Hoofdpijn in de apotheek

Transcription

1 Hoofdpijn in de apotheek Prof. Dr. Koen Paemeleire Dienst Neurologie, Universitair Ziekenhuis Gent Vakgroep Medische Basiswetenschappen, Universiteit Gent

2 Overzicht 1. Epidemiologie 2. Red flags 3. Medication-overuse headache 4. Migraine screener 5. Acute behandeling migraine in officina 6. Tools voor patiënten 7. Besluiten

3 1. Epidemiologie Hoofdpijn: top 10 disability in Europa Migraine (6%?, 15-18%? ) Tension-type headache (E of C 2-3 %) Primary care! Medication-overuse headache ( 1%) = secondary headache

4 1. Epidemiologie

5 Acute treatment: epidemiological data Treatment of migraine in different European countries 100% 80% 60% 40% 20% 0% Sweden Finland Norway Netherlands Israel Germany Spain Italy Greece Triptans prescribed drugs OTC Courtesy Prof. Dr. Stefan Evers

6 Acute treatment: epidemiological data Migraine patients with triptans 70% 60% 50% 40% 30% 20% 10% 0% N F DK S NL SF UK E I D B Courtesy Prof. Dr. Stefan Evers

7 2. Red flags Een 47-jarige man ontwikkelde een plotse, zeer hevige, kloppende hoofdpijn, meest uitgesproken hoog in de nek en aan het achterhoofd. Er is geen voorgeschiedenis van hoofdpijn. Is dit een urgentie?

8 2. Red flags Headache intensity 1 minute Time Thunderclap headache! Subarachnoidale bloeding uit te sluiten!

9 A good history is taken, not just given Detailed History (& Examination) Preliminary Diagnosis YES NO Primary Headache? Secondary Headache? Atypical Features

10 WORRISOME HEADACHE RED FLAGS SNOOP Systemic symptoms (fever, weight loss) or Secondary risk factors (HIV, systemic cancer) Neurologic symptoms or abnormal signs Onset: sudden, abrupt, or split-second Older: new onset and progressive headache, especially in middle-age > 50 Previous headache history: first headache or different (change in attack frequency, severity or clinical features)

11 Table 1 Drugs that may induce headache or worsen pre-existing headache ICHD-II, page 144

12 3. Medication-overuse headache ~ chronische spanningshoofdpijn ~ chronische migraine (bijna) dagelijkse hoofdpijn ochtendlijke hoofdpijn refractair aan preventieve behandeling pogingen tot stoppen: ontwenningsverschijnselen medication-overuse toxicomanie! Ψ co-morbiditeit: depressie, angst

13 3. Medication-overuse headache Medication overuse simple analgesics > paracetamol < ASA, NSAID opioids combination analgetisics ergotamine triptans barbiturates (<) 15 d/m 10 d/m

14 3. Medication-overuse headache Combinatiepreparaten

15 3. Medication-overuse headache

16 4. Migraine screener De migraine ijsberg 39% Diagnose Migraine 48% 61% 1989 Geen diagnose Migraine 52% 1999 Lipton et al., American Migraine Study II

17 4. Migraine screener A) n 5 aura B) 4-72 h C) unilateral pulsating 2/ / +++ D) 1/ photo- & phonophobia nausea ± vomiting

18 4. Migraine screener PIN photophobia nausea inability to function Sens 81 % Spec 75 % PPW 93 % Neurology (2003), 61(3):

19 4. Migraine screener

20 5. Acute behandeling migraine

21 Migraine Anno 2009 NON - PHARMACOLOGIC ACUTE PREVENTIVE

22 5. Acute behandeling migraine 1. Paracetamol 2. Acetylsalicylic acid 3. NSAIDs 4. Triptans 5. Ergotamine 6. Dihydroergotamine 7. Combinations

23 5. Acute behandeling migraine 5.1 Paracetamol Paracetamol vs placebo Paracetamol 1000 mg N = 4, n = attacks % painfree 2h Lipton 2000, Hoernecke 1993, Diener 2005, Freitag 2008 Reported in 2/4 trials Paracetamol (22%) was SS better than placebo (11%) in one trial. In the other trial paracetamol (26%) was better than placebo (15%), but no statistics for this comparison were provided. Moderate QOE

24 5. Acute behandeling migraine 5.2 Acetylsalicylic acid Acetylsalicylic acid vs placebo Acetylsalicylic acid N =8, 650 mg 1000 mg n= attacks % pain-free 2h reported in 7/8 trials In 4 trials ASA (20-29%) was SS better than placebo (6-17%). In three other trials the difference between ASA (14-22%) and placebo (5-14.5%) didn t reach statistical significance, but there was a trend towards better efficacy with ASA. One of these trials used a lower dose of ASA (650 mg) Moderate QOE Tfelt-Hansen 1984, Lange 2000, MacGregor 2002,Boureau 1994, Diener 2004b, Lipton 2005, Diener 2005, Diener 2004a Acetylsalicylic acid N =1, 1 % pain-free 2h Acetylsalicylic acid 44% High QOE IV 1000 mg n=160 attack Placebo 14% SS Diener 1999

25 5. Acute behandeling migraine 5.3 NSAIDs NSAIDs vs placebo Ibuprofen mg N=7, n = attack-3 months % pain-free 2h reported in 5/7 trials. In 4 trials ibuprofen (15-33%) was SS better than placebo (2-13%). In 1 study there was a NS difference. A meta-analysis which studies lowdose ibuprofen only ( mg) finds a number to treat of 13 for ibuprofen 200 mg and 9 for ibuprofen 400 mg. Kellstein 2000, Havanka-Kanniainen 1989, Codispoti 2001, Sandrini 1998,Diener 2004, Goldstein 2006, Suthisisang 2007, Misra 2007 Diclofenac p.o mg or 75 mg IM N=6, n=938 1 attack-3 months % pain-free 2h Reported in 3/6 trials. In all trials, diclofenac (24-45%) was SS better than placebo (12-25%) Massiou 1991, Dahlof 1993, Diclofenac-K 1999, Diener, 2005, Vecsei 2007 (p.o.), Bigal 2002 (IM) Naproxen mg N=2, n=148 Headache intensity 1 2 periods of 6 attacks or 3 months (whichever Occurred first) Both trials reported a SS lower headache intensity after naproxen compared with placebo. In one trial, only data from the 1h time point and no absolute numbers were reported, in the other trial the difference was very small (2.1 vs 2.3 on a 0-3 points scale). Moderate QOE High QOE Very low QOE Nestvold 1985, Sargent 1988

26 5. Acute behandeling migraine 5.4 Triptans

27 5. Acute behandeling migraine 5.5 Combinations Paracetamol + acetylsalicylic acid vs placebo Paracetamol 400 mg + acetylsalicylic acid 500 mg N = 1, n =707 2 attacks time to 50% pain relief Diener 2005 PAR+ASA (1h13) was SS better than placebo (2h13) Low QOE Paracetamol + acetylsalicylic acid + caffeine vs placebo Paracetamol mg + acetylsalicylic acid 500 mg + caffeine mg N = 4, n = attacks % pain-free 2h Lipton 1998, Goldstein 2005, Diener 2005, Goldstein 2006 reported in 2/4 trials In one trial paracetamol + acetylsalicylic acid + caffeine (21%) was SS better then placebo (7%). In the other trial paracetamol + acetylsalicylic acid + caffeine was also SS better than placebo, but no absolute numbers were reported. Moderate QOE Paracetamol + codeine vs placebo Paracetamol 400 mg + codeine 25mg N = 1, n =259 3 attacks % pain-free 2h Boureau 1994 The difference between paracetamol + codeine (18%) and placebo (11%) was NS Moderate QOE

28 5. Acute behandeling migraine 5.5 Combinations Paracetamol + acetylsalicylic acid vs placebo Paracetamol 400 mg + acetylsalicylic acid 500 mg N = 1, n =707 2 attacks time to 50% pain relief Diener 2005 PAR+ASA (1h13) was SS better than placebo (2h13) Low QOE Paracetamol + acetylsalicylic acid + caffeine vs placebo Paracetamol mg + acetylsalicylic acid 500 mg + caffeine mg N = 4, n = attacks % pain-free 2h Lipton 1998, Goldstein 2005, Diener 2005, Goldstein 2006 reported in 2/4 trials In one trial paracetamol + acetylsalicylic acid + caffeine (21%) was SS better then placebo (7%). In the other trial paracetamol + acetylsalicylic acid + caffeine was also SS better than placebo, but no absolute numbers were reported. Moderate QOE Paracetamol + codeine vs placebo Paracetamol 400 mg + codeine 25mg N = 1, n =259 3 attacks % pain-free 2h Boureau 1994 The difference between paracetamol + codeine (18%) and placebo (11%) was NS Moderate QOE

29 5. Acute behandeling migraine 5.5 Combinations Paracetamol + acetylsalicylic acid vs placebo Paracetamol 400 mg + acetylsalicylic acid 500 mg N = 1, n =707 2 attacks time to 50% pain relief Diener 2005 PAR+ASA (1h13) was SS better than placebo (2h13) Low QOE Paracetamol + acetylsalicylic acid + caffeine vs placebo Paracetamol mg + acetylsalicylic acid 500 mg + caffeine mg N = 4, n = attacks % pain-free 2h Lipton 1998, Goldstein 2005, Diener 2005, Goldstein 2006 reported in 2/4 trials In one trial paracetamol + acetylsalicylic acid + caffeine (21%) was SS better then placebo (7%). In the other trial paracetamol + acetylsalicylic acid + caffeine was also SS better than placebo, but no absolute numbers were reported. Moderate QOE Paracetamol + codeine vs placebo Paracetamol 400 mg + codeine 25mg N = 1, n =259 3 attacks % pain-free 2h Boureau 1994 The difference between paracetamol + codeine (18%) and placebo (11%) was NS Moderate QOE

30 Summary of PCT % 2h pain-free (placebo) % 2h pain-free placebo substracted PARACETAMOL 22 (11) 11 ACETYLSALICYLIC ACID ASA mg PO (6-17) 8-12 NSAIDS ibuprofen (2-13) diclofenac (12-25) naproxen?? TRIPTANS oral ~30-40 (5-10) ~ SC sumatriptan (18-19) ERGOTAMINE ± CAFFEINE?? DIHYDROERGOTAMINE (NS/PO)?? COMBINATIONS paracetamol + ASA?? paracetamol + ASA+ caffeine 21 (7) 14 sumatriptan + naproxen (6-10) 24

31 5. Acute behandeling migraine Over-the-counter drugs for acute migraine attacks: literature review and recommendations. Pharmacotherapy Apr;23(4): Six of every 10 patients with migraine treat their headache exclusively with over-the-counter (OTC) products. Overreliance on OTC agents contributes to preventable morbidity and drug-induced headaches. In the studied populations, acetaminophen, aspirin, ibuprofen, and an aspirin-acetaminophen-caffeine combination product were shown to be more effective than placebo at reducing moderate or severe migraine pain to mild or no pain by 2 hours after administration. However, published trials of OTC agents have systematically excluded patients enduring morbidity with 50% or more of attacks and/or vomiting with 20% or more of attacks.

32 5. Acute behandeling migraine Over-the-counter drugs for acute migraine attacks: literature review and recommendations. Pharmacotherapy Apr;23(4): Patients who experience disability during the predominance of their attacks are poor candidates for OTC-exclusive therapy and should seek a physician's help for migraine-specific prescription drugs. For those with migraine who encounter disability with less than 50% of attacks and/or vomiting with less than 20% of attacks, sole treatment with OTC products is a feasible option. Patients who fail to obtain acceptable relief after an adequate trial of OTC agents also should be referred to a physician. Pharmacists are well positioned to assess whether patients could benefit from OTC agents or should seek a physician's assistance.

33 J Headache Pain (2007) 8:S1-S47

34 J Headache Pain (2007) 8:S1-S47

35 J Headache Pain (2007) 8:S1-S47

36 6. Tools voor patiënten én apothekers 1. i.s.m. Belgian Headache Society 2. World Headache Alliance 3. RIZIV Consensusconferentie Migraine ( ) 4. European Headache Federation 5. Domus Medica richtlijn Hoofdpijn (volgt)

37 7. Besluiten Migraine patiënten 6/10 enkel OTC niet steeds effectief/risico MOH diagnose (iceberg) Welke OTC? Paracetamol (1000 mg) ASA (1000 mg) Ibuprofen ( mg) Paracetamol-ASA-caffeine max 6-8 dagen/maand! Situatie in Vlaanderen?

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