headaches-clinical-case.pdf

Headaches

Clinical case scenarios for GPs and practice nurses

NICE clinical guideline 150

September 2012

Support for education and learning

Clinical case scenarios: Headaches September 2012 of 38

These clinical case scenarios accompany the clinical guideline: 'Headaches'

(available at www.nice.org.uk/guidance/CG150).

Issue date: September 2012

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© National Institute for Health and Clinical Excellence, 2012. All rights reserved. This

material may be freely reproduced for educational and not-for-profit purposes. No

reproduction by or for commercial organisations, or for commercial purposes, is

allowed without the express written permission of NICE.

This is a support tool for implementation of the NICE guidance.

It is not NICE guidance.

This resource has been developed to illustrate the application of the recommendations in ‘Headaches’ (NICE clinical guideline 150) in practice and should only be used to support learning. Patients' needs should be assessed holistically, and it is acknowledged that they may have needs beyond the scope of these case studies. These cases do not reflect treatment plans for actual patients and should not be used as such. If an individual clinician has any queries or concerns about the relationship between NICE guidance and this educational resource they should always refer to the original guidance published by NICE, and this should in all cases be regarded as the only definitive statement of the guidance.

Implementation of the guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement this guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have regard to promoting equality of opportunity. Nothing in the guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

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Contents

Contents ............................................................................................................. 3

Introduction......................................................................................................... 4

NICE clinical case scenarios ........................................................................... 4

Headaches ...................................................................................................... 5

Learning objectives ......................................................................................... 6

Clinical case scenarios for GPs and practice nurses .......................................... 7

Case scenario 1: Joseph, acute migraine (paediatric) .................................... 7

Case scenario 2: Anaka, migraine prophylaxis ............................................. 15

Case scenario 3: Malcolm, cluster headache ............................................... 28

Case scenario 4: Nisha, acute migraine (adult) ............................................ 36

Other implementation tools............................................................................... 38

Acknowledgements .......................................................................................... 38


Introduction

NICE clinical case scenarios

Clinical case scenarios are an educational resource that can be used for

individual or group learning. Each question should be considered by the

individual or group before referring to the answers

These 4 clinical case scenarios have been put together to improve your

knowledge of headaches and its application in practice. They illustrate how the

recommendations from ‘Headaches’ (NICE clinical guideline 150) can be

applied to the care of patients presenting with previously diagnosed headache

to GPs and practice nurses.

The clinical case scenarios are available to be used for individuals or in a group

setting.

You will need to refer to the NICE clinical guideline to help you decide what

steps you would need to follow to diagnose and manage each case, so make

sure that users have access to a copy (either online at

www.nice.org.uk/guidance/CG150 or as a printout). You may also want to refer

to the headaches NICE pathway.

Each case scenario includes details of the person’s initial presentation, their

medical history and their clinician’s summary of the situation after examination.

The clinical decisions about diagnosis and management are then examined

using a question and answer approach. Relevant recommendations from the

NICE guideline are quoted in the text (after the answer), with corresponding

recommendation numbers. Information and detail from the full guideline has

been included in the answers and the 'supporting information' boxes. The

language used when responding to the hypothetical patients has been written in

such a way to ensure that the guideline recommendations are reflected

accurately and the learning objectives are achieved. In practice it is

acknowledged when providing patients with information, clinicians will deliver

this in a way which meets the patients' needs. In addition, it is noted that many

patients will have holistic needs which go beyond the scope of these fictional

http://www.nice.org.uk/guidance/CG150


http://pathways.nice.org.uk/headaches

http://guidance.nice.org.uk/CG150/Guidance


cases and therefore these cases should not be used as treatment plans for any

patients.

These clinical case scenarios form part of a package of education and learning

tools developed to support implementation of the Headaches guideline. Other

tools within the package are:

Diagnosis poster: This will provide quick reference diagnosis support for

clinicians

An academic detailing aid (ADA): This is designed for use by experienced

prescribing and medicines management personnel to support discussion

with prescribers on medicines for management of acute migraine

Headaches

Headaches are one of the most common neurological problems presented to

GPs and neurologists. They are painful and debilitating for individuals, an

important cause of absence from work or school and a substantial burden on

society.

Headache disorders are classified as primary or secondary. The aetiology of

primary headaches is not fully understood and they are classified according to

their clinical pattern. The most common primary headache disorders are

tension-type headache, migraine and cluster headache. Secondary headaches

are attributed to underlying disorders and include, for example, headaches

associated with medication overuse, giant cell arteritis, raised intracranial

pressure and infection. Medication overuse headache most commonly occurs in

those taking medication for a primary headache disorder. The major health and

social burden of headaches is caused by the primary headache disorders and

by medication overuse headache.

The NICE clinical guideline on headaches makes recommendations on the

diagnosis and management of the most common primary headache disorders in

young people (aged 12 years and older) and adults. Many people with

headache do not have an accurate diagnosis of headache type. Healthcare

professionals can find the diagnosis of headache difficult, and both people with

headache and their healthcare professionals can be concerned about possible

http://guidance.nice.org.uk/CG150/DiagnosisPoster/pdf/English

http://guidance.nice.org.uk/CG150/AcademicDetailingAid/pdf/English


underlying causes. Improved recognition of primary headaches will help the

generalist clinician to manage headaches more effectively, allow better

targeting of treatment and potentially improve quality of life and reduce

unnecessary investigations for people with headache.

The NICE clinical guideline on headaches and these clinical case scenarios

assumes that prescribers will use a drug’s summary of product characteristics

to inform decisions made with individual patients.

Drug dosages are specified in recommendations where the dosage for that

indication is not included in the ‘British national formulary’.

The guideline recommends some drugs for indications for which they do not

have a UK marketing authorisation at the date of publication, if there is good

evidence to support that use. The prescriber should follow relevant professional

guidance, taking full responsibility for the decision. The patient (or their parent

or carer) should provide informed consent, which should be documented. See

the General Medical Council’s Good practice in prescribing medicines –

guidance for doctors and the prescribing advice provided by the Joint Standing

Committee on Medicines (a joint committee of the Royal College of Paediatrics

and Child Health and the Neonatal and Paediatric Pharmacists Group) for

further information. Where recommendations have been made for the use of

drugs outside their licensed indications (‘off-label use’), these drugs are marked

with a footnote in the recommendations.

Learning objectives

The learning objectives for these clinical case scenarios are to improve

knowledge on:

how to manage acute migraine

best practice for migraine prophylaxis (including migraine prophylaxis for

women and girls of childbearing potential)

treating cluster headaches, including the key points about ordering home

and ambulatory oxygen

where to find information for patients on acute migraine, migraine

prophylaxis and cluster headaches.

http://www.gmc-uk.org/guidance/ethical_guidance/prescriptions_faqs.asp


http://www.rcpch.ac.uk/child-health/childrens-medicines/childrens-medicines#Unlicensed_medicines_statement


Clinical case scenarios for GPs and practice nurses

Case scenario 1: Joseph, acute migraine (paediatric)

Presentation

Joseph is a 14-year-old boy. He attends your clinic accompanied by his mum,

Claire. He presents with a 2-month history of headaches that he describes as

“banging” and that make his head “very very sore”. He says that in the past

2 months he has had 6 of these headaches. He also says that light hurts his

eyes when he has the headaches. He does not feel nauseous or vomit during

the headaches. Claire tells you that when Joseph has the headaches he is

unable to go to school and that the headaches last from 2 to 4 hours. She gives

Joseph paracetamol and if that doesn’t work she also gives him ibuprofen.

Joseph reports that this combination of medication helps but that it still hurts a

lot until the headache eventually goes completely.

Joseph and Claire ask if Joseph’s headaches are migraines and if there is

anything more he can take to ease the pain and reduce the amount of time he is

taking off school.

Next steps for management

1.1 Question

Based on the history provided, and using the diagnosis poster as a quick

reference to recommendations in section 1.1 and 1.2 of the guideline, you

diagnose migraine without aura. Claire asks what this means for Joseph. How

would you answer this?



1.1 Answer

You would explain the diagnosis to Claire and Joseph and reassure them that a

serious underlying cause is unlikely, based on Joseph’s history and your

examination of him, which showed no abnormalities. You would tell them that

migraines are a well-recognised problem although what causes them is not

known for certain. You would reassure Claire and Joseph that you appreciate

the large impact the headaches are having on Joseph’s life. You would give

them written information about migraine in a format suitable for both, and

include information about support organisations (see box below). Given that

Joseph is likely to have recurrent migraines that will need treatment, you would

explain the risk of medication overuse headache.

Relevant recommendations

Include the following in discussions with the person with a headache

disorder:

– a positive diagnosis, including an explanation of the diagnosis and

reassurance that other pathology has been excluded and

– the options for management and

– recognition that headache is a valid medical disorder that can have a

significant impact on the person and their family or carers. [1.3.4]

Give the person written and oral information about headache disorders,

including information about support organisations. [1.3.5]

Explain the risk of medication overuse headache to people who are using

acute treatments for their headache disorder. [1.3.6]

Supporting information

The following organisations provide information and support for people with

migraine and are listed in NICE Information for the public:

Migraine Action, 0116 275 8317

www.migraine.org.uk

The Migraine Trust, 020 7361 6975

www.migrainetrust.org

http://publications.nice.org.uk/IFP150

http://www.migraine.org.uk/

http://www.migrainetrust.org/



1.2 Question

For acute management of Joseph’s migraine, you would tell Joseph and Claire

that Joseph could have nasal sumatriptan (at the time of publication of these

cases [September 2012], only nasal sumatriptan had a UK marketing

authorisation for this indication in people aged under 18 years), to take along

with a non steroidal anti-inflammatory or paracetamol. However, Claire is

concerned about Joseph taking 2 drugs and asks if there is an option for him to

take just 1 drug. How would you answer this?


1.2 Answer

You would tell Claire and Joseph that adding nasal sumatriptan, to paracetamol

or a non steroidal anti-inflammatory would be the most effective option for

relieving his migraines, but that Joseph could try taking just nasal sumatriptan to

see whether it works better than paracetamol or ibuprofen. You would explain

that the triptan would come as a nasal spray because it is not usually prescribed

in tablet or capsule form for people aged under 18.

You would tell Claire and Joseph that the other option would be monotherapy

with either paracetamol or NSAID and you would ensure that the dose was

optimised. However, since Joseph has already tried both of these drugs and

they didn’t work well enough, triptan would be a suitable option for him to try

next.


Offer combination therapy with an oral triptan1 and an NSAID, or an oral

triptan1 and paracetamol, for the acute treatment of migraine, taking into

account the person's preference, comorbidities and risk of adverse events.

For young people aged 12–17 years consider a nasal triptan in preference

to an oral triptan1. [1.3.10]

For people who prefer to take only one drug, consider monotherapy with an

oral triptan1, NSAID, aspirin2 (900 mg) or paracetamol for the acute

treatment of migraine, taking into account the person's preference,

comorbidities and risk of adverse events. [1.3.11]

Related recommendation

Do not offer ergots or opioids for the acute treatment of migraine. [1.3.14] 1 At the time of publication (September 2012), triptans (except nasal sumatriptan) did not have a UK

marketing authorisation for this indication in people aged under 18 years. The prescriber should follow

relevant professional guidance, taking full responsibility for the decision. The patient (or their parent or

carer) should provide informed consent, which should be documented. See the General Medical Council’s

Good practice in prescribing medicines – guidance for doctors and the prescribing advice provided by the

Joint Standing Committee on Medicines (a joint committee of the Royal College of Paediatrics and Child

Health and the Neonatal and Paediatric Pharmacists Group) for further information. 2 Because of an association with Reye’s syndrome, preparations containing aspirin should not be offered

to people aged under 16 years.





1.3 Question

Claire asks what they should do if the nasal triptan doesn’t work and whether

there are there alternative medications.

a) How would you answer this?

b) What tool could you use to help assess the effectiveness of the nasal triptan?


1.3 Answer

a) You would explain that Joseph should try the sumatriptan nasal spray for at

least 3 headaches because it isn’t possible to tell whether it’s working based on

just 1 headache. If it still doesn’t work well enough then they should return to

you and you would offer combination therapy with nasal sumatriptan, and a non

steroidal anti-inflammatory. You explain that it is a case of finding out which

type of treatment works best for Joseph.

b) You could give Joseph a headache diary containing prompts for him to

record the frequency, duration and severity of his headaches as well as his

response to the triptan. Headache diaries are more accurate than recall and

allow patterns of events to be more clearly seen. They also play an important

role in acknowledging the impact of headache. You would explain to Joseph

and Claire that keeping the diary will help them to learn more about his

migraines, for example whether they occur in patterns and whether they are

triggered by anything in particular. The diary will also enable them to record any

changes in how often the migraines happen, how painful they are, how well the

treatments for them are working and any side effects from the treatments. You

would use this information in the standard review you carry out after starting or

changing Joseph’s treatment.


When prescribing a triptan1, start with the one that has the lowest

acquisition cost; if this is consistently ineffective, try one or more alternative

triptans. [1.3.12]

Consider using a headache diary:

– to record the frequency, duration and severity of headaches

– to monitor the effectiveness of headache interventions

– as a basis for discussion with the person about their headache disorder

and its impact. [1.3.1] 1 At the time of publication (September 2012), triptan (except nasal sumatriptan) did not have a UK



carer) should provide informed consent, which should be documented. See the Good practice in

prescribing medicines – guidance for doctors for further information.





1.4 Question

Claire and Joseph thank you for your help and leave. As you are reflecting on

Joseph's case, you think about other treatment options that might be suitable for

Joseph if the triptan nasal spray doesn’t work well enough for him. What other

treatment options would be available?


1.4 Answer

You could try combination of the nasal sumatriptan with paracetamol.

Alternatively you might then consider trying a different formulation of nasal

triptan (at the time of publication of these cases [September 2012], only nasal

sumatriptan had a UK marketing authorisation for this indication in people aged

under 18 years), triptan tablets or melts, but you would prefer not to prescribe

these for Joseph because they are usually only given to people aged 18 and

over. In addition to different formulations of nasal triptan, or triptan tablets or

melts, you might consider adding an anti-emetic to Joseph’s treatment, taking

into account the risk of side effects and Joseph and Claire’s preferences.


Consider an anti-emetic in addition to other acute treatment for migraine

even in the absence of nausea and vomiting. [1.3.13]

Also see recommendations 1.3.10 and 1.3.12 above.

Supporting information (pages 167–168 of full guideline)

An anti-emetic may have an effect on migraine itself and is a useful adjunct

even if the patient does not have significant nausea and vomiting.

Anti-emetics can trigger extrapyramidal side effects. The risk of these is higher

in people aged under 20 years.

There may be practical difficulties ingesting a number of drugs together. This

may trigger more nausea and vomiting.

The decision to add an anti-emetic is likely to depend on patient preference and

experience of benefit without anti-emetic. Many will find it preferable and easier

to use fewer drugs.


Case scenario 2: Anaka, migraine prophylaxis

Presentation

Anaka is a 28-year-old woman who was diagnosed with migraine with aura

6 months ago. She has, on average, 1 migraine attack per week, for which she

takes triptan, an NSAID and an anti-emetic. Because Anaka has migraine about

4 times per month, she is unlikely to develop medication overuse headache.

You are therefore happy with her current treatment plan. However, during an

attack, she is unable to work or continue her normal daily activities. She also

worries a lot about when the next attack is going to happen and their frequency

causes her to take a lot of time off work.


Be alert to the possibility of medication overuse headache in people whose

headache developed or worsened while they were taking the following

drugs for 3 months or more:

– triptans, opioids, ergots or combination analgesic medications on

10 days per month or more or

– paracetamol, aspirin or an NSAID, either alone or in any combination,

on 15 days per month or more. [1.2.7]


2.1 Question

You note from Anaka's records that other than the medication mentioned above

she is not taking any other forms of medication. You want to confirm that she is

not a taking combined hormonal contraceptive for contraception purposes. Why

is this?


2.1 Answer

There is an increased risk of ischaemic stroke in people with migraine with aura.

This risk is increased in women using combined hormonal contraception.

Anaka confirms that she currently uses contraception but not a combined

hormonal contraceptive.


Do not routinely offer combined hormonal contraceptives for contraception

to women and girls who have migraine with aura. [1.3.22]



Women with migraine with aura (pages 327–328 of full guideline)

It is important to note that recommendation 1.3.22 refers to the use of combined

hormonal contraceptives for contraceptive purposes only.

The World Health Organization, 2009 (medical eligibility criteria) recommends

that the oral contraceptive pill should not be used in women with migraine with

aura at any age. The UK eligibility criteria (UKMEC), 2009 and UK Faculty of

Sexual and Reproductive Health, 2011 both recommend that the use of

combined hormonal contraceptive methods represent an unacceptable risk for

women with migraine with aura.

References/further sources of information:

Department of Reproductive Health WHO. Medical eligibility criteria for

contraceptive use. 4th edition. World Health Organization; 2009

Faculty of Sexual and Reproductive Healthcare. UK Medical Eligibility Criteria

for contraception use. 2009. [Last accessed: 13 July 2012]

http://www.fsrh.org/pdfs/UKMEC2009.pdf

Faculty of Sexual and Reproductive Healthcare Clinical Effectiveness Unit

RCoOaG. Clinical guidance; combined hormonal contraception 2011 (updated

2012). Accessible at

http://www.fsrh.org/pdfs/CEUGuidanceCombinedHormonalContraception.pdf


2.2 Question

Anaka asks if there is anything that can be done to reduce the frequency of her

migraine attacks.

http://www.fsrh.org/pdfs/UKMEC2009.pdf

http://www.fsrh.org/pdfs/CEUGuidanceCombinedHormonalContraception.pdf


2.2 Answer

You would tell Anaka about the option of prophylactic treatment. Explain that

prophylactic treatments prevent, rather than cure, a condition, and that for

migraines they aim to reduce the frequency, severity and duration of the

attacks. You explain the risks and benefits of prophylactic treatment – ensuring

she understands her risk of migraine recurrence and severity, with and without

prophylaxis, and her risk of adverse effects.


Discuss the benefits and risks of prophylactic treatment for migraine with

the person, taking into account the person’s preference, comorbidities, risk

of adverse events and the impact of the headache on their quality of life.

[1.3.16]


2.3 Question

The NICE guideline recommends offering topiramate or propranolol for the

prophylactic treatment of migraine. When discussing the most suitable

prophylaxis for Anaka what important information do you need to tell her about

topiramate?


2.3 Answer

Given that Anaka is of child bearing potential, it is important for her to be aware

that topiramate is associated with a risk of fetal malformations. Additionally, as

Anaka has confirmed that she is currently using contraception, she needs to be

aware that there is potential for topiramate to impair the effectiveness of

hormonal contraceptives. With Anaka's consent you arrange an appointment for

her with the contraceptive service so she can talk about the options for suitable

contraception if she were to take topiramate.


Offer topiramate1 or propranolol for the prophylactic treatment of migraine

according to the person’s preference, comorbidities and risk of adverse

events. Advise women and girls of childbearing potential that topiramate is

associated with a risk of fetal malformations and can impair the

effectiveness of hormonal contraceptives. Ensure they are offered suitable

contraception. [1.3.17] 1 At the time of publication (September 2012), topiramate did not have a UK marketing

authorisation for this indication in people aged under 18 years. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. The patient (or their parent or carer) should provide informed consent, which should be documented. See the General Medical Council’s Good practice in prescribing medicines – guidance for doctors and the prescribing advice provided by the Joint Standing Committee on Medicines (a joint committee of the Royal College of Paediatrics and Child Health and the Neonatal and Paediatric Pharmacists Group) for further information.





Contraception for women and girls taking topiramate (page 217 of full

guideline)

Further detail on contraception for women and girls taking topiramate is

available in The epilepsies NICE clinical guideline 137, The diagnosis and

management of the epilepsies in adults and children in primary and secondary

care. There is a section specifically concerning Women and girls with epilepsy.

This guideline refers to the BNF (www.bng.org) and Summary of Product

Characteristics (SPC) (www.medicines.org.uk/emc)

Further sources of information:


RCoOaG, (2012) Drug interactions with hormonal contraception. Available from

http://www.fsrh.org/pdfs/CEUGuidanceDrugInteractionsHormonal.pdf


RCoOaG (2010) CEU statement: antiepileptic drugs and contraception.

Available from: http://www.fsrh.org/pdfs/CEUStatementADC0110.pdf


2.4 Question

Following consultation with the contraceptive service, Anaka decides that she

does not want to use any of the contraceptives that were recommended as

suitable and reliable for use with topiramate. You therefore suggest propranolol

for migraine prophylaxis.

a) How would you assess the effectiveness of the propranolol?

b) When would you review the need to continue this prophylaxis?

http://guidance.nice.org.uk/CG137

http://publications.nice.org.uk/the-epilepsies-the-diagnosis-and-management-of-the-epilepsies-in-adults-and-children-in-primary-and-cg137/guidance#women-and-girls-with-epilepsy

http://www.bng.org/

http://www.medicines.org.uk/emc

http://www.fsrh.org/pdfs/CEUGuidanceDrugInteractionsHormonal.pdf

http://www.fsrh.org/pdfs/CEUStatementADC0110.pdf


2.4 Answer

a) You would provide Anaka with a headache diary that contains prompts to

record the frequency, duration and severity of her headaches as well as her

response to the propranolol. Headache diaries are more accurate than relying

on a person’s memory, and allow patterns of events to be more clearly seen.

Diaries also play an important role in acknowledging the impact of headaches.

You would advise Anaka to complete the diary in order to: understand any

patterns or triggers that may cause her symptoms; be more alert to changes in

the regularity or severity of her attacks; and learn the effectiveness of any new

medications she takes. It will also help inform the standard review process, to

assess the treatment’s effectiveness and the presence of side effects after

starting or changing a treatment plan.


Offer topiramate1 or propranolol for the prophylactic treatment of migraine

according to the person’s preference, comorbidities and risk of adverse

events. Advise women and girls of childbearing potential that topiramate is

associated with a risk of fetal malformations and can impair the

effectiveness of hormonal contraceptives. Ensure they are offered suitable

contraception. [1.3.17]

Consider using a headache diary:

– to record the frequency, duration and severity of headaches

– to monitor the effectiveness of headache interventions

– as a basis for discussion with the person about their headache disorder

and its impact. [1.3.1] 1 At the time of publication (September 2012), topiramate did not have a UK marketing

authorisation for this indication in people aged under 18 years. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. The patient (or their parent or carer) should provide informed consent, which should be documented. See the General Medical Council’s Good practice in prescribing medicines – guidance for doctors and the prescribing advice provided by the Joint Standing Committee on Medicines (a joint committee of the Royal College of Paediatrics and Child Health and the Neonatal and Paediatric Pharmacists Group) for further information.




b) Continuing treatment when it is no longer needed puts the person at risk of

having side effects and drug interactions. Experts agree that many people can

stop prophylaxis after 6 months of treatment and continue to benefit from the

prophylactic treatment. Therefore, you would review Anaka’s need to continue

prophylactic treatment at 6 months.


2.5 Question

Anaka asks if there is anything else she can do or take, such as a natural

remedy, which could help reduce her migraine intensity. How would you

address this?


Review the need for continuing migraine prophylaxis 6 months after the

start of prophylactic treatment. [1.3.20]


2.5 Answer

You would tell Anaka that taking riboflavin (400 mg once a day) may help to

reduce her migraine frequency and intensity. You would tell her that products

containing riboflavin can be purchased from pharmacies and health food stores.

You could also tell Anaka that if propranolol is unsuitable or ineffective you will

consider offering her a course of acupuncture.


Advise people with migraine that riboflavin (400 mg1 once a day) may be

effective in reducing migraine frequency and intensity for some people.

[1.3.21]

If both topiramate2 and propranolol are unsuitable or ineffective, consider a

course of up to 10 sessions of acupuncture over 5–8 weeks or gabapentin3

(up to 1200 mg per day) according to the person’s preference, comorbidities

and risk of adverse events. [1.3.18] 1 At the time of publication (September 2012), riboflavin 400 mg did not have a UK marketing

authorisation for this indication but is available as a food supplement. When advising this option, the

prescriber should take relevant professional guidance into account. See the General Medical Council’s

Good practice in prescribing medicines – guidance for doctors and the prescribing advice provided by the

Joint Standing Committee on Medicines (a joint committee of the Royal College of Paediatrics and Child

Health and the Neonatal and Paediatric Pharmacists Group) for further information. 2 At the time of publication (September 2012), topiramate did not have a UK marketing authorisation for

this indication in people aged under 18 years. The prescriber should follow relevant professional

guidance, taking full responsibility for the decision. The patient (or their parent or carer) should provide

informed consent, which should be documented. See the General Medical Council’s Good practice in

prescribing medicines – guidance for doctors and the prescribing advice provided by the Joint Standing

Committee on Medicines (a joint committee of the Royal College of Paediatrics and Child Health and the

Neonatal and Paediatric Pharmacists Group) for further information. 3 At the time of publication (September 2012), gabapentin did not have a UK marketing authorisation for

this indication. The prescriber should follow relevant professional guidance, taking full responsibility for

the decision. The patient (or their parent or carer) should provide informed consent, which should be

documented. See the General Medical Council’s Good practice in prescribing medicines – guidance for

doctors and the prescribing advice provided by the Joint Standing Committee on Medicines (a joint

committee of the Royal College of Paediatrics and Child Health and the Neonatal and Paediatric

Pharmacists Group) for further information.










Additional information

Products containing riboflavin can be purchased from pharmacies and

reputable health food stores.


2.6 Question

Anaka tells you that her mum also takes treatment to prevent migraines, but

that she takes amitriptyline. Anaka says amitriptyline works for her mum and

asks why she has not been offered it. How would you answer this question?


2.6 Answer

You would tell her that, following a recent review, NICE (a national organisation

that advises the NHS about the effective use of drugs) recommended that

prophylaxis with topiramate or propranalol should be offered first and if those

did not work then acupuncture or gabapentin should be offered. NICE

recommended that if someone was already having treatment with amitriptyline

and it was working then they could continue with that treatment.


For people who are already having treatment with another form of

prophylaxis such as amitriptyline1, and whose migraine is well controlled,

continue the current treatment as required. [1.3.19] 1 At the time of publication (September 2012), amitriptyline did not have a UK marketing authorisation

for this indication. The prescriber should follow relevant professional guidance, taking full responsibility

for the decision. The patient (or their parent or carer) should provide informed consent, which should be






2.7 Question

If Anaka wants to become pregnant in the future, but still needs migraine

prophylaxis, what should you do?





2.7 Answer

Migraine without aura often improves during pregnancy. However, migraine with

aura is more likely to continue throughout pregnancy. If Anna becomes

pregnant you should therefore assess whether she needs prophylaxis during

her pregnancy. If she does, then you would seek specialist advice. This could

be advice over the telephone to avoid delaying a prescription that would

otherwise require a referral. You would also review and discuss her use of

triptan, NSAIDs and anti-emetics, because of the risks associated with these

medications during pregnancy.


Seek specialist advice if prophylactic treatment for migraine is needed

during pregnancy. [1.3.25]

Offer pregnant women paracetamol for the acute treatment of migraine.

Consider the use of a triptan1 or an NSAID after discussing the woman’s

need for treatment and the risks associated with the use of each medication

during pregnancy. [1.3.24] 1 At the time of publication (September 2012), triptan (except nasal sumatriptan) did not have a UK






2.8 Question

Anaka asks you if there is any reading she can do to learn more about her

condition.

a) In your discussion with Anaka, what information and support would you

provide as a minimum?

b) What further information would you provide to Anaka?




2.8 Answer

a) As a minimum, you would explain to Anaka about her diagnosis and reassure

her that other pathology has been excluded. You would reassure Anaka that

this type of headache is a well-recognised problem and that you understand

that it is having a big impact on her life.

b) You would provide Anaka with information (in a format suitable for her) about

headache disorders, including information about support groups (see box

below).



disorder:








Explain the risk of medication overuse headache to people who are using

acute treatments for their headache disorder. [1.3.6]


The following organisations provide information and support for people with

migraine and are listed in NICE Information for the public:

Migraine Action, 0116 275 8317

www.migraine.org.uk

The Migraine Trust, 020 7361 6975

www.migrainetrust.org


http://www.migraine.org.uk/

http://www.migrainetrust.org/


Case scenario 3: Malcolm, cluster headache

Presentation

Malcolm is a 31-year-old man. He has a history of severe headaches, which he

says cause him the worst pain he’s ever felt. When he gets these headaches,

he has pain on 1 side of his head, around his eye and along the side of his face.

He also experiences drooping or swelling of the eyelid, watery eye and nasal

congestion, on the same side as the headache.

Malcolm experienced the severe headache for the first time 2 weeks ago for

which he went to accident and emergency, where he was given a CT scan. The

CT scan was normal and you have been asked to evaluate Malcolm.

Malcolm tells you that, since his first severe headache 2 weeks ago, he has

experienced 6 more headaches. He says that on average his severe headaches

last from 30 to 90 minutes.

Based on Malcolm's history and using the diagnosis poster as a quick reference

to recommendations in section 1.1 and 1.2 of the guideline you diagnose him

with cluster headache1.


3.1 Question

What advice and support can you offer Malcolm about his diagnosis?

1 It is acknowledged that this diagnosis process is likely to be more complex than this case represents

however, for the purpose of the case scenario diagnosis has been simplified.



3.1 Answer

At a minimum, you would explain the diagnosis and reassure Malcolm that other

pathology has been excluded. You would also talk about the options for

management (see below) and reassure him that you recognise these severe

headaches are having a big impact on him. You would also provide Malcolm

with information about cluster headache in a format suitable for him and include

information about support organisations.



disorder:









The following organisation provides information and support for people with

cluster headache and is listed in NICE Information for the public:

OUCH(UK), 01646 651 979

www.ouchuk.org


3.2 Question

When you ask Malcolm about how his attacks have been since his admission to

the emergency department, he becomes upset and says that that they are very

painful. He asks if there is any more that can be done to reduce the pain during

attacks. What interventions could help Malcolm during an attack?


http://ouchuk.org/html/


3.2 Answer

You would offer Malcolm subcutaneous or nasal triptan. You need to make

Malcolm aware that the nasal triptan does not have UK marketing authorisation

for this indication (correct at time of publication of these case scenarios in

September 2012). Malcolm is concerned about injecting himself; therefore, you

decide to offer him nasal triptan. You document that Malcolm has consented to

this treatment. You highlight that, if he is not receiving adequate relief with the

nasal triptan, you will meet with Malcolm again and talk about subcutaneous

triptan.

You would also assess Malcolm's medical history and note that he has no

history of respiratory disease or COPD. You would offer Malcolm home and

ambulatory oxygen. As required, you would explain that during an attack he will

need to use a non-rebreathing mask and reservoir bag, and that the oxygen will

be running at a flow rate of at least 12 litres per minute. The home oxygen is for

use if he has an attack at home. The ambulatory oxygen is for him to take out

and use if he has an attack while he is away from home (recognising that

attacks happen at unpredictable intervals). You would explain that this will allow

him to treat his attack at the earliest opportunity.



Offer oxygen or a subcutaneous1 or nasal triptan2 for the acute treatment of

cluster headache. [1.3.27]

When using oxygen for the acute treatment of cluster headache:

– use 100% oxygen at a flow rate of at least 12 litres per minute with a

non-rebreathing mask and a reservoir bag and

– arrange provision of home and ambulatory oxygen. [1.3.28]

1 At the time of publication (September 2012), subcutaneous triptan did not have a UK marketing

authorisation for this indication in people aged under 18 years. The prescriber should follow relevant

professional guidance, taking full responsibility for the decision. The patient (or their parent or carer)

should provide informed consent, which should be documented. See the General Medical Council’s Good

practice in prescribing medicines – guidance for doctors and the prescribing advice provided by the Joint

Standing Committee on Medicines (a joint committee of the Royal College of Paediatrics and Child

Health and the Neonatal and Paediatric Pharmacists Group) for further information. 2 At the time of publication (September 2012), nasal triptan did not have a UK marketing authorisation








3.3 Question

You are prescribing Malcolm the nasal triptan. How much should you prescribe?








3.3 Answer

Because of the frequent nature of attacks during a bout of cluster headaches, it

is important that Malcolm has an adequate supply of medication to reduce the

pain. You would calculate this according to his history of cluster bouts and

based on the manufacturer’s maximum daily dose.


When using a subcutaneous1 or nasal triptan2, ensure the person is offered

an adequate supply of triptans calculated according to their history of

cluster bouts, based on the manufacturer’s maximum daily dose. [1.3.29]

Be alert to the possibility of medication overuse headache in people whose

headache developed or worsened while they were taking the following

drugs for 3 months or more:

– triptans, opioids, ergots or combination analgesic medications on

10 days per month or more or

– paracetamol, aspirin or an NSAID, either alone or in any combination,

on 15 days per month or more. [1.2.7]

1 At the time of publication (September 2012), subcutaneous triptan did not have a UK marketing

authorisation for this indication in people aged under 18 years. The prescriber should follow relevant

professional guidance, taking full responsibility for the decision. The patient (or their parent or carer)

should provide informed consent, which should be documented. See the General Medical Council’s Good

practice in prescribing medicines – guidance for doctors and the prescribing advice provided by the Joint

Standing Committee on Medicines (a joint committee of the Royal College of Paediatrics and Child

Health and the Neonatal and Paediatric Pharmacists Group) for further information. 2 At the time of publication (September 2012), nasal triptan did not have a UK marketing authorisation








3.4 Question

How will you order the oxygen for Malcolm?








3.4 Answer

To order the oxygen you must complete a home oxygen order form (HOOF).

There are sections for ambulatory oxygen and long term or short burst oxygen.

At the time of publication of these case scenarios (September 2012) the HOOF

was available at http://www.pcc.nhs.uk/home-oxygen-order-form. The current

HOOF contains cluster headache as an indication.

As well as ordering the oxygen, it is important to order the non-rebreathing

mask (cushioned). It is essential that all the necessary equipment has been

delivered to Malcolm to make sure he receives the prescribed oxygen.

Additional information

Oxygen supply companies differ by region. For more information see

http://www.homeoxygen.nhs.uk/9.php

Some supply companies can only accept orders for oxygen at 15 litres per

minute. The wording of the guideline recommendation 'use 100% oxygen at a

flow rate of at least 12 litres per minute' allows for ordering more than 12 litres

per minute if the supplier is unable to deliver 12 litres per minute.


3.5 Question

What prophylaxis for cluster headache could you offer Malcolm?

http://www.pcc.nhs.uk/home-oxygen-order-form

http://www.homeoxygen.nhs.uk/9.php


3.5 Answer

In order to reduce the frequency, severity and duration of attacks, you consider

offering Malcolm verapamil. However, because of your lack of experience in

using verapamil for cluster headache, you consult a colleague who is a GP with

a special interest in headaches or neurology (or a consultant neurologist) for

guidance in using this medication before prescribing it.


Consider verapamil1 for prophylactic treatment during a bout of cluster

headache. If unfamiliar with its use for cluster headache, seek specialist

advice before starting verapamil, including advice on electrocardiogram

monitoring. [1.3.31]

1 At the time of publication (September 2012), verapamil did not have a UK marketing authorisation for

this indication in people aged under 18 years. The prescriber should follow relevant professional

guidance, taking full responsibility for the decision. The patient (or their parent or carer) should provide

informed consent, which should be documented. See the General Medical Council’s Good practice in

prescribing medicines – guidance for doctors and the prescribing advice provided by the Joint Standing

Committee on Medicines (a joint committee of the Royal College of Paediatrics and Child Health and the

Neonatal and Paediatric Pharmacists Group) for further information.

Supporting information (page 236 of full guideline)

Verapamil may cause cardiac conduction problems. ECG monitoring is required

before every increase in verapamil dosage and monitoring is also required at

intervals if the person remains on verapamil


3.6 Question

What medications would you not offer Malcolm for the acute management of

his cluster headache attacks?





3.6 Answer

You would not offer paracetamol, NSAIDS, oral triptans, ergots or opioids as

there is no evidence to suggest that they would have any clinical benefit in the

treatment of cluster headache.


Do not offer paracetamol, NSAIDS, opioids, ergots or oral triptans for the

acute treatment of cluster headache. [1.3.30]


Case scenario 4: Nisha, acute migraine (adult)

Presentation

You are an out-of-hours GP and have been called out to visit Nisha. She is a

48-year-old woman who was diagnosed with episodic migraine 10 years ago.

She is taking topiramate for prophylaxis and takes an NSAID and oral triptan for

acute treatment.

Nisha currently has a severe migraine with aura that started 60 minutes ago.

She took her usual oral triptan and NSAID 50 minutes ago and her migraine has

not responded. Nisha has also vomited 6 times during this attack; once just

after taking the oral medication.

4.1 Question

What other acute migraine treatment can you offer Nisha?


4.1 Answer

Given that the oral preparations of NSAID and triptan were not effective for

Nisha, you offer her intramuscular metoclopramide or prochlorperazine.

You also consider offering Nisha a non-oral NSAID or triptan; however, you

decide against this because Nisha has recently taken both of these.


For people in whom oral preparations (or nasal preparations in young

people aged 12–17 years) for the acute treatment of migraine are

ineffective or not tolerated:

– offer a non-oral preparation of metoclopramide or prochlorperazine1 and

– consider adding a non-oral NSAID or triptan2 if these have not been

tried. [1.3.15] 1 At the time of publication (September 2012), prochlorperazine did not have a UK marketing

authorisation for this indication (except for the relief of nausea and vomiting).The prescriber should

follow relevant professional guidance, taking full responsibility for the decision. The patient (or their

parent or carer) should provide informed consent, which should be documented. See the General Medical

Council’s Good practice in prescribing medicines – guidance for doctors and the prescribing advice

provided by the Joint Standing Committee on Medicines (a joint committee of the Royal College of

Paediatrics and Child Health and the Neonatal and Paediatric Pharmacists Group) for further information. 2 At the time of publication (September 2012), triptan (except nasal sumatriptan) did not have a UK





Supporting information (page 169-170 of full guideline)

Anti-emetics are effective for symptom relief, regardless of whether the person

has nausea or vomiting.

Reasons for oral treatment not being appropriate could include vomiting,

previous attempt at oral treatment which has been ineffective.

If the individual has already taken an NSAID or triptan with unsatisfactory

response, do not re-administer the same drug parenterally in addition to the

antiemetic.






Other implementation tools

NICeveloped tools to help organisations implement the clinical guideline on

Headaches (listed below). These are available on the NICE website

(www.nice.org.uk/guidance/CG150).

Diagnosis poster.

Academic detailing aid.

Costing tools.

Clinical audit support.

Baseline assessment tool.

Acknowledgements

NICE would like to thank the staff of the National Clinical Guideline Centre and

the members of the Guideline Development Group, especially:

Professor Martin Underwood, Professor of Primary Care Research,

Warwick Medical School

Dr Kay Kennis, GP with a special interest in headache, Bradford

Dr David Kernick, GP with special interest in headache, Exeter

Dr Carole Gavin, Consultant Emergency Physician, Salford Royal NHS

Foundation Trust

Peter May, patient and carer member, OUCH UK

Dr Norma O’Flynn, National Clinical Guideline Centre, London

Dr Devina Halsall, Senior Pharmacist for Community Pharmacy, NHS

Halton and St Helens, Liverpool.


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