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

Headache types

90%

10% Episodic

primary headaches

Chronic primary headaches

Primary headache

No underlying medical cause:

Tumour

Meningitis

Vascular disorders

Systemic infection

Head injury

Drug-induced

Secondary headache

Underlying medical cause:

Episodic primary headaches

Episodicprimary

headaches

Migraine +/- aura

Tension-type headache (TTH)

Cluster

Probablemigraine

Chronic cluster

Chronic migraine +/- medication overuseChronic tension

Chronic daily headache (CDH)

Hemicrania continuaNew daily persistent

Chronic primary headaches / chronic daily headaches

Rasmussen et al 1991Rasmussen et al 1991

Lifetime prevalence of primary headache

(n=740)

Episodic migraine

Episodic TTH

Chronic daily - all types

16%

78%

4%

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)

Migraine Impact

• Meets WHO definition of disability

• Epidemiology– 6 million people in UK– Women 3x men– most sufferers aged 20 to 50

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

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

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

Indirect cost of migraineFor most sufferers, migraine results in lost

productivity rather than days lost from workWork loss

(%)

0 40 1000

20

40

80

100

60

20 60 80Migraine sufferers (%)

Adapted from von Korff et al 1998Adapted from von Korff et al 1998

30 9010 50 70

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

Objective 2

Headache Diagnosis

This slide kit is for educational purposes only

“Red flags”• Single cohort (Level 3) or expert opinion (Level 4)

• new onset headache in patients who are aged over 50 29-31

• 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

Abbreviated diagnostic checklist based on IHS 2004 criteria

Essential (3)

Essential (2)

Essential (1)

• 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

• Recurrent• No organic disease• Duration 4-72 h

• Unilateral• Pulsating• Moderate / severe• Aggravated by

movement

• Nausea / vomiting• Photo / phonophobia

Migraine Probable migraine Tension-type

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

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)

Other primary headache

• Trigeminal autonomic cephalalgias (TACs)– Cluster headache– Paroxysmal Hemicrania– SUNCT

• Hemicrania continua

• New daily persistent headache

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

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

Objective 3

Headache Management

Non-pharmacological therapies• 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

Adapted from US Headache Consortium Headache GuidelinesAdapted from US Headache Consortium Headache Guidelines

Acute pharmacological therapiesDrug 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

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

Objective 4

Audit

Useful Information

Ideas for Audit

• Number of Migraineurs

• Assess migraine impact and lost time

• Migraine awareness campaign

• Medication Overuse awareness

• Reassess impact and lost time

Migraine Resources

• British Association for the Study of Headache www.bash.org/

• Migraine Action Association www.migraine.org.uk/

• www.sign.ac.uk

Objective 5

Case Study

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

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

Any Questions?