Management of Migraine

Transcription

1 Title of Project: NHS Dumfries & Galloway June 2013 Management of Migraine 1 Reason for the review SIGN 107 Diagnosis and management of headache in adults, advises that patients with migraine and those using opioid-containing medications or overusing triptans are amongst those most at risk of developing Medication Overuse Headache (MOH). The guideline also advises that because of this risk of developing MOH, opioid-containing medications have no role in the treatment of migraine and should therefore not be routinely used for this indication 1. Patients with a migraine diagnosis and who currently use opioid analgesics to treat migraine attacks should be invited into the surgery for a review of their management. While SIGN 107 does not define what constitutes triptan overuse in migraine sufferers, previous studies have reported a mean attack rate of 1.5 migraines per month 2. On this basis, in an audit of triptan use in 9 GP practices in the UK, Williams et al considered that up to 36 triptan tablets per year could be expected to be a low to normal rate of triptan usage among patients with straightforward migraine given that those patients usually only require one or two tablets per attack 3. In order to allow for the possibility that patients being prescribed triptans are more likely to be those with severe or complicated migraine and therefore genuinely require a higher rate of triptan use, Williams et al defined high triptan use as being 54 or more tablets prescribed over a 12 month period. Patients with a high triptan usage should be invited into the surgery for a review of their migraine diagnosis, review of their triptan use, identification of possible causes of any increased frequency of attacks and investigation of suspected non-migrainous headaches such as chronic daily headache and MOH. Such actions would help achieve and maintain a high standard of care for their migraine patients. The final part of the review should focus on compliance with the NHS Dumfries & Galloway Formulary triptan choices. Sumatriptan is the 1 st line choice while zolmitriptan is included as a 2 nd line choice. Patients receiving regular repeat prescriptions for a triptan not listed in the NHS D&G Joint Formulary, should be reviewed by the surgery with a view to switching them to sumatriptan in the first instance or, where this has already been tried and proved to be unsuitable, zolmitriptan should be tried instead. Practices may choose to invite patients into the surgery to discuss this, offer them a telephone consultation or send them a letter advising them of the proposed change in medication with advice to contact the surgery should they want to discuss it. 2 Inclusion Criteria All patients with a diagnosis of migraine and who are being prescribed a regular opioid-containing medication for the condition All patients being prescribed a triptan 3 Exclusion Criteria o Patients with a terminal condition o Patients currently who s condition is currently under review by Consultant Neurologist 4 Preparation and Planning Implementation of audit is as follows: Protocol is to be discussed with all GPs in the practice to ensure that agreement to proceed is reached where Prescribing Support Team are involved*. Computer search of all patients according to the inclusion criteria Review of patients medical notes and repeat prescribing records Data collection sheets to be completed and passed to relevant GP Patients to be invited into practice or telephoned and reviewed as appropriate

2 5 Action Patients who have a diagnosis of migraine and who use regular opioid-medication to manage the condition should be invited into the surgery for a review of their management. Alternatives to opiate analgesics are outlined in the NHS D&G Formulary and are as follows:- Mild to moderate migraine 1 st line:- aspirin or paracetamol or ibuprofen. 2 nd line:- metoclopramide The combination of an analgesic and metoclopramide can be as effective as a triptan Severe migraine 1st line:- sumatriptan 2 nd line:- zolmitriptan Patients being prescribed more than 54 triptan tablets per year to be invited into the surgery for a review of their management. If, as part of this review, it is deemed necessary to continue with triptan therapy, then patients receiving a non-formulary triptan should be switched to sumatriptan if appropriate. If sumatriptan is not appropriate, then zolmitriptan should be considered. Patients receiving regular repeat prescriptions for a non-formulary triptan should be invited into the surgery or contacted by telephone to have their triptan switched to sumatriptan or, if the practice prefers, a letter can be sent to appropriate patients advising them of the change and offering them the opportunity to discuss this with the practice or the relevant Prescribing Support Pharmacist. In those instances where sumatriptan is deemed inappropriate, zolmitriptan should be considered instead. 6 Criteria and Standards Criteria Patients with a diagnosis of migraine should not receive treatment with an opioid-containing medication for this condition Patients receiving regular repeat prescriptions for a triptan should not be allowed to use more than 54 tablets per year without being routinely reviewed Patients who have been issued with a first prescription for a triptan should have received either sumatriptan or zolmitriptan. Standards 0% of patients with a diagnosis of migraine should receive treatment with an opioid-containing medication for this condition 100% of patients who have received more than 54 triptan tablets over the last 12 months should have a documented review of their migraine management 100% of patients prescribed a triptan for the first time should receive sumatriptan or zolmitriptan

3 7 References 1. Scottish Intercollegiate Guidelines Network (SIGN) (2008) Diagnosis and Management of headache in adults. Edinburgh, SIGN. 2. Ferrari M. Migraine. Lancet 1998; 351: Williams D, Cahill T, Dowson A, Fearon H, Lipscombe S, O Sullivan E, et al. Usage of triptans among migraine patients: am audit in nine GP practices. Curr Med Res Opin 2002; 18(1): 1-9 Written by: G Loughran; June 2010 Reviewed and updated by: G Loughran; June 2013 Review to be undertaken by:..... Date:. GP Authorisation: (where PST involved)....

4 Management of migraine Data collection sheet 1: Patients using opioid-containing analgesia All patients on this list to be flagged up to GP for review SURGERY:... DATE:... UNDERTAKEN BY:... Patients name/chi Opioid-containing analgesic being used Current dose and frequency Details of any other current migraine medications

5 Management of migraine Data collection sheet 2: High triptan usage patients All patients on this list to be flagged up to GP for review SURGERY:... DATE:... UNDERTAKEN BY:... Patients name/chi Triptan being used and current dosage instructions Number of tablets used in last 12 months Details of any other current migraine medications

6 Management of migraine Data collection sheet 3: Non-Formulary triptan use All patients on this list to be invited in to surgery, contacted by telephone or sent a letter to have their triptan changed to a formulary choice (Practice should decide on preferred means of communicating this to patients). SURGERY:... DATE:... UNDERTAKEN BY:... Patients name/chi Triptan being used and current dosage instructions Details of any other triptans tried previously Recommendation to GP

7 Suggested letter wording Dear Sir/Madam As a practice, we undertake continuous reviews of the medicines we prescribe to ensure that we are providing the most appropriate treatment for our patients. Recently, we have been asked to review our use of migraine medications to ensure that we are complying with NHS Dumfries & Galloway recommendations. This means that we would like to change the medicine you currently use to treat your migraines to one called sumatriptan/zolmitriptan (delete as appropriate). The recommended dose of this new medicine is one tablet to be taken when you first feel your migraine symptoms starting with one more tablet to be taken at least 2 hours later if your symptoms come back or just haven t gone away in the first place. Pleased be reassured that sumatriptan/zolmitriptan (delete as appropriate) works as well as your current medication and that this change in your prescription will allow us to treat your migraines at least as well as we currently do whilst also making the most of valuable NHS resources. Should you wish to discuss this change with someone then please feel free to make an appointment to speak to your GP or telephone our Prescribing Support Pharmacist... on.... Yours sincerely