MIGRAINE IN PRIMARY CARE ADVISORS Guildford, 24 January 2003, 2-6 pm General Practitioners with a special interest in he

1. MIGRAINE IN PRIMARY CARE ADVISORS Guildford, 24 January 2003, 2-6 pm General Practitioners with a special interest in headache (GPSIH)

2. Introduction and objectives Dr Andrew Dowson Kings’ Headache Service, London

3. Programme • Dr Andrew Dowson: Introduction and objectives • Ms Ann Turner: Plans for the future organisation of headache services in the UK: the perspective from Headache UK • Dr Andrew Dowson: Managing chronic headaches in the clinic • Break • All: Discussion session: Setting up a primary care headache clinic: a practical guide • Dr Andrew Dowson: Conclusions

4. Objectives of today’s meeting • Review Headache UK’s overall plans for UK headache services • Discuss the practicalities of setting up a primary care headache clinic • Discuss the optimal way to manage chronic headaches

5. Outputs • Article on how to set up a headache clinic in primary care • Multidisciplinary focus • Document for RCGP • Article on the management of chronic headaches • Algorithms for CDH and cluster headache • MIPCA newsletter • Slide set

6. Headache UK Organisation of headache services in the UK Ann Turner Chairman Headache UK January 2003

7. What is Headache UK? • An umbrella group representing the 5 national charities currently working in headache: • Migraine Action Association • Migraine Trust • Migraine in Primary Care Advisers • British Association for the Study of Headache • Organisation of the Understanding of Cluster Headache

8. Why do we need it? • To improve and facilitate communication • To avoid duplication of effort and waste of resources • To make best use of increasingly scarce resources • To lobby governmentfor improvement in headache services

9. How did it start? • HW2000 Preliminary discussions • June 2001 Exploratory meeting • October 2001 Group formally formed and objectives identified

10. What has it achieved? • Representations to government and the Department of Health re. the inclusion of headache in the NSF • Official launch of HUK at the Houses of Parliament (June 2002) • Formation of an All Party Parliamentary Group on Primary Headache Disorders (October 2002) • Headache highlighted in House of Commons debate (January 2003) • Developed relationships with other agencies for educational purposes e.g. CPPE and University of Bath

11. Introduction • Development of primary care-led NHS • PCGs and PCTs • Headache services to be incorporated • At present, migraine, cluster headache and other headaches are under-estimated, under-diagnosed and under-treated in the UK • Despite this, the personal and economic burdens of headache are high • Current NHS spending on the management of headache disorders is inadequate, unevenly distributed and not optimally managed

12. Current situation • Overall quality of primary care headache services unknown • Ad hoc services performed on demand • Present services are neither adequate nor cost effective • No national or local targets • Little research, auditing or benchmarking undertaken • Access to headache care is restricted • Few GPs and neurologists are interested in headache • Few nurses and other professionals are employed • Secondary care neurology departments are overstretched, exacerbated by inappropriate referrals for headache • The burden of headache remains high

13. Objectives • To review the organisation of headache services in primary care and recommend changes necessary to improve headache care • An initial document was prepared in 2000 • Headache UK will revise the document and use it to lobby government agencies and healthcare providers BASH 2000

14. Aims • To expand the role of primary care in the management of headache disorders • Improve patients’ access to effective care • Achieve consensus among professional organisations • Implementation of a multidisciplinary approach to care • Headache services to be re-organised in a stratified way • Local general practice • Primary care headache centres • Secondary care headache centres • Tertiary care centres BASH 2000

15. Local general practice

16. Local general practice: principles • Each GP should provide a first-line headache service • All GPs should be well educated in headache diagnosis and management • All GPs should work according to accepted guidelines • Nurses and pharmacists could take over many roles in headache management with appropriate training • Headache diploma (Leeds Metropolitan University)

17. Principles of headache management in primary care Sinister / Cluster / Chronic Referral to specialist Migraine Follow-up Treatment plan Assess severity Diagnosis Consultation • Attack frequency and pain severity • Impact on patient’s life • Non-headache symptoms • Patient factors • Establish goals • Acute therapy • Possible prophylactic therapy Assess outcome of therapy • Specific consultation • Treatment history • Patient education, counselling and buy-in • Screen for headache type

18. Consultation Taking a careful history is essential • Use of a headache history questionnaire is recommended • Patient education • Advice, leaflets, websites and patient organisations (Migraine Action Association, OUCH [cluster headache], Migraine Trust) • Patient-centred care • Patients to take charge of their own management • Effective communication between patient and physician MIPCA 2002

19. Diagnosis • Careful differential diagnosis required • IHS diagnostic criteria are comprehensive, but may be too complex for everyday use in primary care • Simple but comprehensive scheme required for the differential diagnosis of headache subtypes • Diagnosis can then be confirmed with additional questions MIPCA 2002

20. Management individualised for each patient Assess illness severity • Attack frequency and duration • Pain severity • Impact on daily living • Impact questionnaires (MIDAS/HIT) • Non-headache symptoms • Patient factors • History, preference and other illnesses Individualise care to the illness severity and needs of each patient MIPCA 2002

21. Follow-up procedures • Instigate proactive long-term follow-up procedures • Monitor the outcome of therapy • Headache diaries • Impact questionnaires (MIDAS/HIT) • Make appropriate treatment decisions

22. Individual headaches • Migraine • In most cases, management can occur in primary care • Cluster headache / CDH • Initial diagnosis made in primary care • Initial management probably best conducted in secondary care (long waiting lists) • Follow-up and long-term management devolved into primary care • Sinister headaches • Diagnosis and management in secondary care

23. Implementation of guidelines: multidisciplinary approach • Primary care headache team • GP, practice nurse, ancillary staff and sometimes pharmacist (core team) • Community pharmacist • Community nurses • Optician • Dentist • Complementary practitioners • Specialist physician (additional resource) Associate team members MIPCA 2002

24. Primary care Pharmacist Practice nurse Ancillary staff Primary care physician Patient MIPCA 2002 Core team

25. Roles of GP and nurse • GP • Overall diagnosis and management of the patient • Nurse • Advice and information • Initial triage assessment • Conduct investigations and tests • Review follow-up assessments • Role in prescribing (from 2003) • Also possible role for pharmacists in the future

26. Primary care Pharmacist Practice nurse Ancillary staff Community nurse Optician Primary care physician Dentist Complementary practitioner Patient MIPCA 2002 Associate team Core team

27. Requirements • Implementation of new diagnostic and management guidelines • Training for GPs, nurses and pharmacists • Role of specific GP educators? • User-friendly guide for patients • In association with patient groups • Information on preparation for consultation and realistic expectations

28. Issues • Government target: 75% of practices currently conducted in secondary care will be transferred to primary care within the next 7 years • Need to change current practices and patterns of behaviour • Most GPs do not practice individualised care • Increased flexibility needed • Role of the ‘specialist patient’

29. Primary care headache centres

30. Primary care headache centres • Headache referral centres established within • Individual GP clinics • PCGs • PCTs • Resource / Interest driven • Each centre staffed by people with an interest in headache management: • Physicians • Specialist nurses • Physical therapists • Psychologists BASH 2000

31. Primary care Pharmacist Specialist care Practice nurse Ancillary staff Community nurse Physician with expertise in headache: GP; PCT; specialist Optician Primary care physician Dentist Complementary practitioner Patient MIPCA 2002 Associate team Core team

32. Pathways of care Sinister, refractory and rare Headache variant headaches management Secondary and tertiary care specialists Consultation Diagnosis Migraine; Cluster headache; Chronic daily headache Primary care Assess specialist severity Treatment plan Uncomplicated migraine and TTH Primary care Follow - up

33. Requirements • Political and health authority buy in • Sufficient funding • Staff training • Interest / will for service

34. Secondary care headache centres

35. Needs • More specialist care needed for the more complex patient • Needy patients should be seen rapidly • Symbiosis needed between primary and secondary care • Audits of the services that headache centres are offering • More neurologists with a special interest in headache

36. Secondary care headache centres • Establish formally • In association with regional neurological centres? • Services: • Telephone advice to primary care staff/patients? • Emergency • Urgent • Routine • (Education for primary care centres?) Referral services

37. Requirements • Political and health authority buy in • Sufficient funding • Currently under-resourced • Staff training • Interest/will to provide service

38. Conclusions: overall needs • Simple to use, rational, evidence-based guidelines for diagnosis and management in primary care • New MIPCA guidelines? • Implicit role of patient support organisations • Migraine Action Association (MAA) • OUCH (cluster headache) • Educational initiatives for the general public • Specialist patient • Specific schemes of continuing professional development • Audit and development of best practice for all levels of care

39. Managing chronic headaches in the clinic Dr Andrew Dowson

40. Chronic headaches • Chronic daily headache (CDH) • Medication overuse headache (MOH) • Cluster headache • Other headaches • Short, sharp headache • Headaches associated with old age

41. Chronic daily headache (CDH) 10 a. Chronic tension-type headache Headache severity 5 1 2 3 Months

42. Chronic daily headache (CDH) 10 b. Migraine superimposed over CTTH Headache severity 5 1 2 3 Months

43. Chronic daily headache (CDH) 10 c. Chronic migraine Headache severity 5 1 2 3 Weeks

44. CDH - presentation • A history of headaches lasting >4 hours, occurring on >15 days per month1 • May be associated with overuse of symptomatic headache medications (MOH)2 • Analgesics, opioids, ergots, triptans • May be associated with a history of head/neck injury3 1. Headache Classification Committee. Cephalalgia 1988;8 (Suppl 7):1-92 2. Diener H-C, Katsarava Z. Curr Med Res Opin 2001;17 (Suppl 1):17-21 3. Couch JR, Bearss C. Headache 2001;41:559-64

45. CDH – screening / diagnosis • Specific consultation • Headache history • Provide relevant information • Obtain patient’s engagement with care • Conduct differential diagnosis • Monitor for sinister headache • Assess: • Severity (impact, frequency, duration, pain severity, patient preferences, co-morbidities) • Abuse of symptomatic medications? • Neck stiffness/ restricted movement? Dowson AJ. Doctor 2003; in press

46. Exclude sinister Headache (<1%) Patient presenting with headache Q1. What is the impact of the headache on the sufferer’s daily life? low ETTH (40-60%) High Q2. How many days of headache does the patient have every month? Migraine/CDH > 15  15 Migraine (10-12%) Consider short-lasting Headaches (<1%) CDH (5%) Q3. For patients with chronic daily headache, on how may days per week does the patient take analgesic medications? Q4. For patients with migraine, does the patient experience reversible sensory symptoms associated with their attacks? <2 2 Yes No Medication overuse No medication overuse Without aura With aura Dowson AJ et al. Curr Med Res Opin 2002;18:414-39

47. CDH – goals of therapy • Relieve the pattern of daily or near-daily headaches • Prevent all headaches, or • Resume a pattern of original intermittent primary headaches • Reduce the impact on the patient’s daily life

48. CDH – treatment • Physical therapy and exercises to the neck • Patients with neck stiffness • Withdraw offending headache medications • Inpatient or outpatient • Prophylaxis • Antidepressants • Anticonvulsants • Botox? • Limited acute medication • e.g. a triptan if the patient has a history of migraine Dowson AJ. Doctor 2003; in press Dowson AJ et al. CNS Drugs 2003; in press

49. CDH – follow-up • Instigate proactive long-term follow-up procedures to assess pattern of headaches and patients’ response to therapy • Headache diaries • Impact tools • If successful, withdraw prophylaxis gradually and retain acute medications • If unsuccessful, refer Dowson AJ. Doctor 2003; in press Dowson AJ et al. CNS Drugs 2003; in press

50. CDH management – key features • Monitor for sinister headache • Diagnostic assessment • Assess impact on the patient’s daily life • Monitor for medication overuse and head/neck injury • Proactive, long-term, patient-centred approach • Most patients can be managed by primary care specialists or GPs Dowson AJ. Doctor 2003; in press