Download Guidelines for all doctors in the diagnosis and management of

Guidelines for all doctors
in the diagnosis and management of
Migraine and Tension-Type Headache
2004
Writing Committee:
T.J. Steiner
E.A. MacGregor
P.T.G. Davies
Headache in the UK
• Affects nearly everyone occasionally
• Is a problem for around 40% of people
• Is one of the most frequent causes of
consultation in both general practice and
neurological clinics
• Represents an immense socioeconomic
burden
Migraine in the UK
•
•
•
•
Affects 12-15% of the population
Affects 3X more women than men
Most troublesome late teens to early 50s
Also occurs in children and the elderly
Migraine in the UK
• An estimated 187,000 attacks every day
• Almost 90,000 people absent from work or
school as a result
• Annual cost through lost work and
impaired effectiveness may be £1.5 billion
• Despite these statistics migraine seems to
be under-diagnosed and under-treated
Tension-type Headache (TTH)
• Affects up to 80% of people
• Often referred to as a ‘normal’ or ‘ordinary’
headache by patients
• Most do not consult a doctor
• High prevalence results in a similar economic
burden to migraine via lost work or reduced
working effectiveness
• 2-3% of adults have chronic TTH (i.e. TTH >15
days per month)
• Chronic TTH can result in substantial disability
and work absence
British Association for the
Study of Headache (BASH)
Management Guidelines
• Intended for all doctors who manage headache
- in general practice or specialist clinics
• Provide management strategies supported by
specialists in the field
• Should be incorporated by healthcare
commissioners into any agreement for provision
of service
British Association for the
Study of Headache (BASH)
• Headache management requires a flexible
and individualized approach
• BASH Guidelines can be tailored to
individual clinical circumstances
The International Headache
Society Classification
The International Headache Society (IHS)
classifies headache disorders under
primary and secondary conditions
IHS Classification
Primary Headaches
Migraine
– Without aura
– With Aura
Tension-type Headache
– Episodic
– Chronic
Cluster Headache and other trigeminal
autonomic cephalalgias
IHS Classification
Secondary Headaches
• Headache attributed to
–
–
–
–
–
–
–
Head and/or neck trauma
Vascular disorders
Non-vascular intracranial disorders
A substance or its withdrawal
Infection
Disorder of homeostasis
Disorder of cranium neck, eyes, ears, nose, sinuses,
teeth, mouth or other facial or cranial structures
– Psychiatric disorder
• Cranial neuralgias and central causes of pain
• Headache unspecified/not classified
Patient history
The key to diagnosis
• History is all-important
– No diagnostic tests for primary headache
• Patient diaries can help identify patterns of
attacks and aid diagnosis*
• Different headache types are not mutually
exclusive
• Take a separate history for each headache type
• In children, migraine and tension-type headache
may be less distinct than in adults
*Assuming a condition requiring urgent attention has already been ruled out
Headache history
Key questions
TIME
- Onset, frequency, patterns, duration?
CHARACTER
- Site, intensity, nature of pain?
CAUSES
- Predisposing, triggering, aggravating, relieving factors?
- Family history?
RESPONSE
- Patient’s actions and limitations during an attack?
- Medications used?
INTERVALS
- How does the patient feel between attacks?
- Concerns, anxieties and fears about attacks?
Migraine
Diagnostic Pointers
Typically
• Recurrent episodic headaches with moderate or
severe pain
• May be unilateral and/or throbbing
• Last from 4 hours up to 3 days
• Associated with gastrointestinal and visual
symptoms
• Activity is limited and dark/quiet is preferred
• Free from symptoms between attacks
IHS diagnostic criteria
Migraine without aura*
An idiopathic recurring headache with:
A. At least 5 attacks fulfilling B-D
B. Attacks last 4-72 hours
C. At least 2 of the following
- Unilateral location
- Pulsating quality
- Moderate or severe pain intensity
- Aggravated by routine physical activity
D. At least one of the following during an attack
- Nausea and/or vomiting
- Photophobia and phonophobia
E. Not attributed to another disorder
* In children, attacks may be shorter; also more commonly bilateral and GI
disturbance is more prominent
Diagnosis
Migraine with aura
• Aura precedes headache
• Symptoms of migraine aura:
– Transient hemianopic disturbances prior to
headache, lasting 10-30 minutes (occasionally up
to 1 hour)
– A spreading scintillating scotoma (patients may
draw a jagged crescent)
– Other reversible focal neurological disturbances
e.g. unilateral paraesthesiae of hand, arm or face
• Visual blurring and ‘spots’ are not diagnostic
• Patients may have attacks of migraine with aura
and migraine without aura at different times
‘Diagnosis’ by treatment
• Can be tempting to use the specific antimigraine drugs as a diagnostic test
• This approach is likely to mislead
– Low sensitivity
• ‘Triptans’ are at best effective in only three
quarters of attacks
– Low specificity
• TTH in migraineurs can respond to triptans
Tension-type Headache (TTH)
TTH
– Replaces ‘tension headache’ and ‘muscle
contraction headache’
– Typically generalized ‘vice like’ or ‘a tight
band’
– No nausea or photophobia
Tension-type Headache (TTH)
• Occasional TTH is seldom disabling
(unlike chronic TTH)
• Both TTH and migraine are aggravated by
stress (so can be hard to differentiate)
• Headache more often than once a week
may be a mixture of TTH and migraine
• Successful management is dependent on
recognition and management of each
separate headache type
Chronic Daily Headache
(CDH)
CDH
– A descriptive, not diagnostic, term
– Headache occurs on more days than not (>50% of
the time) over weeks or longer
– Affects up to 4% of the population
– Accounts for up to 40% of referrals to special
headache clinics
– Costs the UK economy up to £1 billion per year in
lost working time yet is very poorly characterized
• Headaches occurring every day are generally
not migraine (but may co-exist with migraine)
• CDH includes chronic TTH & Chronic Migraine
Medication Overuse
Headache (MOH)
• Affects an estimated 1 in 50 people
• First noted with phenacetin and
ergotamine
• Typically results from overuse of OTC
analgesics
• A related syndrome occurs with ‘triptans’
• Accurate diagnosis is difficult in the
presence of MOH
• A detailed medication history is essential
Cluster Headache (CH)
• Formerly known as migrainous neuralgia
• Generally affects men (ratio 6:1), often smokers,
in their 20s or older
• Typically occurs in bouts for 6-12 weeks every
one or two years
• Attacks typically occur at night, waking the
patient 1 to 2 hours after falling asleep, lasting
30 to 60 minutes
• Pain is intense, probably as severe as renal
colic, and strictly unilateral
Physical examination of
headache patients
•
•
•
•
Physical examination can reassure patients
Optic fundi should always be examined
Blood pressure measurement is recommended
Examine head and neck for muscle tenderness,
especially in tension-type headache
• Examine jaw and bite
• Some paediatricians recommend head
circumference measurement for children, plotted
on a centile chart
Serious cause of headache 1
Intracranial tumours
–
–
–
–
–
Rarely produce headache until quite large
Epilepsy is a cardinal symptom
Loss of consciousness should be viewed very seriously
Focal neurological signs are generally present
Diagnosis harder in neurological ‘silent areas’ of the frontal
lobes
Meningitis
– Usually accompanied by fever and neck stiffness
– Headache may be generalized or frontal (perhaps radiating
to the neck)
– Nausea and disturbed consciousness may accompany
headache later
Serious cause of headache 2
Subarachnoid haemorrhage (SAH)
–
–
–
–
–
Usually, sudden onset of very severe ‘explosive’ headache
Neck stiffness – may take hours to develop
Classical signs and symptoms may be absent in the elderly
Sometimes confused with migraine ‘thunderclap’ headache
Serious consequences of missing SAH call for a low
threshold of suspicion
Temporal arteritis (TA)
–
–
–
–
Suspect if new headache in patients over 50 years
Headache accompanied by marked scalp tenderness
Headache persistent but often worse at night
Jaw claudication is highly suggestive of TA
Serious cause of headache 3
Primary angle-closure glaucoma
– Rare before middle age
– Headache and eye pain can be dramatic or episodic and mild
Idiopathic intracranial hypertension
– Formerly termed benign intracranial hypertension or
pseudotumor cerebri
– Rare cause, usually in obese young women
– History may suggest raised intracranial pressure
– Papilloedema is diagnostic in adults
– Diagnosis confirmed by CSF pressure measurement
Carbon monoxide (CO) poisoning
– Headache is a symptom of sub-acute toxicity
– Uncommon but potentially fatal
Migraine Management
Overview
• Aim for effective control of symptoms
– A cure is unrealistic
• Under-treatment is not cost-effective
– Results in unnecessary pain and disability
– Repeat consultations are expensive
• Migraine typically varies with time
– Needs may change
Migraine Management
Overview
• Four elements to effective migraine
management in adults
– Correct and timely diagnosis
– Explanation and reassurance
– Identification and avoidance of predisposing/trigger factors
– Drug or non-drug intervention
• Children
– Often respond to conservative migraine
management
– If this fails, most can be managed as adults
Migraine
Predisposing Factors
• Predisposing factors are different from
precipitating/trigger factors
• Five main predisposing factors are
recognized
– Stress
– Depression/anxiety
– Menstruation
– Menopause
– Head or neck trauma
Migraine
Trigger Factors
• Trigger factors are seen in occasional patients
and include
–
–
–
–
Relaxation after stress: weekends/holidays
Change in habit: sleep, travel etc.
Bright lights/loud noise
Diet: alcohol, cheese, citrus fruits, possibly
chocolate (but evidence is inconclusive); missed
or delayed meals
– Strenuous unaccustomed exercise
– Menstruation
• A trigger diary kept by patients can be useful
unless causes introspection
Migraine
Acute Drugs
• Five step treatment ‘ladder’
• Failure on three occasions is the minimum
criterion for moving to the next step
Migraine
Acute Drugs 1
Step 1: Oral analgesics ± Antiemetic
a) Simple analgesics, preferably soluble
– Aspirin or paracetamol or ibuprofen
– NOT codeine or dihydrocodeine
b) As above or prescription-only NSAID
plus prokinetic antiemetic
(metoclopramide or domperidone)
Contraindications:
Aspirin not recommended for children under 16
Metoclopramide not recommended for children or
adolescents
Migraine
Acute Drugs 2
Step 2: Parenteral Analgesic ± Antiemetic
Diclofenac suppositories
Plus
Domperidone suppositories
Contraindications:
Peptic ulcer or lower bowel disease
Diarrhoea
Patient non-acceptance
Migraine
Acute Drugs 3(i)
Step 3: Triptans
Marked inter-patient variation in response – see which
suits the patient best
Ineffective if taken before onset of headache
Some experts suggest adding metoclopramide or
domperidone
Symptoms often relapse within 48 hours
Contraindications:
Uncontrolled hypertension
Risk factors for CHD or CVD
Children under 12 years
Migraine
Acute Drugs 3(ii)
Step 3: Ergotamine
Toxicity and misuse are potential drawbacks
Contraindications:
Ergotamine is not an option if triptans are
contraindicated and should not be taken
concomitantly with a triptan
Beta-blocker therapy
Not advised for children
Migraine
Acute Drugs 4
Step 4: Combinations
Steps 1+3 may be helpful, followed by Steps
2+3
Self-injected diclofenac may be tried
Migraine
Emergency Treatment
Emergency treatment at home
• NOT pethidine
• Intramuscular diclofenac
and/or
• Intramuscular chlorpromazine
– Antiemetic and sedative
Migraine
Repeated Relapse
• Consider naratriptan, eletriptan or
frovatriptan
• Ergotamine
– Prolonged duration of action
• Diclofenac or tolfenamic acid may be used
– Pre-emptively if relapse is anticipated
Migraine
Prophylactic Drugs
• Prophylactic therapy is used (in addition to acute
therapy) to reduce the number of attacks when
acute therapy alone gives inadequate symptom
control
• Criteria for choice of prophylactic drug based on
–
–
–
–
Evidence of efficacy
Comorbidity and effect of drug
Contraindications, including risk of pregnancy
Frequency of dosing: once daily dosing is
preferable
Migraine
Prophylactic Drugs 1
First-line
– Beta-blockers (atenolol,metoprolol,
propranolol, bisoprolol) if not contra-indicated
– Amitriptyline – when migraine co-exists with
•
•
•
•
TTH
Another chronic pain condition
Disturbed sleep
Depression
Migraine
Prophylactic Drugs 2
Second-line
– Sodium valproate
– Topiramate
• Evidence for sodium valproate is
reasonable and clinical usage is extensive
• Evidence for topiramate is very good but
clinical usage is as yet limited
Migraine
Prophylactic Drugs 3
Third-line
– Gabapentin
– Methysergide
– Beta-blockers and amitriptyline (in
combination)
Migraine
Prophylactic drugs 4
Other options (limited efficacy)
– Pizotifen
– Verapamil
– SSRIs
Migraine
Menstrual attacks
Perimenstrual prophylaxis
– Non-hormonal
• Mefenamic acid - first-line in migraine occurring with
menorrhagia and/or dysmenorrhoea
– Oestrogen
• If the women has an intact uterus and is menstruating
regularly, no progestogens are necessary
Combined oral contraceptives
– Migraine without aura in pill-free interval may resolve with a
more oestrogen-dominant pill
– Not recommended for women with migraine with aura
Migraine
HRT
Migraine and hormone replacement therapy
• The menopause itself commonly exacerbates
migraine
• Symptoms can be relieved with HRT
• No evidence that risk of stroke is elevated or
reduced by use of HRT in women with migraine
• Some women on HRT find migraine worsens
– Often solved by reducing dose and/or changing to
non-oral formulation
Migraine
Non-drug Intervention
•
•
•
•
Improving physical fitness
Physiotherapy (but no evidence)
Acupuncture
Psychological therapy
– Relaxation
– Stress reduction
– Coping strategies
– Biofeedback
Tension-type Headache (TTH)
Management
Infrequent episodic TTH (<2 days/week)
• Reassurance
• Symptomatic treatment
– Aspirin, paracetamol or ibuprofen
– Codeine and dihydrocodeine should be
avoided
Tension-type Headache (TTH)
Management
Chronic TTH
• Symptomatic treatment may give shortterm relief but is inappropriate long-term
• Consider a course of naproxen
– May break the cycle
– May stop overuse of analgesics
• Amitriptyline is the prophylactic of choice
Tension-type Headache (TTH)
Management
Non-drug interventions
• Regular exercise
• Physiotherapy
• Stress-coping strategies
• Acupuncture
Co-existing Headaches
Management
• Restrict symptomatic medication
– Max 2 days per week
• Prophylaxis for migraine coexisting with
episodic TTH
– Amitriptyline
– Sodium valproate
BASH Guidelines
Effects of Implementation
• Improve diagnosis
• Increase the number of
patient with migraine
using triptans
• Reduce misuse of
medication, including
triptans
• Reduce the need for
specialist referral
• Improve the overall
effectiveness of
headache management
• Reduce inappropriate
treatment
• Improved treatment for
each patient
• Improve outcome
• Reduce iatrogenic
illness
• Reduce disability
BASH Guidelines
Effects of Implementation
Initially increases the no. of consultations
per patient
BUT
Reduces the overall number of consultations
Raises expectations, especially amongst
those with migraine, leading to more patients
consulting
BUT
Reduces the overall burden of illness, with
savings elsewhere
Audit
Judging Effectiveness
• Aims of Audit
– To measure direct treatment costs
• Consultations, referrals and prescriptions
– To measure headache burden
• Before and after implementation of BASH guidelines
• Migraine Disability Assessment (MIDAS) may be
useful in the audit process
– A self-administered questionnaire
– Measures the adverse effect of headache on work
and social activities over the preceding 3 months