Transcript Slide 1

Headache Care for
Practising Clinicians
Establishing principles for
migraine management in primary
care
Meeting in Vienna at the EFNS
26 October 2002
Introduction
• Recent academic meetings have contained
relatively little material on the management
of migraine in primary care
• However, new guidelines for the
management of migraine have recently been
developed in the USA and the UK
– Headache Consortium
– Primary Care Network
– MIPCA
MIGRAINE IN PRIMARY CARE ADVISORS
• MIPCA is an independent charity working
through research and education to set
standards for the care of headache sufferers
– Dedicated to improve headache management in
primary care
• MIPCA contains physicians, nurses,
pharmacists, other healthcare professionals
and representatives from patient groups
Headache Care for the Practising
Clinician
• We propose a new forum to improve the
standard of headache management in
primary care
– ‘Headache Care for the Practising Clinician’
• Annual meeting (Copenhagen style)
• 2nd meeting in October 2003 in Monte Carlo
• Great interest from the pharmaceutical
industry
• Arrangements set up in 1st Annual Meeting in
2002
– Migraine Trust for US
– EFNS for whole world
1st Annual Meeting: Programme
8.00 am: Breakfast and Introduction
8.30 am: Diagnosis of headache in
primary care
9.30 am: Coffee break
9.45 am: Principles of managing migraine
in primary care
10.45 am: Agreeing principles of
migraine management for
international use
1st Annual Meeting: Programme
11.30 am: Break
11.50 am: Agreeing the faculty and
programme for the 2nd HCPC
meeting in October 2003 in
Monte Carlo
1.00 pm: Close and Lunch
1st Annual Meeting: Objectives
• Develop agreed principles of migraine
management for use in primary care
– Review the latest initiatives that have
developed migraine guidelines
– Agree principles of care that can be
recommended for international use
• Agree the programme and faculty for
the 2003 meeting
1st Annual Meeting: Outcomes
• Produce specific outcomes for wide
dissemination
– Article to be published in a peer-reviewed
journal
– ‘Popular’ newsletter designed for primary
care physicians
– Slide set for educational use
– Further outcomes to be defined
1st Annual Meeting: Progress to date
• Meeting held with US PCPs at the
Migraine Trust in London
– Agreed that PCPs should the main focus
of care for headache management
– Need for an independent organisation
driven by practising clinicians
– Multidisciplinary approach recommended
– A separate committee will be set up to
move forward the HCPC initiative in the
USA
Developing agreed principles
of migraine management for
use in primary care
Recent initiatives for migraine
management in primary care
• Starting points for new initiatives
– US Headache Consortium1
– US Primary Care Network2
– UK MIPCA Guidelines3
– German guidelines4
– Canadian guidelines5
1Headache
Consortium. Neurology 2000; www.aan.com. 2Bedell AW et al.
Primary Care Network 2000. 3Dowson AJ et al. MIPCA 2000. 4Diener HC et
al. Nervenheilkunde 1997;16:500-10. 5Pryse-Phillips WEM et al. Can Med
Assoc J 1997;156:1273-87.
US Headache Consortium guidelines
Migraine
diagnosis
Disability
assessment
Patient
communication
and education
Individualised
management
Stratified
care
IHS criteria
Assessments of
migraine impact
Attack frequency
 Attack severity
 Degree of disability
 Non-headache symptoms
 Patient participation
– preference
– prior response
– co-existent conditions

Lipton RB, Silberstein SD. Neurology 2001;56 (Suppl 1):35-42.
US Primary Care Network guidelines
Impact-based recognition of migraine
How do headaches interfere with your life?
How frequently do you experience headaches of any type?
Has there been any change in your headache pattern
over the last 6 months?
How often and how effectively do you use medication
to treat headaches
≤2 headaches per week
>2 headaches per week
Acute treatment strategy
Preventative treatment strategy
Provide patient education and instruction
Tailor intervention to the patient’s needs and select the best
therapy for each patient
Treat as early as possible in the attack
Abort migraine symptoms and disability within 2−4 hours
of initiating therapy
Address patient expectations and compliance by
providing patient education and instruction
Develop a formal management plan
Use headache diaries
Reduce attack frequency, duration, severity and disability
Prevent the development of CDH
Choice of acute treatments
Mild headache: triptans, isometheptene, NSAIDs,
OTC combination analgesics
Moderate to severe headaches: triptans or NSAIDS or
OTC combination analgesics if previously successful
Choice of preventative medications
Beta-adrenergic blocking agents
Tricyclic antidepressants
Anticonvulsants
Bedell AW et al. Primary Care Network 2000.
MIPCA initiative: Establishing new
management guidelines for migraine in
UK primary care
• Update of the existing MIPCA guidelines
– Identification and screening of patients in need of
care
– Development of new diagnostic tools and
algorithms
– Best management practice
• Utilising evidence-based medicine wherever
possible
• Incorporating latest data from UK and US
guidelines
What is required
Best practice from existing guidelines
• Detailed history taking, patient education and
engagement with care
• Diagnostic screening and confirmatory differential
diagnosis
• Management individualised 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
Headache Consortium. Neurology 2000; www.aan.com.
Bedell AW et al. Primary Care Network 2000.
Dowson AJ et al. MIPCA 2000.
Overall diagram for migraine
management
Management individualised
for each patient
Consultation
•Specific
consultation
•Treatment
history
•Patient
education,
counselling
and
engagement
Diagnosis
•Screen for
headache type
• Differentiate
migraine from
other
headaches
Assess
severity
•Attack frequency
and pain severity
•Impact on
patient’s life
(MIDAS / HIT)
•Non-headache
symptoms
•Patient factors
Treatment
plan
•Establish goals
•Behavioural
therapy
•Acute therapy
•Possible
prophylactic
therapy
•Complementary
therapy?
Follow-up
Assess outcome
of therapy
New MIPCA algorithm
Initial consultation and
treatment
Copyright MIPCA 2002, all rights reserved
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
(+/- aura)
Intermittent
moderate-to severe migraine
(+/- aura)
Behavioural/complementary therapies
Aspirin/NSAID (large dose)
Aspirin/paracetamol plus anti-emetic
Initial consultation
Rescue
Initial treatment
Oral triptan
Rescue
Nasal spray/subcutaneous
triptan
Dowson AJ et al. Curr Med Res Opin 2002;18:414-39.
New MIPCA algorithm
Follow-up consultation and
treatment
Copyright MIPCA 2002, all rights reserved
Initial
Initial
treatment
treatment
Oral triptan
Aspirin/NSAID (large dose)
Aspirin/paracetamol plus anti-emetic
If initial treatment unsuccessful
Rescue
Oral triptan
Follow-up treatment
Alternative oral triptan
Nasal spray/subcutaneous
triptan
If unsuccessful
Frequent headache
(i.e. 4 attacks per month)
Migraine
Consider prophylaxis +
acute treatment for
breakthrough migraine
attacks
If unsuccessful
Chronic daily
Headache (CDH)?
If
management
unsuccessful
Consider referral
Dowson AJ et al. Curr Med Res Opin 2002;18:414-39.
Outputs from the UK project
 Peer-reviewed article published in Curr Med
Res Opin
 MIPCA newsletter (‘popular GP’ version)
 Summary and article in Guidelines
 Slide set
 CD Rom
• Further meetings and educational items
planned for GPs, specialists, nurses,
pharmacists and patients
Dowson AJ et al. Curr Med Res Opin 2002;18:414-39.
Developing agreed principles of
migraine management for
international use in primary care
Screening and diagnosis for
headache
Processes
• First consultation
–
–
–
–
–
Screening
Patient education and engagement with care
Diagnosis
Assessment of illness severity
Implementation of initial treatment plan
• Follow-up consultations
– Monitor success of therapy and modify treatment
if necessary
Screening procedures: history taking,
patient education and engagement
Taking a careful history is essential
– Use of a headache history questionnaire is
recommended
• Patient education
– Advice, leaflets, websites and patient
organisations
• Patient engagement with care
– Patients to take charge of their own management
– Effective communication between patient and
physician
Headache Consortium. Neurology 2000; www.aan.com.
Bedell AW et al. Primary Care Network 2000.
Migraine diagnosis: IHS criteria
• Five or more lifetime headache attacks lasting 4-72
hours each and symptom-free between attacks
• Two or more of the following headache features:
–
–
–
–
Moderate-severe pain
Unilateral
Throbbing/pulsating
Exacerbated by routine activities
• One or more of the following non-headache features:
– Aura
– Nausea
– Photophobia/phonophobia
• Exclusion of secondary headaches
Headache Classification Committee of the IHS. Cephalalgia 1988;7 (Suppl 7):19-28
Screening / diagnosis of headache
• Proposal: the IHS diagnostic criteria are too
limited in scope and complex 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 with
additional questions, if required
– Possibly based on the IHS criteria
– Headache diaries
Four-item questionnaire
A. Exclude sinister headaches
New-onset, acute headaches
associated with other symptoms
– e.g. rash, neurological deficit, vomiting,
pain/tenderness, accident/head injury,
hypertension
– Neurological change/deficit does not
disappear when the patient is pain-free
between attacks
– Develop algorithm for sinister headaches
Dowson AJ, Cady RC. Rapid Reference to Migraine 2002.
Exclude sinister
Headache (<1%)
Patient presenting
with headache
Four-item questionnaire
1. What is the impact of the headache on
the sufferer’s daily life?
(screens for migraine/chronic
headaches and ATTH)
Exclude sinister
Headache (<1%)
ETTH
(40-60%)
low
Patient presenting
with headache
Q1. What is the impact of the headache
on the sufferer’s daily life?
High
Migraine/CDH
The diagnostic importance of
headache impact
•
•
•
The vast majority of episodic, impactful
headaches reported by patients are caused
by migraine1
The migraine process may present as true
migraine, migrainous headache and TTH2
TTH is usually not impactful and few
patients consult a physician for it3
1Dowson
2Lipton
3Lipton
A et al. Cephalalgia 2002;22:590-1.
RB et al. Headache 2000;40:783-91.
RB et al. Neurology 2002; 58 (9 Suppl 6):27-31.
Assessing headache impact
•
•
Headache diaries
Two impact questionnaires have also been
developed
–
–
–
Migraine Disability Assessment (MIDAS)
Questionnaire
Headache Impact Test (HIT)
Both questionnaires are
•
•
•
Reliable and valid measures of impact
Have wide applications in headache management
HIT may be a particularly sensitive diagnostic tool
Dowson A. Curr Med Res Opin 2001;17:298-309.
Four-item questionnaire
2. How many days of headache does the
patient have every month?
(screens for migraine and chronic
headaches)
>15 = chronic headaches
15 = migraine
Headache Classification Committee of the IHS. Cephalalgia 1988;7 (Suppl 7):1-92
Exclude sinister
Headache (<1%)
ETTH
(40-60%)
low
Patient presenting
with headache
Q1. What is the impact of the headache
on the sufferer’s daily life?
High
Migraine/CDH
> 15
CDH
(5%)
Q2. How many days of headache
does the patient have every month?
 15
Migraine
(10-12%)
Four-item questionnaire
B. Consider short-lasting chronic
headaches
3 minutes may be short, sharp
headaches
15 min - 3 hours may be cluster
headache
Dowson AJ, Cady RC. Rapid Reference to Migraine 2002.
Exclude sinister
Headache (<1%)
ETTH
(40-60%)
low
Patient presenting
with headache
Q1. What is the impact of the headache
on the sufferer’s daily life?
High
Migraine/CDH
 15
> 15
CDH
(5%)
Q2. How many days of headache
does the patient have every month?
Consider short-lasting
Headaches (<1%)
Migraine
(10-12%)
Four-item questionnaire
3. For patients with chronic daily
headache, on how many days per
week does the patient take analgesic
medication?
(screens for medication overuse
headaches)
2 = medication overuse
<2 = no medication overuse
Silberstein SD, Lipton RB. Curr Opin Neurol 2000;13:277-83
Olesen J. BMJ 1995;310:479-80.
Exclude sinister
Headache (<1%)
ETTH
(40-60%)
Patient presenting
with headache
Q1. What is the impact of the headache
on the sufferer’s daily life?
low
High
Migraine/CDH
Q2. How many days of headache
does the patient have every month?
 15
> 15
Consider short-lasting
Headaches (<1%)
CDH
(5%)
Migraine
(10-12%)
Q3. For patients with chronic daily
headache, on how may days per week
does the patient take analgesic medications?
<2
No medication
overuse
2
Medication
overuse
Four-item questionnaire
4. For patients with migraine, does the
patient experience reversible sensory
symptoms associated with their
attacks?
(screens for migraine with aura and
migraine without aura)
Headache Classification Committee of the IHS. Cephalalgia 1988;7 (Suppl 7):19-28
Migraine with aura diagnosis: IHS
criteria
• At least three of the following four characteristics:
– One or more fully reversible aura symptoms*
– One or more aura symptoms develop over >4 min, or two or
more symptoms occur in succession
– No single aura symptom lasts >60 min
– The migraine headache occurs <60 min after the end of the
aura symptoms
• Exclusion of secondary headaches
*e.g. visual disturbances, speech disturbances and
sensations affecting other areas of the body
Headache Classification Committee of the IHS. Cephalalgia 1988;7 (Suppl 7):19-28
Exclude sinister
Headache (<1%)
ETTH
(40-60%)
Patient presenting
with headache
Q1. What is the impact of the headache
on the sufferer’s daily life?
low
High
Q2. How many days of headache
does the patient have every month?
Migraine/CDH
 15
> 15
Q3. For patients with chronic daily
headache, on how may days per week
does the patient take analgesic medications?
<2
No medication
overuse
Migraine
(10-12%)
Consider short-lasting
Headaches (<1%)
CDH
(5%)
Q4. For patients with migraine, does the
patient experience reversible sensory
symptoms associated with their attacks?
2
Medication
overuse
Yes
With aura
No
Without aura
Consulting patients with episodic
headaches
•
•
•
•
Migraine: 94%
ETTH: 2.9%
Sinister: <1%
Short-lasting headaches: <1%
Dowson AJ et al. Cephalalgia 2002;22:591.
Headache diagnosis: Discussion
• What is required:
– New headache diaries
– Simple questionnaire that confirms
diagnostic screen
– Algorithm for the diagnosis of sinister
headaches
Developing agreed principles of
migraine care for international
use in primary care
Management of migraine
Management individualised for each
patient
Assess illness severity
• Impact on daily living
– MIDAS/HIT questionnaires
•
•
•
•
Attack frequency and duration
Pain severity
Non-headache symptoms
Patient factors
– History, preference and other illnesses
Matchar DB et al. Neurology 2000; www.aan.com.
Bedell AW et al. Primary Care Network 2000.
Assessment of severity
Intermittent, lower impact
migraine
Intermittent, higher impact
migraine
Impact lower, without
significant time loss, e.g.:
MIDAS Grade I or II
HIT Grade 1 or 2
Impact higher, with significant
time loss, e.g.:
MIDAS Grade III or IV
HIT Grade 3 or 4
Headaches mild-to-moderate in
intensity
Headaches moderate or severe
in intensity
Non-headache symptoms not
severe in intensity
Significant non-headache
symptoms, possibly severe
Matchar DB et al. Neurology 2000; www.aan.com.
Bedell AW et al. Primary Care Network 2000.
Lipton RB et al. JAMA 2000;284:2599-605.
Provision of individualised treatment
plan
•
•
•
•
Evidence-based medicine (Duke database)
suggests:
Behavioural therapy recommended for all
Acute therapy recommended for all
Prophylactic therapy recommended for
certain patients
Complementary therapies may be useful as
adjunctive therapy
Headache Consortium. Neurology 2000; www.aan.com.
Bedell AW et al. Primary Care Network 2000.
Individualising care – behavioural and
physical therapy
Duke recommended therapies
• Behavioural:
–
–
–
–
Biofeedback and relaxation
Stress reduction
Avoidance of triggers
Food intolerances under investigation by MIPCA
• Physical
– Cervical manipulation
– Massage
– Exercise
Campbell JK et al. Neurology 2000; www.aan.com.
Bedell AW et al. Primary Care Network 2000.
Individualising care – acute medications
• Goals: to rapidly relieve the headache and
other symptoms, and permit the return to
normal activities within 2 hours1,2
• Acute medications should be provided for all
patients2
• Strategy: individualised care, patients have a
portfolio of medications to treat attacks of
differing severities, and have access to
rescue medications if the initial therapy fails3
1Matchar
DB et al. Neurology 2000; www.aan.com.
2Dowson AJ et al. MIPCA 2000.
3Dowson AJ. Migraine and Other Headaches: Your Questions Answered. 2003; in
press.
Individualised care for migraine
Migraine
diagnosis
Severity
assessment
Stratified care
Migraine attack
Mild to moderate migraine
Moderate to severe migraine
Initial therapy
Initial therapy
If unsuccessful
Rescue
Rescue
Staged care
Dowson AJ. Migraine and Other Headaches: Your Questions Answered.
2003; in press
Acute medications: Duke
recommended 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
Matchar DB et al. Neurology 2000; www.aan.com.
Acute medications: Duke
recommended 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
– Symptomatic treatment
Matchar DB et al. Neurology 2000; www.aan.com.
Caveats on triptan use
• Most patients are effectively treated with an oral
triptan
– Differences between the oral triptans are small and of
uncertain clinical significance
• Patients with unpredictable or fast-onset attacks
may benefit from ODT or nasal spray formulations
• Patients with incapacitating attacks may benefit from
nasal spray or subcutaneous formulations
• Subcutaneous sumatriptan is an effective rescue
medication
• Switching between alternative triptans is allowed
Dowson AJ, Cady RC. Rapid Reference to Migraine 2002.
Individualising care – prophylactic
medications
• Goals: to reduce headache frequency
by >50%
• Prophylactic medications should be
provided:
– For patients with frequent, high-impact
migraine attacks (4/month)
– Where acute medications are ineffective or
precluded by safety concerns
– For patients who overuse acute
medications and/or have CDH
Ramadan NM et al. Neurology 2000; www.aan.com.
Bedell AW et al. Primary Care Network 2000.
Silberstein SD, Goadsby PJ. Cephalalgia 2002;22:491-512.
Caveats on prophylactic medications
• Consider comorbidities before
prescribing prophylaxis
• Patients with medication overuse
headache should have acute
medications withdrawn before initiating
prophylaxis
• Acute medications should also be
provided for breakthrough attacks
Ramadan NM et al. Neurology 2000; www.aan.com.
Bedell AW et al. Primary Care Network 2000.
Dowson AJ et al. MIPCA 2000.
Silberstein SD, Goadsby PJ. Cephalalgia 2002;22:491-512.
Prophylactic medications: Duke
recommended treatments
• First-line medications:
– Beta-blockers
– Valproate
– Amitriptyline
• Second-line medications
–
–
–
–
–
–
Serotonin antagonists
Calcium channel antagonists
Other anticonvulsants
Riboflavin
NSAIDs
SSRIs
Ramadan NM et al. Neurology 2000; www.aan.com.
Silberstein SD, Goadsby PJ. Cephalalgia 2002;22:491-512.
Individualising care – complementary
therapies
Effective therapies (Duke database)
•
•
•
•
•
Feverfew
Magnesium
Vitamin B2
Acupuncture
Low-dose aspirin?
• However: use only accredited
complementary practitioners
Dowson AJ, Cady RC. Rapid Reference to Migraine 2002.
Follow-up procedures
• Instigate proactive long-term follow-up
procedures
• Monitor the outcome of therapy
– Headache diaries
– Impact questionnaires (MIDAS/HIT)
• Make appropriate treatment decisions
Dowson AJ, Cady RC. Rapid Reference to Migraine 2002.
Follow-up treatment decisions
• Acute medications
– Patients effectively treated should continue with the original
therapy
– Patients who fail on original therapy should be offered other
therapies
• Prophylactic medications
– Ensure medication is provided for an adequate time period
(up to 3 months)
– If effective, treatment can continue for 6 months, after which
it may be tapered off
– If ineffective, another prophylactic medication may be tried
– Usual contraindications apply
• Patients refractory to repeated acute and
prophylactic medications should be referred to a
specialist
– Assess quantity of medication used before referral
Dowson AJ, Cady RC. Rapid Reference to Migraine 2002.
Implementation of guidelines
• Primary care headache team
– PCP, practice nurse, ancillary staff and sometimes
pharmacist (core team)
• Nurse practitioner/internist (USA)
–
–
–
–
–
–
–
Pharmacist
Community nurses
Associate team
Optician
members
Dentist
Complementary practitioners
Specialist physician (additional resource)
And . . . The patient
Dowson AJ et al. Curr Med Res Opin 2002;18:414-39.
Primary care
Community nurse
Optician
Pharmacist
Practice
nurse
Specialist
care
Ancillary
staff
Primary care
physician
Physician with expertise
in headache:
PCP; PCT; specialist
Dentist
Complementary
practitioner
Patient
Associate team
Copyright MIPCA 2002,
all rights reserved
Core team
Dowson AJ et al. Curr Med Res Opin 2002;18:414-39.
New management algorithm
Initial consultation and
treatment
Detailed history, patient education and engagement
Diagnostic screening and differential diagnosis
Assess illness severity
Impact (MIDAS or HIT questionnaires)
Attack frequency and duration
Pain severity
Non-headache symptoms
Patient history and preferences
Intermittent, lower impact
migraine
(+/- aura)
Intermittent, higher impact
Migraine (+/- aura)
Behavioural/complementary therapies
Aspirin/NSAID (large dose)
Aspirin/paracetamol plus anti-emetic
Analgesic-isometheptene
Initial consultation
Rescue
Initial treatment
Appropriate triptan
Rescue
Increased dose / alternative
formulation triptan
Symptomatic treatment
New management algorithm
Follow-up consultation and
treatment
Initial
Initial
treatment
treatment
Aspirin/NSAID (large dose)
Aspirin/paracetamol plus anti-emetic
Analgesic-isometheptene
Appropriate triptan
If initial treatment unsuccessful
Appropriate triptan
Rescue
Follow-up treatment
Increased dose / alternative
formulation triptan
Symptomatic treatment
If unsuccessful
Frequent headache
(i.e. 4 attacks per month)
Migraine
Consider prophylaxis +
acute treatment for
breakthrough migraine
attacks
If unsuccessful
Chronic daily
Headache (CDH)?
If
management
unsuccessful
Consider referral
Migraine management: Discussion
• Provide guidelines for the use of
analgesics
• Evidence-based review of acute and
prophylactic medications
• Consider concurrent comorbidities in
the choice of prophylaxis
Principles of migraine
management in primary care
Principles of headache management
• Initial principles created by MIPCA in the UK
– ‘10 Commandments’
• Principles modified by 1st HCPC Meeting in
London
– 1st step to ‘internationalise’ principles
• Key objective of Vienna meeting
– To agree on recommended international
principles that can be customised for use in
separate countries
Dowson AJ et al. Curr Med Res Opin 2002;18:414-39.
Agreed principles of
migraine management for
international use
Screening/diagnosis
1. Almost all headaches are
benign/primary and can be managed
by all practising clinicians.
(The most common presenting
headache is migraine.
However, monitor for sinister
headaches and refer if necessary.)
Screening/diagnosis
2. Use questions / a questionnaire
assessing impact on daily living for
diagnostic screening and to aid
management decisions.
(Any stable pattern of episodic, high
impact headaches should be given a
default diagnosis of migraine.
PCPs, nurses and pharmacists can all
apply the questionnaire.)
Management
3. Share migraine management between
the clinician and patient.
(The patient taking control of their
management
and
the clinician providing education and
guidance.)
Management
4. Provide individualised care for
migraine and encourage patients to
treat themselves.
(Migraine attacks are highly variable
in frequency, duration,
symptomatology and impact.)
Management
5. Follow-up patients, preferably with
migraine diaries.
(Invite the patient to return for further
management and apply a proactive
policy.)
Management
6. Assess the success of therapy using
specific outcome measures and
monitor the use of acute and
prophylactic medications regularly.
Management
7. Adapt migraine management to
changes that occur in the illness and
its presentation over the years.
(e.g. migraine may change to chronic
daily headache over time.)
Treatments
8. Provide acute medication to all
migraine patients and recommend it is
taken as early as possible in the
attack.
(Triptans are the most effective acute
medications for migraine. Avoid the
overuse of all drugs to avoid
medication overuse headache.)
Treatments
9. Provide rescue medication /
symptomatic treatment if the initial
therapy fails.
(Narcotics may be appropriate in
certain circumstances in
compassionate use.)
Treatments
10. Prescribe prophylactic medications to
patients who have four or more
migraine attacks per month or who
are resistant to acute medications.
(First-line prophylactic medications
are beta-blockers, sodium valproate
and amitriptyline.)
Treatments
11.Consider concurrent comorbidities in
the choice of appropriate prophylactic
medications.
Treatments
12.Work with the patient to achieve
comfort with the treatment
recommended and that it is practical
for their lifestyle and headache
presentation.
Outputs from the 2002 meeting
•
•
•
•
Principles for managing migraine in
primary care
Peer-reviewed article published in
learned journal
Newsletter (‘popular PCP’ version)
Slide set
Further educational items to be
defined