Welcome to the program!

Transcription

1 Calgary Headache Assessment & Management Program (CHAMP) EDUCATION SESSION Welcome to the program!

2 What is the Purpose of this To provide you with: Session? accurate and current headache information the option to ask our staff questions a roadmap to CHAMP a chance to think about what you want your time in CHAMP to look like and to create a plan 2

3 What is the Purpose of This Session? To tell you about CHAMP s unique structure: The majority of your time will be spent completing a lifestyle assessment, attending workshops and lectures, and seeing CHAMP s nurses/ allied health providers. If it s still required, you will see the CHAMP neurologist for 1-3 visits in approximately months from now. 3

4 Who Is This Session For? All or most of the information in this session can be used by people with: -migraine headaches - tension-type headaches - post-traumatic (e.g., concussion) headaches Some of this information can be used by people with: - cluster headaches - trigeminal neuralgia/facial pain - other headache types 4

5 Session Outline Introduction to the program Headache Diagnosis Medical treatment of headaches Behavioral Approaches for headache management CHAMP program components and roadmap

6 Calgary Headache Assessment & Management Program (CHAMP) Located at 2 sites: 1) South Health Campus 4448 Front Street S.E. (5 th Floor) Phone (403) ) Richmond Road Diagnostic and Treatment Center 1820 Richmond Road S.W. Phone (403)

7 Calgary Headache Assessment & Management Program (CHAMP) Psychologist Research Headache Physicians Our Team Nurses Occupational Therapists Physiotherapists You Your Family Doctor Registered Dieticians Kinesiologist Clerks Pharmacist

8 A Multi-Faceted Approach Sleep Quality Exercise Routine Food Choices & Eating Patterns Good Posture Habits Medications -symptomatic -preventative HEADACHE SELF-MANAGEMENT Adequate Hydration Self- Monitoring (Diaries) Stress Management Strategies Pacing & Lifestyle Balance Trigger Management

9 How We Measure Success Reduced frequency, intensity, and/or duration of headache Improved day-to-day function despite headaches (coping) Quality of life improvement/satisfaction Sense of control over headaches

10 Headache Days / Month (N = 85)** *P< **CHAMP self management groups, headache days by patient report at baseline and 3 months post self management. 10

11 CHAMP s Cancellation Policy If you can t make it to a booked appointment, workshop, or lecture, please give us 2 days notice. That way someone else can be booked into the spot and you can be rebooked. If an appointment is missed without 2 days notice, you may be discharged. 11

12 CHAMP s Cancellation Policy If you have to cancel any type of appointment (including groups), please call (403) Sometimes it s not possible to give 2 days notice (e.g., in times of sickness). Please call anyway, and we will discuss the situation together.

13 Headache: Diagnosis and Use of Medications Calgary Headache Assessment and Management Program (CHAMP) 13

14 Medical Section Outline How are headaches diagnosed? Where does the pain come from? Acute medications to relieve headache attacks. Preventative medications to reduce headache frequency. Medication overuse headache. 14

15 Headache Diagnosis The first decision: Are the headaches: Secondary Headaches? or Primary Headaches?

16 Secondary Headaches: Headaches from an Identifiable Cause Examples: 1. Head/neck injury 2. Medication Overuse 3. Caffeine withdrawal 4. Alcohol Induced 5. Meningitis 6. Brain tumor 7. Brain Hemorrhage 8. Neuralgias 9. Others

17 Primary Headache: Headaches with no Examples: other Underlying Cause 1. Migraine with or without aura 2. Tension-type headache 3. Cluster headache 4. others

18 Chronic Migraine and Chronic Tension-Type Headache Chronic migraine: migraine with headache on more than 14 days a month Chronic tension-type headache: tension-type headache on more than 14 days a month. Some people may have migraine on some days and tension-type headache on other days

19 How do we diagnose primary headaches? Migraine without aura At least 5 attacks, 4-72 hrs 2 of: One-sided Moderate-severe Throbbing Worse with routine activity 1 of: Nausea/vomiting Light and sound sensitivity No other cause Tension-Type Headache At least 10 attacks, 30 min-7 days 2 of: - Mild-moderate intensity - Bilateral - Tight, non-throbbing, band-like headache - No worsening with activity Both of: - No nausea or vomiting - No more than one of light or sound sensitivity No other cause

20 What is an aura? Nervous system symptoms that come on slowly before a migraine and last less than 1 hour Occur in 1/3 of migraine patients Vision changes Numbness/Pins and needles Speech problems Less commonly, weakness, dizziness Resolve completely

21 What Causes the Pain in a Migraine Attack?

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23 Migraine in the population

24 Migraine Treatment Basics Lifestyle issues Specific triggers Treatment for individual headache attacks (acute therapy) Non-medication Medications Preventing headache attacks - Preventative medications - Behavioural strategies

25 Choosing Acute Migraine Medications Mild Attacks: ASA, Acetaminophen (Tylenol), Ibuprofen (Advil) Moderate: NSAIDS (Ibuprofen, Naproxen, Diclofenac, Others) Triptans Severe Attacks: DHE, Triptans

26 Treating Acute Migraine Attacks Treat early in the attack if you can Avoid too frequent use NSAIDS and Triptans can be taken together Medications that include codeine, oxycodone, or other opioids are not recommended for routine use (e.g., Percocet or Tylenol #1,2,3,4) 26

27 The Triptans: Medications Designed Specifically for Migraine 27

28 Tension-Type Headaches Attacks are often not severe, so not all attacks require medication. For individual attacks, NSAIDs (Ibuprofen, Naproxen, etc.) are best. 28

29 Preventive Medication Consider a daily preventive if: you have significant disability despite the use of acute treatments. you need to use acute medications so frequently that you are at risk for medication-induced headache. Preventive medications need to be taken every day

30 Migraine Preventive Medications Certain blood pressure medications (e.g., Propranolol) Certain antidepressants (e.g., Amitriptyline) Certain anti-seizure medications (e.g., Topiramate) Others (e.g., Botulinum toxin A (Botox) for chronic migraines) Certain vitamins, minerals, herbs Riboflavin (400 mg per day)* Magnesium citrate ( mg per day)* Coenzyme Q10 (150 mg twice a day)* *If you re pregnant or thinking of becoming pregnant, talk to your doctor or ask about our handout.* 30

31 Preventive Medications for Other Headache Types Tension-type headache: Amitriptyline, Nortriptyline, Venlafaxine Cluster headache: Verapamil, Lithium Post-traumatic headaches: Depends on the headache type 31

32 Preventive Medication Key Messages It may take up to 3 months for a preventive medication to work effectively. You may need to be on a high enough dose for the medication to work. Taking too much pain medication may limit how well a preventive medication will work. 32

33 Too much of a good thing: Medication Overuse Headache Taking too much pain medication can cause more headaches.

34 How much is too much? Triptans, opioids, DHE, ergotamine (e.g. migranal, imitrex, codeine, demerol, 222s, Tylenol #3) 10 or more days/month for more than 3 mo.

35 How much is too much? NSAIDs (ibuprofen, naproxen, diclofenac, etc.), ASA, acetaminophen 15 or more days/month for more than 3 mos. 35

36 Example of Medication Overuse 36

37 One Year After Stopping Overuse. 37

38 Medication Overuse: Case Two 58 year old male (LGB) Migraine since 12 years of age Chronic daily headache for at least ten years prior to being seen, associated with daily use of acetaminophen and ibuprofen On amitriptyline 25 mg daily In October, 2013, he attended the CHAMP education session, and stopped his medication overuse.

39 His headaches worsened, but after two weeks they were much improved. Headaches reduced to one migraine attack every two months 39

40 Treating Medication Overuse Patient Education Stop medication overuse (support available) Provide a good acute medication Start a preventive medication 40

41 Key Messages Understand your headaches and diagnosis. Become skilful in using acute medications. Use preventive medications if necessary. Avoid medication overuse. Ask about a handout you and your doctor can review. Use diaries to monitor headaches and medication use. Attend the CHAMP medication lecture. 41

42 Opportunity To Enter Research Trials Medication Overuse Study - 3 month study For chronic migraine sufferers (more than 14 days of headache per month) Use pain medications on 15 or more days per month Migraine and Exercise Study - 6 month study For migraine sufferers ages Are interested in an exercise program and are not currently exercising regularly Sleep and Migraine Study 6 month study For migraine sufferers age 18+ with sleep problems Participants will complete an 8-week on-line educational workshop If interested, please sign up during the break *30 days of diaries are needed to assess eligibility

43 For more information go to 43

44 Behavioural Headache Strategies 44

45 Behavioural Approach in Headache Treatment interventions intended to change the behaviour of a headache sufferer with the goal of reducing symptoms, improving functional status, or improving health related quality of life. Penzien et al. 2005

46 Why Consider Behavioural Strategies? The individual prefers a non-drug approach. Effective medications cannot be taken or don t work. The patient is pregnant, has plans to become pregnant or is nursing. There is excessive use of acute medication. High stress levels or limited stress coping skills.

47 Main Behavioural Strategies 1) Identify and Manage Triggers 2) Lifestyle Adjustments 3) Relaxation 4) Cognitive Behavioural Therapy (Self Talk)

48 Behavioral Strategy #1: Identify and Manage Triggers Become aware of potential triggers Determine your personal headache triggers (Daily headache diary entries can help.) Minimize/avoid the triggers you can control Develop a coping plan for times when you cannot control triggers (e.g., weather change)

49 Some Common Triggers (Identified by Patients in Belief Surveys ) *Stress/Let down Anxiety/worry and depression Overexertion Caffeine, alcohol MSG, Aspartame, Nitrates Odors/fumes Weather (e.g., Chinooks) Hormones (e.g., menstrual cycle) Changes in eating or sleeping habits

50 Headache Triggers: CHALLENGES not everyone has the same triggers the exact way in which headaches are triggered is still not known for sure most triggers work in combination, and it can be hard to tease out which ones are involved.

51 Migraine Trigger Threshold Theory Danger Zone skipped breakfast Trigger Threshold poor sleep Precautionary Zone

52 Migraine Trigger Threshold Theory Chinook Danger Zone Trigger Threshold skipped breakfast poor sleep Precautionary Zone

53 Examples from Research Showing How Triggers Add Up Headache was more likely to follow two consecutive days of poor sleep and high stress than either poor sleep or high stress alone. Stress on its own didn t impact migraine, but it did during the premenstrual phase. 53

54 Migraine Trigger Threshold Theory The objective of headache trigger management is to keep your trigger level below your threshold. Reduce your trigger load (minimize/avoid exposure) Raise your threshold (regular aerobic exercise, preventive medication)

55 Behavioural Strategy #2: Lifestyle Adjustments This involves adjustments in the areas of: hydration and nutrition caffeine intake sleep routine and habits exercise and posture stress management

56 Lifestyle Adjustments eat at regular intervals (every 3-4 hours) avoid foods high in simple carbohydrates (sugars), especially eaten alone drink litres of fluid per day limit caffeine to no more than 100* mg per day; consider reducing it to 2 times/week or stopping it completely. * (e.g., ~ 8-oz. cup of brewed coffee, 2 cups of black tea, 3 cups of green tea, 1 energy drink).

57 Lifestyle Adjustments Maintain a consistent sleep-wake schedule daily make regular physical activity part of your routine learn about stretching and strengthening exercises to support good postural habits practice a relaxation strategy daily (e.g. diaphragmatic breathing, meditation)

58 Modifiable Risk Factors Associated with Developing Chronic Daily Headache Medication overuse Obesity Poor sleep Caffeine intake > 100 mg/day Habitual (daily) snoring Stressful life events (e.g., moves, deaths, marital status changes, other highly stressful events) 58

59 Headache Behavioural Strategy #3: Relaxation Relaxation can be used to help prevent headaches or stop headaches in their early stages. Relaxation practice can: counteract the stress response manage negative emotions, enhance sleep help manage pain.

60 Relaxation Research Regular use of relaxation techniques is associated with less frequent and less intense headaches for most individuals with migraine and tension headaches. Progressive Muscle Relaxation Diaphragmatic Breathing Visualization/Imagery Meditation

61 The Physical Stress Response When someone perceives they are under stress, their body reacts with the stress response (fight or flight): -Increased heart rate -Shallow breathing -Release of hormones (Adrenalin) -Muscle Tension The stress response can be a trigger for headaches.

62 Relaxation Resources Free relaxation tracks Relaxation Workshop Self-Management Workshop Apps (e.g., Stop, Breathe & Think) 62

63 Behavioural Strategy #4: Cognitive Behavioural Therapy (Self Talk) Negative/Unhelpful thoughts and behaviour can generate stress and stress-related headaches A coping style of self-talk can help reduce stress and negative emotions The person is less vulnerable to stress-related headache

64 CHAMP Behavioural Programs Lifestyle Assessment individual appointment Workshops/Lectures small group format Dates, times, locations on schedule Call (403) to register. 64

65 Lifestyle Assessments Focuses on key health domains (sleep habits, hydration/nutrition, exercise and posture, and stress) Guidance given for lifestyle adjustments in these domains that can improve headache management Identify/clarify your goals for headache management Identify program workshops that may help you work towards your goals

66 Self Management Workshop An opportunity to learn and practice coping skills for headache management, including: Relaxation techniques Stress Management Pacing Self-talk strategies A supportive group environment Increase your confidence in your ability to have control over your headaches

67 Bodyworks Workshop Postural Awareness and Adjustments Stretching and Strengthening Exercises

68 Relaxation Workshop Focus is primarily on relaxation skills; stress management is also addressed An 8-week self-study format: - 3 clinic sessions, - 2 phone contacts - self-study at home

69 Web-Based Sleep Workshop Ongoing enrollment 8 parts Designed for people with headaches and sleep problems An alternative to traditional workshops 69

70 Nutrition and Headache Lecture Addresses what a healthy diet means for people with headaches. Examines potential dietary triggers for headache and associated management strategies. 70

71 Medication Lecture Learn about medications used to prevent headaches. Learn about medications used to treat headaches. Learn about medication overuse headache. 71

72 Ergonomics Lecture An introduction to possible ergonomic risk factors in headache and strategies to address them. Job modification ideas General work survival strategies

73 CHAMP Client Lori Age 28 Referral letter: Chronic migraines +?MOH Maxalt, Naproxen, Tylenol #3 Known triggers: posture, delayed meals, poor sleep, menstruation 73

74 CHAMP Client Lori Education Session: May 2014 Lifestyle Assessment: June 2014 Plan (as identified by Lori): (1) Posture Body Works, Ergonomics, 1:1 kinesiology if required (2) Nutrition Nutrition Lecture, Increase hydration, more frequent meals/snacks (3) Stress Management Self Management Workshop (4) Meds/Supplements/MOH Medication Lecture; start recording painkiller use in diaries to establish frequency (5) Miscellaneous Self-Management Attend Sleep Lecture, Relaxation Workshop, and continue recording in diary. 74

75 CHAMP Client Lori - Timeline June headache days/month (intensity 1-10/10) July-Aug 2014 Medication/Ergonomics lectures, Body Works Sleep/Nutrition lectures, Self Mgmt. Workshop Sept.-Nov 2014 Relaxation Workshop Oct April Dec Kinesiologist appointments (additional stretches/core exercises/body mechanics) CHAMP MD Appointment ( Elavil, Propranolol) Discharged from program 10 headache days/month; (intensity 1-5/10) 75

76 What s Next? Participate in a Lifestyle Assessment Enroll in CHAMP Workshops and Lectures Participate in a CHAMP Clinical Trial (study)

77 CHAMP Website Workshop schedules Blank headache diaries Useful information 77