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Czech headache guidelines for general practitioners
Jolana Marková Thomayer University Hospital Prague
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Guideline concept
Guideline goal: Improve headache management by first-line physicians
Improvement diagnosis using appropriate tools Improve treatment
Increase awareness and interest of general practitioners in headache
Initiative of Czech GP society
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Guideline preparation
GP addressed CHS Identification of major issues to be covered
(based on GPs’ needs) Creation of joint team (GPs and neurologists) to
work on guidelines Guideline draft
Assessment by neurologists Assessment by GPs (not team members)
Final version of guidelines
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Guideline implementation
Establishmentof guideline team
First draft andpublic discussion
Final versionof guideline
Introduction of guidelines at the congress of GPsociety
Implementationof guideline
Managementaudit andfeedback to GPs
Implementationof findings andguidelineup-date
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Expectations of specialists
Neurologists' expectations: Higher awareness among first-line
physicians Improved diagnosis Improved management
Patients visit the specialist better diagnosed,in a shorter time after the appearance of headache
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Headache
Classification and Diagnostic Criteria for Headache Disorders (IHS)
Primary headache disorders 1–4
Secondary headache disorders 5–12
Cranial Neuralgias 13-14
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Headache Important features in headache history:
Attack onset Pain location Attack duration Attack frequency and timing Pain severity Pain quality Associated features
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Headachealarms
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Headache alarms
• Sudden-onset severe headache• Accelerating pattern of headache• Headache begins after the age of 50• Severe headache with fever and vomiting• Headache with focal neurological symptoms• Headache in patient with cancer or HIV
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Primary Headaches
• Migraine• Tension-type headache• Cluster headache• Trigeminal autonom. cephalalgias
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• Headache attributed to head and/or neck trauma• Headache attributed to vascular disorder• Headache attributed to non-vascular intracranial disorder• Headache attributed to a substance or its
withdrawal• Headache attributed to infection
Secondary Headaches
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• Headache attributed to homeostasis disorder• Headache or facial pain attributed to disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other cranial structure• Headache attributed to psychiatric disorder• Cranial neuralgias
Secondary Headaches
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Focus on practical applicability in first-line.
• Diagnosis of migraine• Treatment
• Acute migraine attack• Prophylactic treatment
• Follow up
Migraine
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Not only headache – combination of neurological, gastrointestinal and autonomic changes
Prodrome phaseAuraHeadache and asssociated symptomsHeadache resolution phase
Migraine-phases
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Complex of focal neurological symptoms- positive or negative phenomenaPrecedes or accompanies an attackLast less than 60 minutesVisual ( scotoma,color shapes,migration)SensoryMotorLanguage disturbances
Migraine- Aura
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Unilateral – hemicraniaSevere intensityThrobbing, pulsating characterAggravated by physical activityAccompanied with nausea, vomitingPhotophobia, phonophobia
Depression,fatigue, anxiety, irritabily are common in migraine patients
Migraine - headache
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ACUTE ATTACK TREATMENT:
• Mild forms: NSAID, ASA, Paracetamol and/or combinations with prokinetics• Moderate forms: Triptans• Severe forms: Triptans (incl. nasal spray, inj.) and prophylaxis
Migraine – therapy
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Since generic sumatriptan entered the Czech market it has been used widely by the majority of migraine patients.
Generic entry has also enabled GPs to prescribe effective medication at a lower price level.
Migraine – therapy
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PROPHYLACTIC TREATMENT:• Anticonvulsants (valproic acid, topiramat)• Beta-blockers• Calcium channel blockers• Antidepressants (tricyclics, SSRI)
Prophylactic treatment remains fully under the neurologist's competence. Indication is consistent with IHS criteria.
Migraine – therapy
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Introduction of adapted, simple questionnaire for use in first-line.
Own development as:• MIDAS perceived as rather complicated for
patients and physicians
• Interpretation often imprecise
Migraine – diagnosis
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Diagnostic scheme – migraine
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Impact of migraine questionnaireto assess disability level
“How much does headache negatively influenceyour daily activities (work, school, social activities, housework)”
Slightly, not much (mild migraine)Treatment: ASA, Paracetamol, NSAID, combination with
prokinetics
Moderately (moderate migraine) Treatment: Triptans
Significantly (severe migraine)Treatment: Triptans and prophylactics. Patient indicated for
specialist consultation.
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Pressing/tightening qualityMild or moderate intensityBilateral locationNo aggravation by walking stairsNo nausea or vomitingOften depression
High lifetime prevalence (70–90%)
Tension – type headache
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Acute treatment analgesics, NSAIDs, muscle relaxants
Prophylactic treatment antidepressants
– tricyclics, SSRI non-pharmacological treatment – relaxation, physical therapy techniques
Tension – type headache
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Subarachnoid hemorrhage
• sudden-onset severe headache• stiff neck• nausea, vomiting• alteration of consciousness• often beginning during physical activity
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• urgent admission to hospital• CT, lumbal puncture• neurosurgeon – consultation
• angiography• intervention • pharmacological treatment to prevent complications
Subarachnoid hemorrhage
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Headache in stroke patients
Various combinations of headache, focal neurological deficits and alteration of consciousness
• ischemic stroke • hemorrhagic stroke
Admission to hospital is needed in the shortest possible time in every stroke patient.
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Headache in patientswith brain tumor
• pain quality similar to tension-type headache, bilateral• neurological focal symptoms, epileptic seizure as an initial symptom • elevated intracranial pressure • personality changes
CT, MRI, neurosurgery
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Medication overuse headache
Headache often increase in frequency Patients develop a pattern of daily or nearly
daily headache with increasing medication use Simple analgetics, combined analgetics, NSA,
ergots, triptans, opioids High depression comorbidity Headache now is caused by medication
overuse
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Medication overuse headache
Headache present on more than 15days/month Pain is dull, presssing-tightening quality, mild or moderate intensity bilateral location no aggravation by walking stairs Substance intake on (10-15) days /months on a
regular basis for 3 months Headache has developed or markedly
worsened during substance overuse
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Medication overuse headache
Treatment Patient wants to stop with overuse stop substance intake completedly-
detoxification pain control with parenteral therapy estabilishment of effective prophylactic
treatment patient education estabilishment of outpatient methods of pain
control
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Cervicogenic headache
Occipital or suboccipital pain Neck tendrness a muscle spasms that may
produce pain Limitation of movementr or unusual postures Sensory abnormalities in the distribution of the
upper cervical roots
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Cervicogenic headache
Clinical, laboratory or imaging evidence of a disorder or lesion within the cervical spine or soft tissues of the neck
Headache is mostly unilateral Mild or moderate intensity nausea or vomiting sometimes No photo or phonophobia Sometimes vertigo or instability
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Cervicogenic headache
Treatment
NSA, myorelaxants, analgetics- only a short time
Antidepressants – tricyclics, SSRI Physioterapy Long term living style improvement
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Traumatic and post-traumatic headache
Acute posttraumatic headache Chronic posttraumatic headache Whiplash injury Headache attributed to traumatic intracranial
haematoma – epidural, subdural
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Traumatic and post-traumatic headache
Headache accompanied by other symptoms
Dizziness Difficulty in concentration Personality changes Sleep disturbances Anxiety Depression Vertigo
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Traumatic and post-traumatic headache
Diagnostic methods Clinical neurological examination Imaging – RTG, CT, MRI
Treatment Transport to the hospital Neurosurgery Intensive care
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Thank you for your attention