1. Headaches Clinical case scenarios for group discussion Support for education and learning 2 nd Edition – January 2016

2. Implementing NICE guidance www.nice.org.uk What this presentation covers Introduction to clinical case scenarios Background NICE Pathway The cases NICE Evidence Find out more

3. Implementing NICE guidance www.nice.org.uk Clinical case scenarios Each scenario includes details of the patient’s initial presentation. The clinical decisions about diagnosis and management are then examined using a question and answer approach. Relevant recommendations from the NICE guideline are quoted in the notes and additional information and detail from the full guideline is added to answers. These clinical case scenarios form part of a package of education and learning materials which include an Academic detailing aid and Diagnosis poster to support CG150, Headaches.Academic detailing aid Diagnosis poster

4. Implementing NICE guidance www.nice.org.uk Background: Headaches Headaches are one of the most common neurological problems presented to GPs and neurologists. Most common primary headache disorders are tension-type headache, migraine and cluster headache. Improved recognition of primary headaches will help the generalist clinician to manage headaches more effectively, allow better targeting of treatment and potentially improve quality of life and reduce unnecessary investigations for people with headache.

5. Implementing NICE guidance www.nice.org.uk Click here to go to NICE Pathways website NICE Pathways The NICE Headaches Pathway shows all the recommendations in the Headaches guideline.

6. Implementing NICE guidance www.nice.org.uk Learning objectives The learning objectives for these clinical case scenarios are to improve knowledge on: how to manage acute migraine. best practice for migraine prophylaxis (including migraine prophylaxis for women and girls of childbearing potential). treating cluster headaches, including the key points about ordering home and ambulatory oxygen. where to find information for patients on acute migraine, migraine prophylaxis and cluster headaches.

7. Implementing NICE guidance www.nice.org.uk Case scenario 1 Joseph, acute migraine (paediatric)

8. Implementing NICE guidance www.nice.org.uk Presentation Joseph is a 14-year-old boy. He attends your clinic accompanied by his mum, Claire. He presents with a 2-month history of headaches that he describes as “banging” and that make his head “very very sore”. He says that in the past 2 months he has had 6 of these headaches. He also says that light hurts his eyes when he has the headaches. He does not feel nauseous or vomit during the headaches. Claire tells you that when Joseph has the headaches he is unable to go to school and that the headaches last from 2 to 4 hours. She gives Joseph paracetamol and if that doesn’t work she also gives him ibuprofen. Joseph reports that this combination of medication helps but that it still hurts a lot until the headache eventually goes completely. Joseph and Claire ask if Joseph’s headaches are migraines and if there is anything more he can take to ease the pain and reduce the amount of time he is taking off school.

9. Implementing NICE guidance www.nice.org.uk 1.1 Question Based on the history provided, and using the diagnosis poster as a quick reference to recommendations in section 1.1 and 1.2 of the guideline, you diagnose migraine without aura.diagnosis poster Claire asks what this means for Joseph. How would you answer this?

10. Implementing NICE guidance www.nice.org.uk 1.1 Answer You would explain the diagnosis to Claire and Joseph and reassure them that a serious underlying cause is unlikely, based on Joseph’s history and your examination of him, which showed no abnormalities. You would tell them that migraines are a well-recognised problem although what causes them is not known for certain. You would reassure Claire and Joseph that you appreciate the large impact the headaches are having on Joseph’s life. You would give them written information about migraine in a format suitable for both, and include information about support organisations (see information in notes). Given that Joseph is likely to have recurrent migraines that will need treatment, you would explain the risk of medication overuse headache.

11. Implementing NICE guidance www.nice.org.uk 1.2 Question For acute management of Joseph’s migraine, you would tell Joseph and Claire that Joseph could have nasal sumatriptan, to take along with a non steroidal anti-inflammatory or paracetamol. However, Claire is concerned about Joseph taking 2 drugs and asks if there is an option for him to take just 1 drug. How would you answer this? At the time of publication of these cases (January 2016), only nasal sumatriptan had a UK marketing authorisation for this indication in people aged 12 to 18 years

12. Implementing NICE guidance www.nice.org.uk 1.2 Answer You would tell Claire and Joseph that adding nasal sumatriptan, to paracetamol or a non steroidal anti-inflammatory would be the most effective option for relieving his migraines, but that Joseph could try taking just nasal sumatriptan to see whether it works better than paracetamol or ibuprofen. You would explain that the triptan would come as a nasal spray because it is not usually prescribed in tablet or capsule form for people aged under 18. You would tell Claire and Joseph that the other option would be monotherapy with either paracetamol or NSAID and you would ensure that the dose was optimised. However, since Joseph has already tried both of these drugs and they didn’t work well enough, triptan would be a suitable option for him to try next.

13. Implementing NICE guidance www.nice.org.uk 1.3 Question Claire asks what they should do if the nasal triptan doesn’t work and whether there are there alternative medications. a) How would you answer this? b) What tool could you use to help assess the effectiveness of the nasal triptan?

14. Implementing NICE guidance www.nice.org.uk 1.3 Answer a)You would explain that Joseph should try the sumatriptan nasal spray for at least 3 headaches because it isn’t possible to tell whether it’s working based on just 1 headache. If it still doesn’t work well enough then they should return to you and you would offer combination therapy with nasal sumatriptan, and a non steroidal anti-inflammatory. You explain that it is a case of finding out which type of treatment works best for Joseph. b)You could give Joseph a headache diary containing prompts for him to record the frequency, duration and severity of his headaches as well as his response to the triptan. You would explain to Joseph and Claire that keeping the diary will help them to learn more about his migraines (See next slide).

15. Implementing NICE guidance www.nice.org.uk 1.3 Answer (headache diary) Headache diaries are more accurate than recall and allow patterns of events to be more clearly seen. They also play an important role in acknowledging the impact of headache. Keeping the diary will help the patient to learn more about their migraines, for example whether they occur in patterns and whether they are triggered by anything in particular. The diary will also enable them to record any changes in how often the migraines happen, how painful they are, how well the treatments for them are working and any side effects from the treatments. You would use this information in the standard review you carry out after starting or changing treatment.

16. Implementing NICE guidance www.nice.org.uk 1.4 Question Claire and Joseph thank you for your help and leave. As you are reflecting on Joseph's case, you think about other treatment options that might be suitable for Joseph if the triptan nasal spray doesn’t work well enough for him. What other treatment options would be available?

17. Implementing NICE guidance www.nice.org.uk 1.4 Answer You could try combination of the nasal sumatriptan with paracetamol. Alternatively you might then consider trying a different formulation of nasal triptan, triptan tablets or melts, but you would prefer not to prescribe these for Joseph because they are usually only given to people aged 18 and over. In addition to different formulations of nasal triptan, or triptan tablets or melts, you might consider adding an anti-emetic to Joseph’s treatment, taking into account the risk of side effects and Joseph and Claire’s preferences. At the time of publication of these cases (January 2016), only nasal sumatriptan had a UK marketing authorisation for this indication in people aged 12 to 18 years

18. Implementing NICE guidance www.nice.org.uk Case scenario 2 Anaka, migraine prophylaxis

19. Implementing NICE guidance www.nice.org.uk Presentation Anaka is a 28-year-old woman who was diagnosed with migraine with aura 6 months ago. She has, on average, 1 migraine attack per week, for which she takes triptan, an NSAID and an anti- emetic. Because Anaka has migraine about 4 times per month, she is unlikely to develop medication overuse headache. You are therefore happy with her current treatment plan. However, during an attack, she is unable to work or continue her normal daily activities. She also worries a lot about when the next attack is going to happen and their frequency causes her to take a lot of time off work.

20. Implementing NICE guidance www.nice.org.uk 2.1 Question You note from Anaka's records that other than the medication mentioned above she is not taking any other forms of medication. You want to confirm that she is not a taking combined hormonal contraceptive for contraception purposes. Why is this?

21. Implementing NICE guidance www.nice.org.uk 2.1 Answer There is an increased risk of ischaemic stroke in people with migraine with aura. This risk is increased in women using combined hormonal contraception. Anaka confirms that she currently uses contraception but not a combined hormonal contraceptive.

22. Implementing NICE guidance www.nice.org.uk 2.2 Question Anaka asks if there is anything that can be done to reduce the frequency of her migraine attacks.

23. Implementing NICE guidance www.nice.org.uk 2.2 Answer You would tell Anaka about the option of prophylactic treatment. Explain that prophylactic treatments prevent, rather than cure, a condition, and that for migraines they aim to reduce the frequency, severity and duration of the attacks. You explain the risks and benefits of prophylactic treatment – ensuring she understands her risk of migraine recurrence and severity, with and without prophylaxis, and her risk of adverse effects.

24. Implementing NICE guidance www.nice.org.uk 2.3 Question The NICE guideline recommends offering topiramate or propranolol and considering amitryptiline for the prophylactic treatment of migraine. When discussing the most suitable prophylaxis for Anaka what important information do you need to tell her about topiramate?

25. Implementing NICE guidance www.nice.org.uk 2.3 Answer Given that Anaka is of child bearing potential, it is important for her to be aware that topiramate is associated with a risk of fetal malformations. Additionally, as Anaka has confirmed that she is currently using contraception, she needs to be aware that there is potential for topiramate to impair the effectiveness of hormonal contraceptives. With Anaka's consent you arrange an appointment for her with the contraceptive service so she can talk about the options for suitable contraception if she were to take topiramate.

26. Implementing NICE guidance www.nice.org.uk 2.4 Question Following consultation with the contraceptive service, Anaka decides that she does not want to use any of the contraceptives that were recommended as suitable and reliable for use with topiramate. You therefore suggest propranolol for migraine prophylaxis. a) How would you assess the effectiveness of the propranolol? b) When would you review the need to continue this prophylaxis?

27. Implementing NICE guidance www.nice.org.uk 2.4 (a) Answer a) You would provide Anaka with a headache diary that contains prompts to record the frequency, duration and severity of her headaches as well as her response to the propranolol. Headache diaries are more accurate than relying on a person’s memory, and allow patterns of events to be more clearly seen. Diaries also play an important role in acknowledging the impact of headaches. You would advise Anaka to complete the diary in order to: understand any patterns or triggers that may cause her symptoms; be more alert to changes in the regularity or severity of her attacks; and learn the effectiveness of any new medications she takes. It will also help inform the standard review process, to assess the treatment’s effectiveness and the presence of side effects after starting or changing a treatment plan. See next slide for answer 2.4 (b)

28. Implementing NICE guidance www.nice.org.uk 2.4 (b) Answer b) Continuing treatment when it is no longer needed puts the person at risk of having side effects and drug interactions. Experts agree that many people can stop prophylaxis after 6 months of treatment and continue to benefit from the prophylactic treatment. Therefore, you would review Anaka’s need to continue prophylactic treatment at 6 months.

29. Implementing NICE guidance www.nice.org.uk 2.5 Question Anaka asks if there is anything else she can do or take, such as a natural remedy, which could help reduce her migraine intensity. How would you address this?

30. Implementing NICE guidance www.nice.org.uk 2.5 Answer You would tell Anaka that taking riboflavin (400 mg once a day) may help to reduce her migraine frequency and intensity. You would tell her that products containing riboflavin can be purchased from pharmacies and health food stores. You could also tell Anaka that if propranolol is unsuitable or ineffective you will consider offering her a course of acupuncture.

31. Implementing NICE guidance www.nice.org.uk 2.6 Question Anaka tells you that her mum also takes treatment to prevent migraines, but that she takes amitriptyline. Anaka says amitriptyline works for her mum and asks why she has not been offered it. How would you answer this question?

32. Implementing NICE guidance www.nice.org.uk 2.6 Answer You would tell her that, following a review, NICE (a national organisation that advises the NHS about the effective use of drugs) recommends: offering prophylaxis with topiramate or propranalol considering treatment with amitriptyline depending on the person’s clinical needs and their preferences. You discuss the risks and benefits of amitriptyline so she can consider treatment with this medicine as an alternative to topiramate or propranolol.

33. Implementing NICE guidance www.nice.org.uk 2.7 Question If Anaka wants to become pregnant in the future, but still needs migraine prophylaxis, what should you do?

34. Implementing NICE guidance www.nice.org.uk 2.7 Answer Migraine without aura often improves during pregnancy. However, migraine with aura is more likely to continue throughout pregnancy. If Anna becomes pregnant you should therefore assess whether she needs prophylaxis during her pregnancy. If she does, then you would seek specialist advice. This could be advice over the telephone to avoid delaying a prescription that would otherwise require a referral. You would also review and discuss her use of triptan, NSAIDs and anti- emetics, because of the risks associated with these medications during pregnancy.

35. Implementing NICE guidance www.nice.org.uk 2.8 Question Anaka asks you if there is any reading she can do to learn more about her condition. a) In your discussion with Anaka, what information and support would you provide as a minimum? b) What further information would you provide to Anaka ?

36. Implementing NICE guidance www.nice.org.uk 2.8 Answer a) As a minimum, you would explain to Anaka about her diagnosis and reassure her that other pathology has been excluded. You would reassure Anaka that this type of headache is a well-recognised problem and that you understand that it is having a big impact on her life. b) You would provide Anaka with information (in a format suitable for her) about headache disorders, including information about support groups (see supporting information in notes).

37. Implementing NICE guidance www.nice.org.uk Case scenario 3 Malcolm, cluster headache

38. Implementing NICE guidance www.nice.org.uk Presentation Malcolm is a 31-year-old man. He has a history of severe headaches, which he says cause him the worst pain he’s ever felt. When he gets these headaches, he has pain on 1 side of his head, around his eye and along the side of his face. He also experiences drooping or swelling of the eyelid, watery eye and nasal congestion, on the same side as the headache. Malcolm experienced the severe headache for the first time 2 weeks ago for which he went to accident and emergency, where he was given a CT scan. The CT scan was normal and you have been asked to evaluate Malcolm. Malcolm tells you that, since his first severe headache 2 weeks ago, he has experienced 6 more headaches. He says that on average his severe headaches last from 30 to 90 minutes. Based on Malcolm's history and using the diagnosis poster as a quick reference to recommendations in section 1.1 and 1.2 of the guideline you diagnose him with cluster headache.diagnosis poster

39. Implementing NICE guidance www.nice.org.uk 3.1 Question What advice and support can you offer Malcolm about his diagnosis?

40. Implementing NICE guidance www.nice.org.uk 3.1 Answer At a minimum, you would explain the diagnosis and reassure Malcolm that other pathology has been excluded. You would also talk about the options for management (see case continued) and reassure him that you recognise these severe headaches are having a big impact on him. You would also provide Malcolm with information about cluster headache in a format suitable for him and include information about support organisations (see information in notes).

41. Implementing NICE guidance www.nice.org.uk 3.2 Question When you ask Malcolm about how his attacks have been since his admission to the emergency department, he becomes upset and says that that they are very painful. He asks if there is any more that can be done to reduce the pain during attacks. What interventions could help Malcolm during an attack?

42. Implementing NICE guidance www.nice.org.uk 3.2 Answer You would offer Malcolm subcutaneous or nasal triptan. You need to make Malcolm aware that the nasal triptan does not have UK marketing authorisation for this indication (correct at time of publication of these case scenarios in January 2016). Malcolm is concerned about injecting himself; therefore, you decide to offer him nasal triptan. You document that Malcolm has consented to this treatment. You highlight that, if he is not receiving adequate relief with the nasal triptan, you will meet with Malcolm again and talk about subcutaneous triptan. See next slide for answer 3.2 continued

43. Implementing NICE guidance www.nice.org.uk 3.2 Answer continued You would also assess Malcolm's medical history and note that he has no history of respiratory disease or COPD. You would offer Malcolm home and ambulatory oxygen. As required, you would explain that during an attack he will need to use a non-rebreathing mask and reservoir bag, and that the oxygen will be running at a flow rate of at least 12 litres per minute. The home oxygen is for use if he has an attack at home. The ambulatory oxygen is for him to take out and use if he has an attack while he is away from home (recognising that attacks happen at unpredictable intervals). You would explain that this will allow him to treat his attack at the earliest opportunity.

44. Implementing NICE guidance www.nice.org.uk 3.3 Question You are prescribing Malcolm the nasal triptan. How much should you prescribe?

45. Implementing NICE guidance www.nice.org.uk 3.3 Answer Because of the frequent nature of attacks during a bout of cluster headaches, it is important that Malcolm has an adequate supply of medication to reduce the pain. You would calculate this according to his history of cluster bouts and based on the manufacturer’s maximum daily dose.

46. Implementing NICE guidance www.nice.org.uk 3.4 Question How will you order the oxygen for Malcolm?

47. Implementing NICE guidance www.nice.org.uk 3.4 Answer To order the oxygen you must complete a home oxygen order form (HOOF). There are sections for ambulatory oxygen and long term or short burst oxygen. As well as ordering the oxygen, it is important to order the non- rebreathing mask (cushioned). It is essential that all the necessary equipment has been delivered to Malcolm to make sure he receives the prescribed oxygen.

48. Implementing NICE guidance www.nice.org.uk 3.5 Question What prophylaxis for cluster headache could you offer Malcolm?

49. Implementing NICE guidance www.nice.org.uk 3.5 Answer In order to reduce the frequency, severity and duration of attacks, you consider offering Malcolm verapamil. However, because of your lack of experience in using verapamil for cluster headache, you consult a colleague who is a GP with a special interest in headaches or neurology (or a consultant neurologist) for guidance in using this medication before prescribing it.

50. Implementing NICE guidance www.nice.org.uk 3.6 Question What medications would you not offer Malcolm for the acute management of his cluster headache attacks?

51. Implementing NICE guidance www.nice.org.uk 3.6 Answer You would not offer paracetamol, NSAIDS, oral triptans, ergots or opioids as there is no evidence to suggest that they would have any clinical benefit in the treatment of cluster headache.

52. Implementing NICE guidance www.nice.org.uk Case scenario 4 Nisha, acute migraine (adult)

53. Implementing NICE guidance www.nice.org.uk Presentation You are an out-of-hours GP and have been called out to visit Nisha. Nisha is a 48-year-old woman who was diagnosed with episodic migraine 10 years ago. She is taking topiramate for prophylaxis and takes an NSAID and oral triptan for acute treatment. Nisha currently has a severe migraine with aura that started 60 minutes ago. She took her usual oral triptan and NSAID 50 minutes ago and her migraine has not responded. Nisha has also vomited 6 times during this attack; once just after taking the oral medication.

54. Implementing NICE guidance www.nice.org.uk 4.1 Question What other acute migraine treatment can you offer Nisha?

55. Implementing NICE guidance www.nice.org.uk 4.1 Answer Given that the oral preparations of NSAID and triptan were not effective for Nisha, you offer her intramuscular metoclopramide or prochlorperazine. You also consider offering Nisha a non-oral NSAID or triptan; however, you decide against this because Nisha has recently taken both of these.

56. Implementing NICE guidance www.nice.org.uk NICE Evidence Visit NICE Evidence for the best available evidence on all aspects of Headaches. Click here to go to the NICE Evidence website

57. Implementing NICE guidance www.nice.org.uk Find out more Visit www.nice.org.uk/guidance/CG150 for:www.nice.org.uk/guidance/CG150 the guideline Information for the public costing statement and template baseline assessment tool academic detailing aid diagnosis poster

58. Implementing NICE guidance www.nice.org.uk What do you think? Did the implementation tool you accessed today meet your requirements, and will it help you to put the NICE guidance into practice? If you are experiencing problems accessing or using this tool, please email implementation@nice.org.ukimplementation@nice.org.uk To open the links in this slide set right click over the link and choose ‘open link’