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OH and Headache

OH and Headache. Dr David PB Watson GPwSI Hamilton Medical Group Aberdeen. Objectives. Headache impact and epidemiology Headache diagnosis Headache management audit and useful information case study. Objective 1. Headache Impact and Epidemiology . Primary headache

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OH and Headache

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  1. OH and Headache Dr David PB Watson GPwSI Hamilton Medical Group Aberdeen

  2. Objectives • Headache impact and epidemiology • Headache diagnosis • Headache management • audit and useful information • case study

  3. Objective 1 Headache Impact and Epidemiology

  4. Primary headache No underlying medical cause: Secondary headache Underlying medical cause: • Episodic primary headaches • Chronic primary headaches • Tumour • Meningitis • Vascular disorders • Systemic infection • Head injury • Drug-induced Headache types

  5. Cluster Episodic primaryheadaches Migraine +/- aura Tension-type headache (TTH) Probablemigraine Episodic primary headaches

  6. New daily persistent Hemicrania continua Chronic daily headache (CDH) Chronic migraine +/- medication overuse Chronic tension Chronic cluster Chronic primary headaches / chronic daily headaches

  7. Chronic daily - all types 4% Episodic migraine 16% 78% Episodic TTH Lifetime prevalence of primary headache (n=740) Rasmussen et al 1991

  8. Impact • Episodic TTH –low (common) • Episodic Migraine – high (1 in 10) • Chronic Daily Headache - high ( 1 in 25) • Cluster – very high (1-2 in 1000)

  9. Migraine Impact • Meets WHO definition of disability • Epidemiology • 6 million people in UK • Women 3x men • most sufferers aged 20 to 50

  10. Personal Impact • 187000 migraine attacks experienced every day • 3/4 report disability at least sometimes • 1/3 feel migraine controls their lives • 47% of migraineurs experience depression compared 17% on non migraineurs

  11. Impact of Migraine • UK migraine survey 1999 showed that • 30% were unable to look after their family • 63% were either totally or significantly prevented from going to work • 39% had suffered an attack whilst driving

  12. Economics of Migraine • 50% of migraine sufferers miss up to 26 days work a year • 18 million working days a year lost • lost productivity valued at almost £2 billion a year • sufferers function at 50% efficiency with migraine symptoms for up to 1 week

  13. 100 80 60 40 20 0 Indirect cost of migraineFor most sufferers, migraine results in lost productivity rather than days lost from work Work loss (%) The most severely affected sufferers (40% of the sample) accounted for all days lost from work Almost all sufferers reported reduced productivity equivalent to lost work days 10 20 30 40 50 60 70 80 0 90 100 Migraine sufferers (%) Adapted from von Korff et al 1998

  14. Objective 2 Headache Diagnosis This slide kit is for educational purposes only

  15. “Red flags” • Single cohort (Level 3) or expert opinion (Level 4) • new onset headache in patients who are aged over 5029-31 • abrupt onset (thunderclap) 28-30, 32, 33 • focal symptoms including atypical aura greater than one hour 28, 32, 34, 35 • abnormal neurological examination 28, 29, 35, 36 • altered mental status 28, 30, 34 • altered characteristics or associated features of headache 28, 31 • headache that changes with posture 37 • headache worse in the morning and during physical activity, and the valsalva manoeuvre 28, 38 • patients with risk factors for thrombosis 34, 39, 40 • new onset headache in a patient with a history of HIV infection 41 • jaw claudication 16 • neck stiffness 30 • fever 42 • new onset headache in a patient with a history of cancer 9

  16. Abbreviated diagnostic checklist based on IHS 2004 criteria Probable migraine Migraine Tension-type • Recurrent • No organic disease • Duration 4-72 h • Unilateral • Pulsating • Moderate / severe • Aggravated by movement • Nausea / vomiting • Photo / phonophobia • Recurrent • No organic disease • Duration 4-72 h • Moderate / severe • + one other • Recurrent • No organic disease • Duration 0.5 h-7 days • Generalised • Pressure / tightness • Slight / moderate • Photo / phonophobia Essential (3) Essential (2) Essential (1) Essential (3) = all items essential for diagnosis; Essential (2) = two items from list essential for diagnosis; Essential (1) = one item from list essential for diagnosis IHS 2004

  17. What features make migraine more likely? • episodic severe headache that causes disability11, 23, 24 • nausea16, 23 • sensitivity to light during migraine headache16, 23 • sensitivity to light between migraine attacks 25 • aura16, 18 • sensitivity to noise16 • exacerbation by physical activity16 • positive family history of migraine16 • The features which give the greatest sensitivity and specificity are disability, nausea and sensitivity to light23 • ID Migraine validation study (Level 3)

  18. Other primary headache • Trigeminal autonomic cephalalgias (TACs) • Cluster headache • Paroxysmal Hemicrania • SUNCT • Hemicrania continua • New daily persistent headache

  19. What features make TACs more likely? • The following features differentiate trigeminal autonomic cephalalgias from migraine: 16, 26 (Level 4) • Onset: rapid in TAC, gradual in migraine • Duration: TACs < 3 hours, migraine 4 - 72 hours • Frequency: multiple attacks may occur daily in TACs • Restlessness during an attack: 100% in cluster headache, 50% in paroxysmal hemicrania • Prominent ipsilateral autonomic features in TACs • Features which differentiate trigeminal autonomic cephalalgias from each other and from trigeminal neuralgia are listed in Annex 2

  20. Diagnosis Summary • Key question is impact • Default diagnosis for intermittent headache is migraine(Landmark study 90%) • Migraine v Cluster imagine typical patient • Chronic headache consider medication overuse

  21. Objective 3 Headache Management

  22. Behavioural treatments include: stress management / relaxation training regular diet and sleep trigger identification and avoidance avoidance of excessive over-the-counter medications Physical treatments include: natural remedies / complementary medicines acupuncture transcutaneous electrical nerve stimulation occlusal adjustment cervical manipulation Non-pharmacological therapies Adapted from US Headache Consortium Headache Guidelines

  23. Drug class Analgesics 5-HT1B/1D agonists (Triptans) antiemetics Drug name Aspirin 900 mg, ibuprofen 400mg Almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan ,zolmitriptan Domperidone, prochloroperazine Avoid opioids Acute pharmacological therapies

  24. Management Summary • Provide acute medication to all migraine patients and recommend it is taken early • Provide rescue medication • Tailor treatment to the individual • Prophylactic Rx if high impact • Lifestyle management important

  25. Objective 4 Audit Useful Information

  26. Ideas for Audit • Number of Migraineurs • Assess migraine impact and lost time • Migraine awareness campaign • Medication Overuse awareness • Reassess impact and lost time

  27. Migraine Resources • British Association for the Study of Headache www.bash.org/ • Migraine Action Association www.migraine.org.uk/ • www.sign.ac.uk

  28. Objective 5 Case Study

  29. Migraine and Sickness absence • Triggers • Long hours • Stress • Sleep disturbance • Missing meals • Travel/jet lag • Office lighting • Hormones • Disabling headache and ? DDA • Reasonable adjustments eg dark room, lie down, flexi time, • No medication 100% effective, acute treatment side effects

  30. Case Study • ITU nurse aged 28 with chronic migraine and medication overuse headache • Issues include • Shift work affecting sleep, diet, exercise • Work pressures, short staffed, studying for exam, often lack of senior staff, management attitude to sick leave, lack of understanding/empathy from colleagues

  31. Any Questions?

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