Headache Diagnosis and Management in Primary Care

Approaches to Treatment Step care Staged care Stratified care

MIDAS Migraine Disability Validated Sensitive to change, so good for follow- up Link to online version of MIDASMIDAS disability.net/About_Midas/questionna ire5.pdf disability.net/About_Midas/questionna ire5.pdf

HIT-6 Validated Good for differential diagnosis Scoring Mild impairment Moderate Severe ≥60

Likelihood Ratios for diagnosis of migraine Positive LRNegative LR

Overall Management Algorithm

MIPCA Diagnostic Screening Algorithm

Can we make that algorithm operate in the background and suggest steps in the Plan? Hook it to a Headache Condition Summary?

MIPCA Management Algorithm

Close-up 1

Migraine Prophylaxis...

...Migraine Prophylaxis

Headache Action Plans My choice

Meds Teaches

Diary

Patient Handouts

PowerChart Opportunities Integrate Diagnosis decision aids into history-taking Migraine Action Plan integrates PowerChart management orders with patient handout

Migraine Action Plan Potential Future patient feedback into chart Recent HA pattern Treatment response Adverse effects

Headache Dashboard Medications amitriptyline 10 mg 3 hs Maxalt MLT 10 Aleve onset, 2 in 30 min levothyroxine 125 mcg/d Diagnoses Migraine Insomnia Hypothyroidism Cervical Dysplasia 2002 > cryo Dysthymia Allergies & Intolerances sulfa > as a child penicillin > hives Imitrex SC > chest pain, anxiety (refuses to take again) Headache Pathway 1.Consult: Hx, Tx history, education, buy-in 2.Diagnosis: screen for HA type 3.Severity assessment: Frequency, Pain severity, Impact on pt’s life, Non-HA symptoms, Patient factors 4.Treatment Plan: Establish goals, Behavioral therapy, Acute therapy, Possible prophylactic therapy, Complementary therapy 5.Follow-up: Assess outcomes Paula Pound DOB: 02/11/1967 MRN: ph Headache Diary Headache 1Headache 2Headache 3 Date / time Prodrome / aura Pain (1-10) Location / type of pain Other symptoms Possible triggers Meds taken Did med help? Med side effects Other therapies Did another tx help?

Headache Dashboard Medications amitriptyline 10 mg 3 hs Maxalt MLT 10 Aleve onset, 2 in 30 min levothyroxine 125 mcg/d Diagnoses Migraine Insomnia Hypothyroidism Cervical Dysplasia 2002 > cryo Dysthymia Allergies & Intolerances sulfa > as a child penicillin > hives Imitrex SC > chest pain, anxiety (refuses to take again) Headache Pathway 1.Consult: Hx, Tx history, education, buy-in 2.Diagnosis: screen for HA type 3.Severity assessment: Frequency, Pain severity, Impact on pt’s life, Non-HA symptoms, Patient factors 4.Treatment Plan: Establish goals, Behavioral therapy, Acute therapy, Possible prophylactic therapy, Complementary therapy 5.Follow-up: Assess outcomes Paula Pound DOB: 02/11/1967 MRN: ph Outcome measures Midas scores # HA / mo Missed work days Non-HA sx Tabular form for temporal trends Brought into PowerForm by nurse at checkin Drugs tried, failed, why Topamax Inderal

Allergies & Intolerances sulfa > as a child Imitrex SC > chest pain, anxiety (refuses to take again) penicillin > hives Allergies & Intolerances sulfa > as a child Imitrex SC > chest pain, anxiety (refuses to take again) penicillin > hives Allergies & Intolerances sulfa > as a child Imitrex SC > chest pain, anxiety (refuses to take again) penicillin > hives Allergies & Intolerances sulfa > as a child Imitrex SC > chest pain, anxiety (refuses to take again) penicillin > hives Allergies & Intolerances sulfa > as a child Imitrex SC > chest pain, anxiety (refuses to take again) penicillin > hives Allergies & Intolerances sulfa > as a child Imitrex SC > chest pain, anxiety (refuses to take again) penicillin > hives Algorithm formatting question...

Positive Likelihood Ratio

Negative Likelihood Ratio