1. Headache Diagnosis and Management in Primary Care

2. Approaches to Treatment Step care Staged care Stratified care

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

7. HIT-6 Validated Good for differential diagnosis Scoring Mild impairment 50-55 Moderate 56-59 Severe ≥60

10. Likelihood Ratios for diagnosis of migraine Positive LRNegative LR 00.80.4

11. Overall Management Algorithm

12. MIPCA Diagnostic Screening Algorithm

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

14. MIPCA Management Algorithm

16. Close-up 1

18. Migraine Prophylaxis...

19. ...Migraine Prophylaxis

20. Headache Action Plans My choice

21. Meds Teaches

23. Diary

29. Patient Handouts

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

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

35. Headache Dashboard Medications amitriptyline 10 mg 3 hs Maxalt MLT 10 Aleve 220 4 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: 99 88 77 66 5 ph 573-911-9876 email: ppound@cool.comppound@cool.com 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?

36. Headache Dashboard Medications amitriptyline 10 mg 3 hs Maxalt MLT 10 Aleve 220 4 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: 99 88 77 66 5 ph 573-911-9876 email: ppound@cool.comppound@cool.com 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

38. 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...

39. Positive Likelihood Ratio

40. Negative Likelihood Ratio