MIGRAINE IN PRIMARY CARE ADVISORS New guidelines for the management of migraine by nurses London, 6...

MIGRAINE IN PRIMARY CARE ADVISORS

New guidelines for the management of migraine by nurses

London, 6 December 2002, 2-6 pm

Introduction

Dr Andrew J Dowson

Director of the King’s Headache Service

King’s College Hospital

London

MIPCAMIGRAINE IN PRIMARY CARE ADVISORS

• MIPCA is an independent charity working through research and education to set standards for the care of headache sufferers– Dedicated to improve headache management in

primary care

• MIPCA contains physicians, nurses, pharmacists, other healthcare professionals and representatives from patient groups

Objectives of today’s meeting

• Discuss the present and future roles of the practice nurse and nurse practitioner in primary care

• Disseminate the new MIPCA guidelines on migraine management in primary care

• Discuss the optimal way for nurses to utilise these guidelines in their practice:– Triage and in Practice Nurses’ own surgeries– Initiation and switching of therapy– Individualising care– Follow-up

Programme for today

2.00 pm: IntroductionDr Andrew Dowson

2.15 pm: Overview of the current role of the practice nurse in the clinic

Ms Jan Dungay2.45 pm: The new MIPCA guidelines for

migraine management in primary careDr Sue Lipscombe

4.00 pm: Tea break

Programme for today

4.30 pm: The future

Ms Heather MacBean

5.00 pm: Discussion: how can nurses use the new migraine guidelines?

Moderator: Dr Andrew Dowson

5.45 pm: Conclusions

6.00 pm: Close

Outcomes from the meeting

• Article to be published in an academic peer-reviewed nurse journal

• ‘Popular’ newsletter designed for the general nurse audience

• Slide set for educational use

Overview of the current role of the practice nurse in the clinic

Ms Jan Dungay

Practice Nurse

Merstham

Surrey

Overview

• Qualifications

• General roles– Clinics– Patient care

• Current roles in the management of migraine

Qualifications of practice nurses

• Practice Nurses are employed by the GP to work within their practice

• RGN – all

• Practice Nurse course (some)Nurse Practitioners

Roles

• ‘To aid and promote health care and protection in the community’

• Specialisation– All practice nurses are encouraged to

specialise in certain areas and attend appropriate training and updates

• e.g. diabetes and asthma

General surgery and designated clinics

• New Patient Health Checks• MOTs• Flu clinics• Travel clinics• Cervical smears• HRT• Asthma• Diabetes• Cardiac• Baby vaccinations• Phlebotomy• Treatment rooms

Roles in patient care

• Intermediate between the patient and the GP– Patients feel that they can talk more easily

to a Practice Nurse– Patients feel that the Practice Nurse can

spend more time with them• Patients are very aware of a GP’s time

• Particularly older women

Current roles in the management of migraine

• Identify migraine sufferers– Serendipitously during regular duties– Proactively during health clinics

• Discuss migraine and its treatment

• Assist patient in self-management

Serendipitous consultation

• Patients presenting with other problems or queries may mention migraine and can be followed up– HRT clinics– Travel vaccinations

Proactive consultation

• The nurse asks directly about headaches during health checks– New Patient Health Checks– MOTs– Treatment clinics

• Follow-up if the answer is positive

• Patients are often happy to discuss in this way

Current management

• Discuss migraine with the patient and provide information

• Refer to the GP for medication• Suggest the patient should return to

the nurse or GP if migraine continues or medication causes problems

• Very important to reassure patients that they can and should return to receive follow-up care

Future needs of the Practice Nurse

• Migraine clinics in GP practices currently limited

• The nurse needs to have access to courses for up-to-date information on:– Migraine care and treatment– Patient self-management strategies– Medication efficacy and side effects

• Implementation through GP interventions and nurse follow-up

The new MIPCA guidelines for migraine management in primary care

Dr Sue LipscombePark Crescent New Surgery

Brighton

Recent initiatives for migraine management in primary care

• Starting points for new initiatives– US Headache Consortium1

– US Primary Care Network2

– UK MIPCA Guidelines3

– German guidelines4

– Canadian guidelines5

1Headache Consortium. Neurology 2000; www.aan.com. 2Bedell AW et al. Primary Care Network 2000. 3Dowson AJ et al. MIPCA 2000. 4Diener HC et

al. Nervenheilkunde 1997;16:500-10. 5Pryse-Phillips WEM et al. Can Med Assoc J 1997;156:1273-87.

http://www.aan.com/

MIPCA initiative: Establishing new management guidelines for migraine in

UK primary care

• Update of the existing MIPCA guidelines– Identification and screening of patients in need of

care– Development of new diagnostic tools and

algorithms– Best management practice

• Utilising evidence-based medicine wherever possible

• Incorporating latest data from UK and US guidelines

What is required

Best practice from existing guidelines1-3

• Detailed history taking, patient education and buy-in• Diagnostic screening and confirmatory differential

diagnosis• Management individualised for each patient• Prescribing only treatments that have objective

evidence of favourable efficacy and tolerability• Prospective follow-up procedures to monitor the

success of treatment• Specific consultations for headache and a team

approach to management1Headache Consortium. Neurology 2000; www.aan.com.

2Bedell AW et al. Primary Care Network 2000. 3Dowson AJ et al. MIPCA 2000.

http://www.aan.com/

Diagnosis and treatment

Diagnosis Assess severity

Treatment plan

•Screen for headache type

• Differentiate migraine from other headaches

•Attack frequency and pain severity•Impact on patient’s life (MIDAS / HIT)•Non-headache symptoms•Patient factors

•Establish goals•Behavioural therapy•Acute therapy•Possible prophylactic therapy•Complementary therapy?

Consultation

•Specific consultation•Treatment history•Patient education, counselling and buy-in

Follow-up

Assess outcome of therapy

Management individualised for each patient

Overall diagram for migraine management

Processes

• First consultation– Screening– Patient education and buy-in– Diagnosis– Assessment of illness severity– Implementation of initial treatment plan

• Follow-up consultations– Monitor success of therapy and modify

treatment if necessary

Screening procedures1,2

Taking a careful history is essential– Use of a headache history questionnaire is

recommended

• Patient education– Advice, leaflets, websites and patient

organisations

• Patient buy in– Patients to take charge of their own management– Effective communication between patient and

physician1Headache Consortium. Neurology 2000; www.aan.com.

2Bedell AW et al. Primary Care Network 2000.

http://www.aan.com/

Migraine diagnosis: IHS criteria1

• Five or more lifetime headache attacks lasting 4-72 hours each and symptom-free between attacks

• Two or more of the following headache features:– Moderate-severe pain– Unilateral– Throbbing/pulsating– Exacerbated by routine activities

• One or more of the following non-headache features:– Aura– Nausea– Photophobia/phonophobia

• Exclusion of secondary headaches1Headache Classification Committee of the IHS. Cephalalgia

1988;7 (Suppl 7):19-28

Headache diagnosis

• MIPCA proposal: the IHS diagnostic criteria are too limited in scope and complex for everyday use in primary care

• MIPCA has developed a simple but comprehensive scheme for the differential diagnosis of headache subtypes

• Diagnosis can then be confirmed with additional questions, if necessary

Four-item questionnaire

A. Exclude sinister headaches1

New-onset, acute headaches associated with other symptoms

– e.g. rash, neurological deficit, vomiting, pain/tenderness, accident/head injury, hypertension

– Neurological change/deficit does not disappear when the patient is pain-free between attacks

1Dowson AJ, Cady RC. Rapid Reference to Migraine 2002.


1. What is the impact of the headache on the sufferer’s daily life?

(screens for migraine/chronic headaches and ETTH)

Assessing headache impact

• Two impact questionnaires have been developed1

– Migraine Disability Assessment (MIDAS) Questionnaire

– Headache Impact Test

1Dowson A. Curr Med Res Opin 2001;17:298-309.


2. How many days of headache does the patient have every month?

(screens for migraine and chronic headaches)

>15 = chronic headaches

15 = migraine1

1Headache Classification Committee of the IHS. Cephalalgia 1988;7 (Suppl 7):1-92


B. Consider short-lasting chronic headaches1

3 minutes may be short, sharp headaches

15 min -3 hours may be cluster headache



3. For patients with chronic daily headache, on how many days per week does the patient take analgesic medication?

(screens for analgesic-dependent headaches)1,2

2 = analgesic dependent

<2 = not analgesic dependent

1Silberstein SD, Lipton RB. Curr Opin Neurol 2000;13:277-83

2Olesen J. BMJ 1995;310:479-80.


4. For patients with migraine, does the patient experience reversible sensory symptoms associated with their attacks?

(screens for migraine with aura and migraine without aura)1


Migraine with aura diagnosis: IHS criteria1

• At least three of the following four characteristics:– One or more fully reversible aura symptoms*– One or more aura symptoms develop over >4 min, or two or more

symptoms occur in succession– No single aura symptom lasts >60 min– The migraine headache occurs <60 min after the end of the aura

symptoms

• Exclusion of secondary headaches

*e.g. visual disturbances, speech disturbances and sensations affecting other areas of the body


Patient presenting with headache

Migraine/CDH

low

High

Q1. What is the impact of the headache on the sufferer’s daily life?

ETTH

Q2. How many days of headache does the patient have every month?

> 15 15

CDH

Q3. For patients with chronic daily headache, on how may days per week does the patient take analgesic medications?

<2 2

Not analgesicdependent

Analgesic dependent

Migraine

Q4. For patients with migraine, does the patient experience reversible sensory symptoms associated with their attacks?

With aura Without aura

Yes No

Exclude sinister Headache

Consider short-lasting Headaches

Copyright MIPCA 2002, all rights reserved


Assess illness severity1,2

• Attack frequency and duration• Pain severity• Impact on daily living

– MIDAS/HIT questionnaires

• Non-headache symptoms• Patient factors

– History, preference and other illnesses1Matchar DB et al. Neurology 2000; www.aan.com.


http://www.aan.com/

Assessment of severity1,2

Mild-to-moderate migraine Moderate-to-severe migraine

Headaches mild-to-moderate in intensity

Headaches moderate or severe in intensity

Non-headache symptoms not severe in intensity

Significant non-headache symptoms, possibly severe

Impact not significant:

MIDAS Grade I or II

HIT Grade 1 or 2

Significant impact:

MIDAS Grade III or IV

HIT Grade 3 or 4 1Matchar DB et al. Neurology 2000; www.aan.com.


http://www.aan.com/

Provision of individualised treatment plan

Evidence-based medicine (Duke database) suggests:

• Behavioural therapy recommended for all• Acute therapy recommended for all• Prophylactic therapy recommended for

certain patients• Complementary therapies may be useful as

adjunctive therapy

1Headache Consortium. Neurology 2000; www.aan.com. 2Bedell AW et al. Primary Care Network 2000.

http://www.aan.com/

Individualising care – behavioural and physical therapy

Duke recommended therapies• Behavioural:

– Biofeedback and relaxation– Stress reduction– Avoidance of triggers– Food intolerances under investigation by MIPCA

• Physical– Cervical manipulation– Massage– Exercise– Botox?

1Campbell JK et al. Neurology 2000; www.aan.com. 2Bedell AW et al. Primary Care Network 2000.

http://www.aan.com/

Individualising care – acute medications

• Goals: to rapidly relieve the headache and other symptoms, and permit the return to normal activities within 2 hours1,2

• Acute medications should be provided for all patients2

• Strategy: individualised care, patients have a portfolio of medications to treat attacks of differing severities, and have access to rescue medications if the initial therapy fails3

1Matchar DB et al. Neurology 2000; www.aan.com.2Dowson AJ et al. MIPCA 2000.

3Dowson AJ. Migraine and Other Headaches: Your Questions Answered. 2003; in press.

http://www.aan.com/

Individualised care for migraine1

Migrainediagnosis

Severityassessment

Mild to moderate migraine Moderate to severe migraine

Initial therapy Initial therapy

Rescue Rescue

If unsuccessful

Migraine attack

1Dowson AJ. Migraine and Other Headaches: Your Questions Answered. 2003; in press

Stratified care

Staged care

Acute medications: Duke recommended treatments (UK)

• Mild-to-moderate migraine1

• Initial therapies– Aspirin or NSAIDs (high doses)– Aspirin/paracetamol plus anti-emetics– Use if possible before headache starts

• Rescue medications– Oral triptans– Use for any headache severity

1Matchar DB et al. Neurology 2000; www.aan.com.

http://www.aan.com/

Acute medications: Duke recommended treatments (UK)

• Moderate-to-severe migraine1

• Initial therapies– Oral triptans (tablet/ODT)– Use after the headache starts, if possible

when it is mild in intensity

• Rescue medications– Nasal spray or subcutaneous triptans– Symptom control

1Matchar DB et al. Neurology 2000; www.aan.com.

http://www.aan.com/

Caveats on triptan use1

• Most patients are effectively treated with an oral triptan– Differences between the oral triptans are small and of

uncertain clinical significance• Patients with unpredictable or fast-onset attacks

may benefit from ODT or nasal spray formulations• Patients with severe attacks and/or with vomiting

may benefit from nasal spray or subcutaneous formulations

• Subcutaneous sumatriptan is an effective rescue medication

• Beware contraindications (age; pregnancy; heart disease)


Individualising care – prophylactic medications1-3

• Goals: to reduce headache frequency by >50%

• Prophylactic medications should be provided:– For patients with frequent, high-impact migraine

attacks (4/month)– Where acute medications are ineffective or

precluded by safety concerns– For patients who overuse acute medications

and/or have CDH• However: acute medications should also be

provided for breakthrough attacks1Ramadan NM et al. Neurology 2000; www.aan.com.

2Bedell AW et al. Primary Care Network 2000. 3Dowson AJ et al. MIPCA 2000.

http://www.aan.com/

Prophylactic medications: Duke recommended treatments (UK)

• First-line medications:1

– Beta-blockers (propranolol, metoprolol, timolol, nadolol)

– Anticonvulsants* (sodium valproate)– Antidepressants* (amitriptyline)

• Second-line medications– Serotonin antagonists (pizotifen,

methysergide, cyproheptadine)

* Not licensed for migraine in the UK

1Ramadan NM et al. Neurology 2000; www.aan.com.

http://www.aan.com/

Individualising care – complementary therapies

Effective therapies (Duke database)1

• Feverfew*• Magnesium*• Vitamin B2*• Acupuncture*• Low-dose aspirin?*

• However: use only accredited complementary practitioners

* Not licensed for migraine in the UK


Follow-up procedures

• Instigate proactive long-term follow-up procedures1

• Monitor the outcome of therapy– Headache diaries– Impact questionnaires (MIDAS/HIT)

• Make appropriate treatment decisions


Follow-up treatment decisions1

• Acute medications– Patients effectively treated should continue with the original

therapy– Patients who fail on original therapy should be offered other

therapies• Prophylactic medications

– Ensure medication is provided for an adequate time period at an adequate dose (up to 3 months)

– If effective, treatment can continue for 6 months, after which it may be stopped

– If ineffective, another prophylactic medication may be tried– Usual contraindications apply

• Patients refractory to repeated acute and prophylactic medications should be referred to a specialist


Implementation of guidelines

• Primary care headache team1

– PCP, practice nurse, ancillary staff and sometimes pharmacist (core team)

– Pharmacist – Community nurses– Optician – Dentist – Complementary practitioners– Specialist physician (additional resource)– And . . . The patient

Associate team members

Dowson AJ et al. Curr Med Res Opin 2002;18:414-39.

Pharmacist

Community nurse

Optician

Dentist

Complementary practitioner

Patient

Primary care physician

Practice nurse

Physician with expertise in headache:

GP; PCT; specialist

Ancillarystaff

Primary care Specialist care

Associate team Core team



New MIPCA algorithm

Initial consultation and treatment

Detailed history, patient education and buy-inDiagnostic screening and differential diagnosisAssess illness severity

Attack frequency and durationPain severityImpact (MIDAS or HIT questionnaires)Non-headache symptomsPatient history and preferences

Intermittentmild-to-moderate migraine

(+/- aura)

Intermittentmoderate-to severe migraine

(+/- aura)

Aspirin/NSAID (large dose)Aspirin/paracetamol plus anti-emetic

Oral triptan

Nasal spray/subcutaneous triptan

Initial consultation

Initial treatment

Rescue

Rescue

Behavioural/complementary therapies



New MIPCA algorithm

Follow-up consultation and treatment

Aspirin/NSAID (large dose)Aspirin/paracetamol plus anti-emetic

Oral triptan

Initial treatment

Follow-up treatment

Oral triptanAlternative oral triptan

Nasal spray/subcutaneous triptan

Rescue

If unsuccessful

Consider prophylaxis +acute treatment for

breakthrough migraineattacks

Frequent headache(i.e. 4 attacks per month)

Consider referralChronic daily

Headache (CDH)?

Migraine

If unsuccessful

If unsuccessful

Initial treatmentCopyright MIPCA 2002, all rights reserved

If management unsuccessful


‘10 Commandments’ of headache management

Screening/diagnosis

1. Almost all headaches are benign and should be managed in general practice.

(However, monitor for sinister headaches and refer if necessary.)


2. Use questions / a questionnaire assessing impact on daily living for diagnostic screening and to aid management decisions.

(Any episodic, high impact headache should be given a default diagnosis of migraine.)

Screening/diagnosis


Management

3. Share migraine management between the doctor, the nurse and patient.

(The patient taking control of their management

and

the doctor/nurse providing education and guidance.)


Management

4. Provide individualised care for migraine and encourage patients to treat themselves.

(Migraine attacks in and between individuals are highly variable in frequency, duration, symptomatology and impact.)


Management

5. Follow-up patients, preferably with migraine diaries.

(Invite the patient to return for further management and apply a proactive policy.)


Management

6. Adapt migraine management to changes that occur in the illness and its presentation over the years.

(e.g. migraine may change to chronic daily headache over time.)


Treatments

7. Provide acute medication to all migraine patients and recommend it is taken as early as possible in the attack.

(Triptans are the most effective acute medications for migraine. Avoid the use of drugs that may cause analgesic-dependent headache, e.g. regular analgesics, codeine and ergotamine.)


Treatments

8. Prescribe prophylactic medications to patients who have four or more migraine attacks per month or who are resistant to acute medications.

(First-line prophylactic medications are beta-blockers, sodium valproate and amitriptyline.)


Treatments

9. Monitor prophylactic therapy regularly.


Treatments

10.Ensure that the patient is comfortable with the treatment recommended and that it is practical for their lifestyle and headache presentation.


Conclusions

New MIPCA guidelines

• Diagnostic algorithm

• Management algorithm

• 10 principles of management

The future

Heather MacBeanNurse Practitioner

Holmes ChapelCheshire

Discussion: How can nurses use the new MIPCA guidelines?

Dr Andrew Dowson

Pharmacist

Community nurse

Optician

Dentist

Complementary practitioner

Patient

Primary care physician

Practice nurse

Physician with expertise in headache:

GP; PCT; specialist

Ancillarystaff

Primary care Specialist care

Associate team Core team



Proposals

• The nurse is the first point of contact for the patient in the core team

• The nurse can handle the patient’s initial assessments before they see the GP– Screening

• The nurse can conduct assessments of impact– Diagnosis and individualised care

• The nurse is the first point of contact for follow-up– Headache diaries– Impact assessments– Repeat prescriptions / Switching therapies

Screening procedures

Taking a careful history is essential– Use of a headache history questionnaire is

recommended

• Patient education– Advice, leaflets, websites and patient

organisations

• Patient buy in– Patients to take charge of their own management– Effective communication between patient and

physician

Assessing impact on daily living

Diagnosis

1. What is the impact of the headache on the sufferer’s daily life?

Patient presenting with headache

Migraine/CDH

low

High

Q1. What is the impact of the headache on the sufferer’s daily life?

ETTH

Q2. How many days of headache does the patient have every month?

> 15 15

CDH

Q3. For patients with chronic daily headache, on how may days per week does the patient take analgesic medications?

<2 2

Not analgesicdependent

Analgesic dependent

Migraine

Q4. For patients with migraine, does the patient experience reversible sensory symptoms associated with their attacks?

With aura Without aura

Yes No

Exclude sinister Headache (<1%)

Consider short-lasting Headaches


Nurse


Assess illness severity• Attack frequency and duration• Pain severity• Impact on daily living

– MIDAS/HIT questionnaires

• Non-headache symptoms• Patient factors

– History, preference and other illnesses

Assessment of severity

Mild-to-moderate migraine Moderate-to-severe migraine

Headaches mild-to-moderate in intensity

Headaches moderate or severe in intensity

Non-headache symptoms not severe in intensity

Significant non-headache symptoms, possibly severe

Impact not significant:

MIDAS Grade I or II

HIT Grade 1 or 2

Significant impact:

MIDAS Grade III or IV

HIT Grade 3 or 4

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

Follow-up treatment decisions

• Acute medications– Patients effectively treated should continue with the original

therapy– Patients who fail on original therapy should be offered other

therapies (switching)• Prophylactic medications

– Ensure medication is provided for an adequate time period (up to 3 months)

– If effective, treatment can continue for 6 months, after which it may be stopped

– If ineffective, another prophylactic medication may be tried– Usual contraindications apply

• Patients refractory to repeated acute and prophylactic medications should be referred to a specialist

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