abrupt, or split-second

§ Older: new onset and progressive headache

§ (especially in middle age / over 50)

§ Previous headache history: first headache or different (change I I n attack frequency, severity, or clinical features )

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What about Opioids?

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Communication Strategies

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Barriers to Collaborative Practice

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Bridging the Care Continuum

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Thankyou & Questions….

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