They are updated regularly as new NICE guidance is published. To view the latest version of this NICE Pathway see:

Transcription

1 bring together everything NICE says on a topic in an interactive flowchart. are interactive and designed to be used online. They are updated regularly as new NICE guidance is published. To view the latest version of this NICE Pathway see: NICE Pathway last updated: 02 June 2017 This document contains a single flowchart and uses numbering to link the boxes to the associated recommendations. Page 1 of 10

2 Page 2 of 10

3 1 Diagnosis of s No additional information 2 Tension-type, migraine (with or without aura) and cluster Diagnose tension-type, migraine or cluster according to the features shown in the diagnosis table for tension-type, migraine and cluster [See page 5]. Migraine (with or without aura) Suspect aura in people who present with or without and with neurological symptoms that: are fully reversible and develop gradually, either alone or in succession, over at least 5 minutes and last for 5 60 minutes. Diagnose migraine with aura in people who present with or without and with one or more of the following typical aura symptoms that meet the criteria listed in 'When to suspect aura' above. visual symptoms that may be positive (for example, flickering lights, spots or lines) and/or negative (for example, partial loss of vision) sensory symptoms that may be positive (for example, pins and needles) and/or negative (for example, numbness) speech disturbance. Consider further investigations and/or referral for people who present with or without migraine and with any of the following atypical aura symptoms that meet the criteria listed in 'When to suspect aura' above. motor weakness or double vision or visual symptoms affecting only one eye or poor balance or decreased level of consciousness. Page 3 of 10

4 Quality standards The following quality statement is relevant to this part of the interactive flowchart. 1. Classification of type 3 Menstrual-related migraine Suspect menstrual-related migraine in women and girls whose migraine occurs predominantly between 2 days before and 3 days after the start of menstruation in at least 2 out of 3 consecutive menstrual cycles. Diagnose menstrual-related migraine using a diary for at least 2 menstrual cycles. For more information on using a diary see 'Headache diaries' under assessment. 4 Medication overuse Be alert to the possibility of medication overuse in people whose developed or worsened while they were taking the following drugs for 3 months or more: triptans, opioids, ergots or combination analgesic medications on 10 days per month or more or paracetamol, aspirin or an NSAID, either alone or in any combination, on 15 days per month or more. 5 Management of s See / Management of s Page 4 of 10

5 Diagnosis table for tension-type, migraine and cluster Headache feature Tension-type Migraine (with or without aura) Cluster Pain location 1 Bilateral Unilateral or bilateral Unilateral (around the eye, above the eye and along the side of the head/face) Pain quality Pressing/tightening (non-pulsating) Pulsing (throbbing or banging in young people aged years) Variable (can be sharp, boring, burning, throbbing or tightening) Pain intensity Mild or moderate Moderate or severe Severe or very severe Effect on activities Not aggravated by routine activities of daily living Aggravated by, or causes avoidance of, routine activities of daily living Restlessness or agitation Other symptoms None Unusual sensitivity to light and/or sound or nausea and/or vomiting Aura 2 Aura symptoms can occur with or without and: On the same side as the : red and/or watery eye nasal congestion and/or runny nose swollen eyelid forehead and facial sweating are fully reversible develop over at least 5 minutes constricted pupil and/or drooping eyelid Page 5 of 10

6 last 5 60 minutes. Typical aura symptoms include visual symptoms such as flickering lights, spots or lines and/or partial loss of vision; sensory symptoms such as numbness and/or pins and needles; and/or speech disturbance. Duration 4 72 hours in adults of 30 minutes continuous 1 72 hours in young people aged years minutes 1 every Frequency of Less than 15 days per month 15 days per month or more for more than 3 months Less than 15 days per month 15 days per month or more for more than 3 months 1 every other day to 8 per day 3, with remission 4 more than 1 month other day to 8 per day 3, with a continuous remission 4 less than 1 month in a 12-month period Diagnosis Episodic tensiontype Chronic tensiontype 5 Episodic migraine (with or without aura) Chronic migraine (with or without aura) 6 Episodic cluster Chronic cluster Page 6 of 10

7 1 Headache pain can be felt in the head, face or neck. 2 For further information on diagnosis of migraine with aura see tension-type, migraine (with or without aura) and cluster [See page 3]. 3 The frequency of recurrent s during a cluster bout. 4 The pain-free period between cluster bouts. 5 Chronic migraine and chronic tension-type commonly overlap. If there are any features of migraine, diagnose chronic migraine. 6 NICE has developed technology appraisal guidance on botulinum toxin type A for the prevention of s in adults with chronic migraine (s on at least 15 days per month of which at least 8 days are with migraine). See prophylactic treatment. Glossary Acute narrow-angle glaucoma An uncommon eye condition that results from blockage of the drainage of fluid from the eye. Symptoms of acute glaucoma may include with a painful red eye and misty vision or haloes, and in some cases nausea. Acute glaucoma may be differentiated from cluster by the presence of a semi-dilated pupil compared with the presence of a constricted pupil in cluster. Bout of cluster The duration over which recurrent cluster s occur, usually lasting weeks or months. occur from 1 every other day to 8 times per day. Giant cell arteritis Also known as temporal arteritis, giant cell arteritis is characterised by the inflammation of the walls of medium and large arteries. Branches of the carotid artery and the ophthalmic artery are Page 7 of 10

8 preferentially involved, giving rise to symptoms of, visual disturbances and jaw claudication. NSAID non-steroidal anti-inflammatory drug Positive diagnosis a diagnosis based on the typical clinical picture that does not require any further investigations to exclude alternative explanations for a patient's symptoms Young people people aged 12 to 17 years Sources in over 12s: diagnosis and management (2012 updated 2015) NICE guideline CG150 Your responsibility Guidelines The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian. Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, Page 8 of 10

9 and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties. Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible. Technology appraisals The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian. Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible. Medical technologies guidance, diagnostics guidance and interventional procedures guidance The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to Page 9 of 10

10 make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer. Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties. Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible. Page 10 of 10