OH and Headache

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?