OH and Headache

Dr David PB Watson GPwSI Hamilton Medical Group Aberdeen

Objectives

• Headache impact and epidemiology • Headache diagnosis • Headache management • audit and useful information • case study

Objective 1

Headache Impact and Epidemiology

Primary headache No underlying medical cause:

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Episodic primary headaches

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Chronic primary headaches

Headache types

90% 10% Secondary headache Underlying medical cause:

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Tumour

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Meningitis

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Vascular disorders

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Systemic infection

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Head injury

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Drug-induced

Episodic primary headaches

Cluster Migraine +/ aura Episodic primary headaches Probable migraine Tension-type headache (TTH)

Chronic primary headaches / chronic daily headaches

New daily persistent Hemicrania continua Chronic daily headache (CDH) Chronic tension Chronic migraine +/ medication overuse Chronic cluster

(n=740)

Lifetime prevalence of primary headache

Chronic daily - all types 4% Episodic migraine 16% 78% Episodic TTH Rasmussen et al 1991

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 migraine

For most sufferers, migraine results in lost productivity rather than days lost from work

Work loss (%) 100 80 60 40 20 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 0 0 10 20 30 40 50 60 70 Migraine sufferers (%) 80 90 100 Adapted from von Korff et al 1998

Objective 2

Headache Diagnosis

This slide kit is for educational purposes only

“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

Migraine Probable migraine Essential (3)

• • •

Recurrent No organic disease Duration 4-72 h

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Recurrent No organic disease Duration 4-72 h Tension-type

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Recurrent No organic disease Duration 0.5 h-7 days Essential (2)

• • • •

Unilateral Pulsating Moderate / severe Aggravated by movement

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Moderate / severe + one other

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Generalised Pressure / tightness Slight / moderate Essential (1)

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Nausea / vomiting Photo / phonophobia

•

Photo / phonophobia 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 disability 11, 23, 24 • nausea 16, 23 • sensitivity to light during migraine headache 16, 23 • sensitivity to light between migraine attacks 25 • aura 16, 18 • sensitivity to noise 16 • exacerbation by physical activity 16 • positive family history of migraine 16 • The features which give the greatest sensitivity and specificity are disability, nausea and sensitivity to light 23 – 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

Objective 3

Headache Management

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 Guidelines

Acute pharmacological therapies

Drug class Analgesics 5-HT 1B/1D agonists (Triptans) Drug name Aspirin 900 mg, ibuprofen 400mg Almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan ,zolmitriptan Domperidone, prochloroperazine antiemetics 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

Objective 4

Audit Useful Information

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

Objective 5

Case Study

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

Any Questions?