Improving Headache Care

Transcription

1 Greater Manchester Neuroscience Centre Improving Headache Care (without breaking the bank) Implementation of useful referral guidelines

2 Scale of the problem Over 10% population suffer from headache 2% suffer chronic migraine (>15 days/month) 4.4% per year consult GP for headache 1 20% of sickness absence from work 2 33% of all neurology referrals 3 1 Latinovic R et al. JNNP 2006;77: Rasmussen BK. Cephalalgia 2001; 21: APPG report on Primary Headache Disorders 2014

3 Scale of the problem Misdiagnosis & mismanagement Patients poorly informed and misusing NHS Most common neurological problem in A&E Greater value for money: Strengthening primary care service Improved access local specialist care

4 Neurology referrals to SRFT:- Most referred before trying any treatment Low Med High V. High Extr. High Treated Untreated Audit results courtesy of Dr Jon Sussman

5 Improve care at all levels More consistent primary care Headache Management Guideline Reduce referrals GP-run Local Headache Networks Longer consultations Tools: Headache pre-screening questionnaires, online Access to quality imaging (MR) Links to secondary care for CPD / discussion Headache nurses / physios / psychologists

6 Adult with Headache rth West Headache Management Guideline Based on NICE CG150 Emergency symptoms? 1 Refer to appropriate on-call hospital team Giant cell arteritis? 2 Check ESR, CRP, FBC and U&E Prednisolone 60mg o.d. immediately Consider urgent referral to rheumatology, ophthalmology or neurology as appropriate 2 (Need temporal artery biopsy within 2 weeks of starting prednisolone) 2WW? 3 2WW referral (use Neurology 2WW form) Red flags? 4 Is it migraine or tension headache? 5 Cluster headache? 5 Prescribe acute treatment (< 10 times/month) 5 Try acute treatments 5 Other secondary causes? e.g. sinusitis, TMJ pain Check: Hb, Ca 2+, TFT,ESR, CRP r/v lifestyle & medication 6 Treat as necessary Refer to Headache Service Still troublesome? Suspect:- Medication overuse headache (MOH)? 5 Drug induced? Stop offending medication (for 2 months if MOH) Is it migraine or tension headache? 5 further treatment Still troublesome? Education and better understanding of the condition can be facilitated by directing patients to NHS Choices: Headaches where a number of information leaflets can be accessed If relevant, consider stopping combined oral contraceptive. te: combined OCP is contraindicated in migraine with aura Ensure not overusing analgesics or triptans 5 - Triptan overuse headache usually improves 2 weeks after ceasing triptan, but can take up to 3 months - Medication overuse headache improves/resolves within 3 months of analgesic cessation Modify lifestyle (adequate sleep, exercise, hydration, cut out caffeine, trigger avoidance, deal with psychosocial factors if possible) Migraine prophylaxis: If necessary, try the following for 3 months at the highest tolerated target dose before judging efficacy:- a) Propranolol MR 80mg o.d. increasing gradually if tolerated to a maximum of 240mg o.d. ; b) If ineffective or contraindicated: Topiramate 25mg o.d. increasing by 25mg every fortnight aiming for a target of 50mg b.d. NOTE: teratogenic and potential interaction with oral contraceptives. Increasing in 15mg increments can enhance tolerability. Often causes paraesthesia (warn patients, not usually a reason to cease) and weight loss. Watch out for worsening depression. c) Other options [unlicensed, but standard practice]: Amitriptyline 10mg o.n. increasing by 10mg a week up to 100mg or Gabapentin 100mg tds increasing by 100mg tds to 900mg tds Tension Type Headache prophylaxis: Amitriptyline as above. Acupuncture, if available. Still troublesome? a) Inadequate response to 3 migraine preventatives at maximally tolerated doses for 3 months each and/or b) Thinking about botulinum toxin treatment (see note 6) and/or c) Diagnostic doubt further treatment

7 Adult with Headache rth West Headache Management Guideline Based on NICE CG150 Emergency symptoms? Refer to appropriate on-call hospital team Thunderclap onset Accelerated/Malignant hypertension Acute onset with papilloedema Acute onset with focal neurological signs Head trauma with raised ICP headache Photophobia + nuchal rigidity + fever +/-rash Reduced consciousness Acute red eye:?acute angle closure glaucoma New onset headache in: 3rd trimester pregnancy/early postpartum Significant head injury especially elderly patients, alcohol dependency, people on anticoagulants

8 Adult with Headache rth West Headache Management Guideline Based on NICE CG150 Emergency symptoms? Refer to appropriate on-call hospital team Giant cell arteritis? Check ESR, CRP, FBC, U&E Prednisolone 60mg o.d. immediately Urine and CXR Consider urgent referral to rheumatology, ophthalmology or neurology. Need temporal artery biopsy within 2 weeks of starting prednisolone 2/10,000 per year. Think about in >50y with new headache Symptoms and signs:- jaw/tongue claudication, amaurosis fugax, scalp tenderness, temporal artery: prominent, tender, diminished pulse, other cranial nerve palsies, limb claudication, associated PMR Many headaches respond to high dose steroids, so do not use response as the sole diagnostic factor ESR can be normal in 10% (check CRP as well)

9 Adult with Headache rth West Headache Management Guideline Based on NICE CG150 Emergency symptoms? Refer to appropriate on-call hospital team Giant cell arteritis? Check ESR, CRP, FBC, U&E Prednisolone 60mg o.d. immediately Urine and CXR Consider urgent referral to rheumatology, ophthalmology or neurology. Need temporal artery biopsy within 2 weeks of starting prednisolone 2WW? 3 2WW referral 2WW suspected cancer referral Headache with features of raised intracranial pressure Actively wakes patient from sleep, but not migaine or cluster Precipitated by Valsalva manoevres i.e. cough, straining at stool Papilloedema Other raised ICP symptoms including Headache present on waking and easing once up (MOH can cause this) and worse when recumbent Pulse-synchronous tinnitus Episodes of transient visual loss when changing posture Headache with new onset seizures Headache with persistent new or progressive neurological deficit A relevant history of malignancy, which might have metastasised to the brain Vomiting without other obvious cause (i.e. not just due to migraine)

10 Adult with Headache rth West Headache Management Guideline Based on NICE CG150 Emergency symptoms? Refer to appropriate on-call hospital team Giant cell arteritis? Check ESR, CRP, FBC, U&E Prednisolone 60mg o.d. immediately Urine and CXR Consider urgent referral to rheumatology, ophthalmology or neurology. Need temporal artery biopsy within 2 weeks of starting prednisolone 2WW? 3 2WW referral Red flags? 4 Refer to Headache Service Red flags for secondary headaches Headache increasing in severity and frequency despite appropriate treatment Undifferentiated headache (not migraine/tth) of recent onset and present for >8weeks Recurrent headaches triggered by exertion Orthostatic headache (headache that occurs in the upright position, suggesting low CSF pressure) New onset headache in:- >50 years old (consider GCA) Immunosuppressed / HIV

11 Adult with Headache rth West Headache Management Guideline Based on NICE CG150 Emergency symptoms? 1 Refer to appropriate on-call hospital team Giant cell arteritis? 2 Check ESR, CRP, FBC and U&E Prednisolone 60mg o.d. immediately Consider urgent referral to rheumatology, ophthalmology or neurology as appropriate 2 (Need temporal artery biopsy within 2 weeks of starting prednisolone) 2WW? 3 2WW referral (use Neurology 2WW form) Red flags? 4 Is it migraine or tension headache? 5 Cluster headache? 5 Prescribe acute treatment (< 10 times/month) 5 Try acute treatments 5 Other secondary causes? e.g. sinusitis, TMJ pain Check: Hb, Ca 2+, TFT,ESR, CRP r/v lifestyle & medication 6 Treat as necessary Refer to Headache Service Still troublesome? Suspect:- Medication overuse headache (MOH)? 5 Drug induced? Stop offending medication (for 2 months if MOH) Is it migraine or tension headache? 5 further treatment Still troublesome? Education and better understanding of the condition can be facilitated by directing patients to NHS Choices: Headaches where a number of information leaflets can be accessed If relevant, consider stopping combined oral contraceptive. te: combined OCP is contraindicated in migraine with aura Ensure not overusing analgesics or triptans 5 - Triptan overuse headache usually improves 2 weeks after ceasing triptan, but can take up to 3 months - Medication overuse headache improves/resolves within 3 months of analgesic cessation Modify lifestyle (adequate sleep, exercise, hydration, cut out caffeine, trigger avoidance, deal with psychosocial factors if possible) Migraine prophylaxis: If necessary, try the following for 3 months at the highest tolerated target dose before judging efficacy:- a) Propranolol MR 80mg o.d. increasing gradually if tolerated to a maximum of 240mg o.d. ; b) If ineffective or contraindicated: Topiramate 25mg o.d. increasing by 25mg every fortnight aiming for a target of 50mg b.d. NOTE: teratogenic and potential interaction with oral contraceptives. Increasing in 15mg increments can enhance tolerability. Often causes paraesthesia (warn patients, not usually a reason to cease) and weight loss. Watch out for worsening depression. c) Other options [unlicensed, but standard practice]: Amitriptyline 10mg o.n. increasing by 10mg a week up to 100mg or Gabapentin 100mg tds increasing by 100mg tds to 900mg tds Tension Type Headache prophylaxis: Amitriptyline as above. Acupuncture, if available. Still troublesome? a) Inadequate response to 3 migraine preventatives at maximally tolerated doses for 3 months each and/or b) Thinking about botulinum toxin treatment (see note 6) and/or c) Diagnostic doubt further treatment

12 A viable model? GP GP GP GP GP GP HA nurse/physio Neurology

13 Adult with Headache rth West Headache Management Guideline Based on NICE CG150 Emergency symptoms? Refer to appropriate on-call hospital team Giant cell arteritis? Check ESR, CRP, FBC, U&E Prednisolone 60mg o.d. immediately Urine and CXR Consider urgent referral to rheumatology, ophthalmology or neurology. Need temporal artery biopsy within 2 weeks of starting prednisolone 2WW? 3 2WW referral Red flags? 4 Refer to Headache Service Is it migraine or tension headache? 5 Primary or Secondary?

14 Brain Tumour Incidence Over 50 Slide adapted from Cancer Research, Accessed vember

15 Categorisation: Primary

16 Brain Tumour Headache What symptoms did they have before? Headache: What % have BT? BT: What symptoms do they have now?

17 Brain Tumours: symptoms BJGP 2007 (any) 6 months Tumour Control Population risk 0.01%

18 Headache: secondary causes What happens to new-onset headache presented to primary care? A case-cohort study using electronic primary care records D Kernick, S Stapley, PJ Goadsby & W Hamilton Cephalalgia 2008 Undifferentiated headache Brain tumour 0.15% 1 in 1250 <50 1 in 360 >50 Primary headache Malignant brain tumour 0.045% i.e. 1 in 2222 Background BT incidence %

19 Brain Tumour Headache: What s it like? Headache common 50% of patients Bland, featureless Episodic Responds to simple analgesic New or change pattern Raised ICP type headache is rare (5.1%)

20 Head scan / referral? Raised ICP headache Early morning / waking Valsalva or exertion triggered Bland unclassifiable headache in over 50s (take proper history) New onset / change in headache >50y HIV Cancer thrombotic tendency Headache+ GCA, atypical aura, seizures, fever and neck stiffness, thunderclap, abnormal neurology?? Therapeutic scan

21 Therapeutic scan and VOMIT GP reassurance < 1y patient reassurance Incidentaloma: 1 in 37 Cysts aneurysms Vascular anomalies Inflammatory Developmental (AC) WML Neoplasms

22 Messages Brain tumours rare (1/10k) Primary headache: brain tumour still rare Diagnose the headache type Think about red flags, even if primary headache Caution: VOMIT from therapeutic scans

23 Migraine Unilateral onset Throbbing 4 72 hours Sensory Sensitivity Light Sound Smells Movement

24 Interrogate Colloquialisms What the patient says It came on suddenly It s constant What it can mean It started today/this week/ year It s episodic but frequent I only get normal headaches Migraine all my life, as has my family It s not migraine It s migraine, just a different part of your head But I know what migraine is you don t. Please see IHSC II photophobia phonophobia The pain makes me want to bang my head on the wall I have to draw the curtains The noisy kids hurt my head The pain is bad and no-one listens to me. I don t really bang my head.

25 IHSC II aura focal neurological symptoms develop over 5-20 minutes last for < 60 minutes

26 Cluster Headache Pain Autonomic Agitation Lasts minutes?? Glaucoma

27 Migraine Treatment: acute Aspirin 900mg + domperidone (+/- paracetamol) NSAID Triptans: 5-HT 1b/d agonists Sumatriptan (Cheapest, fastest acting) Frovatriptan (second-cheapest, slowest acting, longest T½) Almotriptan Zolmatriptan Rizatriptan... <10 days for Triptans <15 days for non-opioid analgesics

28 Migraine Preventatives Propranolol Amitriptyline (pizotifen.no evidence..gain weight and sleepy) Topiramate Wt loss, parasthesia common Memory problems, 1% renal calculi Gabapentin unusual stuff: Botox, methysergide, lisinopril... Alternative stuff: Feverfew+riboflavin, butterburr, Mg, acupuncture

29 NICE prophylaxis Propranolol or Topiramate NICE Guidance Sept 2012

30 NICE prophylaxis TTH Refractory Migraine Stockport PCT: refused funding

31 NICE Botox Chronic Migraine (15 days) Failed 3 preventatives t overusing abortives

32 Adult with Headache Headache Management Pathway Emergency symptoms? Refer to appropriate on-call hospital team Giant cell arteritis? Check ESR, CRP, FBC, LFT Prednisolone 60mg o.d. immediately Urine and CXR Consider urgent referral to rheumatology, ophthalmology or neurology. Need temporal artery biopsy within 2 weeks of starting prednisolone Red flags? Migraine or tension headache? Cluster headache? Prescribe acute treatment (< 10 times/month) Refer Try acute treatments 5 If relevant, stop combined oral contraceptive Secondary causes? e.g. sinusitis, TMJ pain Hb, Ca 2+, TFT,ESR, CRP R/V lifestyle & medication Treat as necessary Refer Still troublesome? Suspect:- Medication overuse headache (MOH)? Drug induced? Stop offending medication (for 2 months if MOH) Can you diagnose migraine or tension headache? further treatment Still troublesome? Ensure not overusing analgesics or triptans 5 Modify lifestyle (adequate sleep, hydration, reduce caffeine intake, trigger avoidance) If prophylaxis necessary, try the following for 3 months at the target dose before judging efficacy:- Migraine prophylaxis a) Propranolol SR 80mg o.d. increase to 160mg o.d. b) If ineffective or contraind: Amitriptyline 10mg o.n. increasing by 10mg/week to 75mg c) Don t bother with pizotifen (weight gain, sedation, little benefit) d) If above ineffective/not tolerated, try Topiramate 25mg o.d. increasing by 25mg every 2-weeks aiming for a target of 50mg b.d. NOTE: teratogenic and potential interaction with combined oral contraceptive Tension Type Headache prophylaxis Amitriptyline 10mg o.n. increasing by 10mg a week up to 75mg or maximum tolerated below that Still troublesome? Continue treatment for 9-12 months; then consider stopping

33 Adult with Headache rth West Headache Management Guideline Based on NICE CG150 Emergency symptoms? Refer to appropriate on-call hospital team Giant cell arteritis? Check ESR, CRP, FBC, LFT Prednisolone 60mg o.d. immediately Urine and CXR Consider urgent referral to rheumatology, ophthalmology or neurology. Need temporal artery biopsy within 2 weeks of starting prednisolone 2WW? 3 2WW referral Red flags? 4 Refer to Headache Service Red flags for secondary headaches Headache increasing in severity and frequency despite appropriate treatment Undifferentiated headache (not migraine/tth) of recent onset and present for >8weeks Recurrent headaches triggered by exertion Orthostatic headache (headache that occurs in the upright position, suggesting low CSF pressure New onset headache in:- >50 years old (consider GCA) Immunosuppressed / HIV