oh and headache dr david pb watson gpwsi hamilton medical group aberdeen
TRANSCRIPT
Objectives
• Headache impact and epidemiology
• Headache diagnosis
• Headache management
• audit and useful information
• case study
Headache types
90%
10% Episodic
primary headaches
Chronic primary headaches
Primary headache
No underlying medical cause:
Tumour
Meningitis
Vascular disorders
Systemic infection
Head injury
Drug-induced
Secondary headache
Underlying medical cause:
Episodic primary headaches
Episodicprimary
headaches
Migraine +/- aura
Tension-type headache (TTH)
Cluster
Probablemigraine
Chronic cluster
Chronic migraine +/- medication overuseChronic tension
Chronic daily headache (CDH)
Hemicrania continuaNew daily persistent
Chronic primary headaches / chronic daily headaches
Rasmussen et al 1991Rasmussen et al 1991
Lifetime prevalence of primary headache
(n=740)
Episodic migraine
Episodic TTH
Chronic daily - all types
16%
78%
4%
Impact
• Episodic TTH –low (common)
• Episodic Migraine – high (1 in 10)
• Chronic Daily Headache - high ( 1 in 25)
• Cluster – very high (1-2 in 1000)
Migraine Impact
• Meets WHO definition of disability
• Epidemiology– 6 million people in UK– Women 3x men– most sufferers aged 20 to 50
Personal Impact
• 187000 migraine attacks experienced every day
• 3/4 report disability at least sometimes
• 1/3 feel migraine controls their lives
• 47% of migraineurs experience depression compared 17% on non migraineurs
Impact of Migraine
• UK migraine survey 1999 showed that– 30% were unable to look after their family– 63% were either totally or significantly
prevented from going to work– 39% had suffered an attack whilst driving
Economics of Migraine
• 50% of migraine sufferers miss up to 26 days work a year
• 18 million working days a year lost
• lost productivity valued at almost £2 billion a year
• sufferers function at 50% efficiency with migraine symptoms for up to 1 week
Indirect cost of migraineFor most sufferers, migraine results in lost
productivity rather than days lost from workWork loss
(%)
0 40 1000
20
40
80
100
60
20 60 80Migraine sufferers (%)
Adapted from von Korff et al 1998Adapted from von Korff et al 1998
30 9010 50 70
The most severely affected sufferers (40% of the sample) accounted for all days lost from work
Almost all sufferers reported reduced productivity equivalent to lost work days
“Red flags”• Single cohort (Level 3) or expert opinion (Level 4)
• new onset headache in patients who are aged over 50 29-31
• abrupt onset (thunderclap) 28-30, 32, 33
• focal symptoms including atypical aura greater than one hour 28, 32, 34, 35
• abnormal neurological examination 28, 29, 35, 36
• altered mental status 28, 30, 34
• altered characteristics or associated features of headache 28, 31
• headache that changes with posture 37
• headache worse in the morning and during physical activity, and the valsalva manoeuvre 28, 38
• patients with risk factors for thrombosis 34, 39, 40
• new onset headache in a patient with a history of HIV infection 41
• jaw claudication 16
• neck stiffness 30
• fever 42
• new onset headache in a patient with a history of cancer 9
Abbreviated diagnostic checklist based on IHS 2004 criteria
Essential (3)
Essential (2)
Essential (1)
• Recurrent• No organic disease• Duration 4-72 h
• Moderate / severe + one other
• Recurrent• No organic disease• Duration 0.5 h-7 days
• Generalised• Pressure / tightness• Slight / moderate
• Photo / phonophobia
• Recurrent• No organic disease• Duration 4-72 h
• Unilateral• Pulsating• Moderate / severe• Aggravated by
movement
• Nausea / vomiting• Photo / phonophobia
Migraine Probable migraine Tension-type
Essential (3) = all items essential for diagnosis; Essential (2) = two items from list essential for diagnosis; Essential (1) = one item from list essential for diagnosis
IHS 2004
What features make migraine more likely?
• episodic severe headache that causes disability11, 23, 24
• nausea16, 23
• sensitivity to light during migraine headache16, 23
• sensitivity to light between migraine attacks 25
• aura16, 18
• sensitivity to noise16
• exacerbation by physical activity16
• positive family history of migraine16
• The features which give the greatest sensitivity and specificity are disability, nausea and sensitivity to light23
– ID Migraine validation study (Level 3)
Other primary headache
• Trigeminal autonomic cephalalgias (TACs)– Cluster headache– Paroxysmal Hemicrania– SUNCT
• Hemicrania continua
• New daily persistent headache
What features make TACs more likely?
• The following features differentiate trigeminal autonomic cephalalgias from migraine: 16, 26 (Level 4)
– Onset: rapid in TAC, gradual in migraine
– Duration: TACs < 3 hours, migraine 4 - 72 hours
– Frequency: multiple attacks may occur daily in TACs
– Restlessness during an attack: 100% in cluster headache, 50% in paroxysmal hemicrania
– Prominent ipsilateral autonomic features in TACs
• Features which differentiate trigeminal autonomic cephalalgias from each other and from trigeminal neuralgia are listed in Annex 2
Diagnosis Summary
• Key question is impact
• Default diagnosis for intermittent headache is migraine(Landmark study 90%)
• Migraine v Cluster imagine typical patient
• Chronic headache consider medication overuse
Non-pharmacological therapies• Behavioural treatments include:
– stress management / relaxation training
– regular diet and sleep
– trigger identification and avoidance
– avoidance of excessive over-the-counter medications
• Physical treatments include:– natural remedies /
complementary medicines
– acupuncture
– transcutaneous electrical nerve stimulation
– occlusal adjustment
– cervical manipulation
Adapted from US Headache Consortium Headache GuidelinesAdapted from US Headache Consortium Headache Guidelines
Acute pharmacological therapiesDrug class
Analgesics
5-HT1B/1D agonists
(Triptans)
antiemetics
Drug name
Aspirin 900 mg, ibuprofen 400mg
Almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan ,zolmitriptan
Domperidone, prochloroperazine
Avoid opioids
Management Summary
• Provide acute medication to all migraine patients and recommend it is taken early
• Provide rescue medication
• Tailor treatment to the individual
• Prophylactic Rx if high impact
• Lifestyle management important
Ideas for Audit
• Number of Migraineurs
• Assess migraine impact and lost time
• Migraine awareness campaign
• Medication Overuse awareness
• Reassess impact and lost time
Migraine Resources
• British Association for the Study of Headache www.bash.org/
• Migraine Action Association www.migraine.org.uk/
• www.sign.ac.uk
Migraine and Sickness absence
• Triggers– Long hours
– Stress
– Sleep disturbance
– Missing meals
– Travel/jet lag
– Office lighting
– Hormones
• Disabling headache and ? DDA
• Reasonable adjustments eg dark room, lie down, flexi time,
• No medication 100% effective, acute treatment side effects
Case Study
• ITU nurse aged 28 with chronic migraine and medication overuse headache
• Issues include– Shift work affecting sleep, diet, exercise– Work pressures, short staffed, studying for
exam, often lack of senior staff, management attitude to sick leave, lack of understanding/empathy from colleagues