1. MIGRAINE IN PRIMARY CARE ADVISORS New guidelines for the management of migraine by nurses London, 6 December 2002, 2-6 pm

2. Introduction Dr Andrew J Dowson Director of the King’s Headache Service King’s College Hospital London

3. M  I  P  C  A MIGRAINE IN PRIMARY CARE ADVISORS MIPCA is an independent charity working through research and education to set standards for the care of headache sufferers –Dedicated to improve headache management in primary care MIPCA contains physicians, nurses, pharmacists, other healthcare professionals and representatives from patient groups

4. Objectives of today’s meeting Discuss the present and future roles of the practice nurse and nurse practitioner in primary care Disseminate the new MIPCA guidelines on migraine management in primary care Discuss the optimal way for nurses to utilise these guidelines in their practice: –Triage and in Practice Nurses’ own surgeries –Initiation and switching of therapy –Individualising care –Follow-up

5. Programme for today 2.00 pm: Introduction Dr Andrew Dowson 2.15 pm: Overview of the current role of the practice nurse in the clinic Ms Jan Dungay 2.45 pm: The new MIPCA guidelines for migraine management in primary care Dr Sue Lipscombe 4.00 pm: Tea break

6. Programme for today 4.30 pm: The future Ms Heather MacBean 5.00 pm: Discussion: how can nurses use the new migraine guidelines? Moderator: Dr Andrew Dowson 5.45 pm: Conclusions 6.00 pm: Close

7. Outcomes from the meeting Article to be published in an academic peer-reviewed nurse journal ‘Popular’ newsletter designed for the general nurse audience Slide set for educational use

8. Overview of the current role of the practice nurse in the clinic Ms Jan Dungay Practice Nurse Merstham Surrey

9. Overview Qualifications General roles –Clinics –Patient care Current roles in the management of migraine

10. Qualifications of practice nurses Practice Nurses are employed by the GP to work within their practice RGN – all Practice Nurse course (some)  Nurse Practitioners

11. Roles ‘To aid and promote health care and protection in the community’ Specialisation –All practice nurses are encouraged to specialise in certain areas and attend appropriate training and updates e.g. diabetes and asthma

12. General surgery and designated clinics New Patient Health Checks MOTs Flu clinics Travel clinics Cervical smears HRT Asthma Diabetes Cardiac Baby vaccinations Phlebotomy Treatment rooms

13. Roles in patient care Intermediate between the patient and the GP –Patients feel that they can talk more easily to a Practice Nurse –Patients feel that the Practice Nurse can spend more time with them Patients are very aware of a GP’s time Particularly older women

14. Current roles in the management of migraine Identify migraine sufferers –Serendipitously during regular duties –Proactively during health clinics Discuss migraine and its treatment Assist patient in self-management

15. Serendipitous consultation Patients presenting with other problems or queries may mention migraine and can be followed up –HRT clinics –Travel vaccinations

16. Proactive consultation The nurse asks directly about headaches during health checks –New Patient Health Checks –MOTs –Treatment clinics Follow-up if the answer is positive Patients are often happy to discuss in this way

17. Current management Discuss migraine with the patient and provide information Refer to the GP for medication Suggest the patient should return to the nurse or GP if migraine continues or medication causes problems Very important to reassure patients that they can and should return to receive follow-up care

18. Future needs of the Practice Nurse Migraine clinics in GP practices currently limited The nurse needs to have access to courses for up-to-date information on: –Migraine care and treatment –Patient self-management strategies –Medication efficacy and side effects Implementation through GP interventions and nurse follow-up

19. The new MIPCA guidelines for migraine management in primary care Dr Sue Lipscombe Park Crescent New Surgery Brighton

20. Recent initiatives for migraine management in primary care Starting points for new initiatives –US Headache Consortium 1 –US Primary Care Network 2 –UK MIPCA Guidelines 3 –German guidelines 4 –Canadian guidelines 5 1 Headache Consortium. Neurology 2000; www.aan.com. 2 Bedell AW et al. Primary Care Network 2000. 3 Dowson AJ et al. MIPCA 2000. 4 Diener HC et al. Nervenheilkunde 1997;16:500-10. 5 Pryse-Phillips WEM et al. Can Med Assoc J 1997;156:1273-87.www.aan.com

21. MIPCA initiative: Establishing new management guidelines for migraine in UK primary care Update of the existing MIPCA guidelines –Identification and screening of patients in need of care –Development of new diagnostic tools and algorithms –Best management practice Utilising evidence-based medicine wherever possible Incorporating latest data from UK and US guidelines

22. What is required Best practice from existing guidelines 1-3 Detailed history taking, patient education and buy-in Diagnostic screening and confirmatory differential diagnosis Management individualised for each patient Prescribing only treatments that have objective evidence of favourable efficacy and tolerability Prospective follow-up procedures to monitor the success of treatment Specific consultations for headache and a team approach to management 1 Headache Consortium. Neurology 2000; www.aan.com.www.aan.com 2 Bedell AW et al. Primary Care Network 2000. 3 Dowson AJ et al. MIPCA 2000.

23. Diagnosis and treatment

24. Diagnosis Assess severity Treatment plan Screen for headache type Differentiate migraine from other headaches Attack frequency and pain severity Impact on patient’s life (MIDAS / HIT) Non-headache symptoms Patient factors Establish goals Behavioural therapy Acute therapy Possible prophylactic therapy Complementary therapy? Consultation Specific consultation Treatment history Patient education, counselling and buy-in Follow-up Assess outcome of therapy Management individualised for each patient Overall diagram for migraine management

25. Processes First consultation –Screening –Patient education and buy-in –Diagnosis –Assessment of illness severity –Implementation of initial treatment plan Follow-up consultations –Monitor success of therapy and modify treatment if necessary

26. Screening procedures 1,2 Taking a careful history is essential –Use of a headache history questionnaire is recommended Patient education –Advice, leaflets, websites and patient organisations Patient buy in –Patients to take charge of their own management –Effective communication between patient and physician 1 Headache Consortium. Neurology 2000; www.aan.com.www.aan.com 2 Bedell AW et al. Primary Care Network 2000.

27. Migraine diagnosis: IHS criteria 1 Five or more lifetime headache attacks lasting 4-72 hours each and symptom-free between attacks Two or more of the following headache features: –Moderate-severe pain –Unilateral –Throbbing/pulsating –Exacerbated by routine activities One or more of the following non-headache features: –Aura –Nausea –Photophobia/phonophobia Exclusion of secondary headaches 1 Headache Classification Committee of the IHS. Cephalalgia 1988;7 (Suppl 7):19-28

28. Headache diagnosis MIPCA proposal: the IHS diagnostic criteria are too limited in scope and complex for everyday use in primary care MIPCA has developed a simple but comprehensive scheme for the differential diagnosis of headache subtypes Diagnosis can then be confirmed with additional questions, if necessary

29. Four-item questionnaire A.Exclude sinister headaches 1 New-onset, acute headaches associated with other symptoms –e.g. rash, neurological deficit, vomiting, pain/tenderness, accident/head injury, hypertension –Neurological change/deficit does not disappear when the patient is pain-free between attacks 1 Dowson AJ, Cady RC. Rapid Reference to Migraine 2002.

30. Four-item questionnaire 1.What is the impact of the headache on the sufferer’s daily life? (screens for migraine/chronic headaches and ETTH)

31. Assessing headache impact Two impact questionnaires have been developed 1 –Migraine Disability Assessment (MIDAS) Questionnaire –Headache Impact Test 1 Dowson A. Curr Med Res Opin 2001;17:298-309.

33. Four-item questionnaire 2.How many days of headache does the patient have every month? (screens for migraine and chronic headaches) >15 = chronic headaches  15 = migraine 1 1 Headache Classification Committee of the IHS. Cephalalgia 1988;7 (Suppl 7):1-92

34. Four-item questionnaire B.Consider short-lasting chronic headaches 1  3 minutes may be short, sharp headaches 15 min -3 hours may be cluster headache 1 Dowson AJ, Cady RC. Rapid Reference to Migraine 2002.

35. Four-item questionnaire 3.For patients with chronic daily headache, on how many days per week does the patient take analgesic medication? (screens for analgesic-dependent headaches) 1,2  2 = analgesic dependent <2 = not analgesic dependent 1 Silberstein SD, Lipton RB. Curr Opin Neurol 2000;13:277-83 2 Olesen J. BMJ 1995;310:479-80.

36. Four-item questionnaire 4.For patients with migraine, does the patient experience reversible sensory symptoms associated with their attacks? (screens for migraine with aura and migraine without aura) 1 1 Headache Classification Committee of the IHS. Cephalalgia 1988;7 (Suppl 7):19-28

37. Migraine with aura diagnosis: IHS criteria 1 At least three of the following four characteristics: –One or more fully reversible aura symptoms* –One or more aura symptoms develop over >4 min, or two or more symptoms occur in succession –No single aura symptom lasts >60 min –The migraine headache occurs <60 min after the end of the aura symptoms Exclusion of secondary headaches *e.g. visual disturbances, speech disturbances and sensations affecting other areas of the body 1 Headache Classification Committee of the IHS. Cephalalgia 1988;7 (Suppl 7):19-28

38. Patient presenting with headache Migraine/CDH low High Q1. What is the impact of the headache on the sufferer’s daily life? ETTH Q2. How many days of headache does the patient have every month? > 15  15 CDH Q3. For patients with chronic daily headache, on how may days per week does the patient take analgesic medications? <2 22 Not analgesic dependent Analgesic dependent Migraine Q4. For patients with migraine, does the patient experience reversible sensory symptoms associated with their attacks? With aura Without aura YesNo Exclude sinister Headache Consider short-lasting Headaches Copyright MIPCA 2002, all rights reserved

39. Management individualised for each patient Assess illness severity 1,2 Attack frequency and duration Pain severity Impact on daily living –MIDAS/HIT questionnaires Non-headache symptoms Patient factors –History, preference and other illnesses 1 Matchar DB et al. Neurology 2000; www.aan.com.www.aan.com 2 Bedell AW et al. Primary Care Network 2000.

40. Assessment of severity 1,2 Mild-to-moderate migraineModerate-to-severe migraine Headaches mild-to- moderate in intensity Headaches moderate or severe in intensity Non-headache symptoms not severe in intensity Significant non-headache symptoms, possibly severe Impact not significant: MIDAS Grade I or II HIT Grade 1 or 2 Significant impact: MIDAS Grade III or IV HIT Grade 3 or 4 1 Matchar DB et al. Neurology 2000; www.aan.com.www.aan.com 2 Bedell AW et al. Primary Care Network 2000.

41. Provision of individualised treatment plan Evidence-based medicine (Duke database) suggests: Behavioural therapy recommended for all Acute therapy recommended for all Prophylactic therapy recommended for certain patients Complementary therapies may be useful as adjunctive therapy 1 Headache Consortium. Neurology 2000; www.aan.com.www.aan.com 2 Bedell AW et al. Primary Care Network 2000.

42. Individualising care – behavioural and physical therapy Duke recommended therapies Behavioural: –Biofeedback and relaxation –Stress reduction –Avoidance of triggers –Food intolerances under investigation by MIPCA Physical –Cervical manipulation –Massage –Exercise –Botox? 1 Campbell JK et al. Neurology 2000; www.aan.com.www.aan.com 2 Bedell AW et al. Primary Care Network 2000.

43. Individualising care – acute medications Goals: to rapidly relieve the headache and other symptoms, and permit the return to normal activities within 2 hours 1,2 Acute medications should be provided for all patients 2 Strategy: individualised care, patients have a portfolio of medications to treat attacks of differing severities, and have access to rescue medications if the initial therapy fails 3 1 Matchar DB et al. Neurology 2000; www.aan.com.www.aan.com 2 Dowson AJ et al. MIPCA 2000. 3 Dowson AJ. Migraine and Other Headaches: Your Questions Answered. 2003; in press.

44. Individualised care for migraine 1 Migraine diagnosis Severity assessment Mild to moderate migraineModerate to severe migraine Initial therapy Rescue If unsuccessful Migraine attack 1 Dowson AJ. Migraine and Other Headaches: Your Questions Answered. 2003; in press Stratified care Staged care

45. Acute medications: Duke recommended treatments (UK) Mild-to-moderate migraine 1 Initial therapies –Aspirin or NSAIDs (high doses) –Aspirin/paracetamol plus anti-emetics –Use if possible before headache starts Rescue medications –Oral triptans –Use for any headache severity 1 Matchar DB et al. Neurology 2000; www.aan.com.www.aan.com

46. Acute medications: Duke recommended treatments (UK) Moderate-to-severe migraine 1 Initial therapies –Oral triptans (tablet/ODT) –Use after the headache starts, if possible when it is mild in intensity Rescue medications –Nasal spray or subcutaneous triptans –Symptom control 1 Matchar DB et al. Neurology 2000; www.aan.com.www.aan.com

47. Caveats on triptan use 1 Most patients are effectively treated with an oral triptan –Differences between the oral triptans are small and of uncertain clinical significance Patients with unpredictable or fast-onset attacks may benefit from ODT or nasal spray formulations Patients with severe attacks and/or with vomiting may benefit from nasal spray or subcutaneous formulations Subcutaneous sumatriptan is an effective rescue medication Beware contraindications (age; pregnancy; heart disease) 1 Dowson AJ, Cady RC. Rapid Reference to Migraine 2002.

48. Individualising care – prophylactic medications 1-3 Goals: to reduce headache frequency by >50% Prophylactic medications should be provided: –For patients with frequent, high-impact migraine attacks (  4/month) –Where acute medications are ineffective or precluded by safety concerns –For patients who overuse acute medications and/or have CDH However: acute medications should also be provided for breakthrough attacks 1 Ramadan NM et al. Neurology 2000; www.aan.com.www.aan.com 2 Bedell AW et al. Primary Care Network 2000. 3 Dowson AJ et al. MIPCA 2000.

49. Prophylactic medications: Duke recommended treatments (UK) First-line medications: 1 –Beta-blockers (propranolol, metoprolol, timolol, nadolol) –Anticonvulsants* (sodium valproate) –Antidepressants* (amitriptyline) Second-line medications –Serotonin antagonists (pizotifen, methysergide, cyproheptadine) * Not licensed for migraine in the UK 1 Ramadan NM et al. Neurology 2000; www.aan.com.www.aan.com

50. Individualising care – complementary therapies Effective therapies (Duke database) 1 Feverfew* Magnesium* Vitamin B2* Acupuncture* Low-dose aspirin?* However: use only accredited complementary practitioners * Not licensed for migraine in the UK 1 Dowson AJ, Cady RC. Rapid Reference to Migraine 2002.

51. Follow-up procedures Instigate proactive long-term follow-up procedures 1 Monitor the outcome of therapy –Headache diaries –Impact questionnaires (MIDAS/HIT) Make appropriate treatment decisions 1 Dowson AJ, Cady RC. Rapid Reference to Migraine 2002.

52. Follow-up treatment decisions 1 Acute medications –Patients effectively treated should continue with the original therapy –Patients who fail on original therapy should be offered other therapies Prophylactic medications –Ensure medication is provided for an adequate time period at an adequate dose (up to 3 months) –If effective, treatment can continue for 6 months, after which it may be stopped –If ineffective, another prophylactic medication may be tried –Usual contraindications apply Patients refractory to repeated acute and prophylactic medications should be referred to a specialist 1 Dowson AJ, Cady RC. Rapid Reference to Migraine 2002.

53. Implementation of guidelines Primary care headache team 1 –PCP, practice nurse, ancillary staff and sometimes pharmacist (core team) –Pharmacist –Community nurses –Optician –Dentist –Complementary practitioners –Specialist physician (additional resource) –And... The patient Associate team members Dowson AJ et al. Curr Med Res Opin 2002;18:414-39.

54. Pharmacist Community nurse Optician Dentist Complementary practitioner Patient Primary care physician Practice nurse Physician with expertise in headache: GP; PCT; specialist Ancillary staff Primary care Specialist care Associate teamCore team Copyright MIPCA 2002, all rights reserved Dowson AJ et al. Curr Med Res Opin 2002;18:414-39.

55. New MIPCA algorithm Initial consultation and treatment

56.  Detailed history, patient education and buy-in  Diagnostic screening and differential diagnosis  Assess illness severity  Attack frequency and duration  Pain severity  Impact (MIDAS or HIT questionnaires)  Non-headache symptoms  Patient history and preferences Intermittent mild-to-moderate migraine (+/- aura) Intermittent moderate-to severe migraine (+/- aura) Aspirin/NSAID (large dose) Aspirin/paracetamol plus anti-emetic Oral triptan Nasal spray/subcutaneous triptan Initial consultation Initial treatment Rescue Behavioural/complementary therapies Copyright MIPCA 2002, all rights reserved Dowson AJ et al. Curr Med Res Opin 2002;18:414-39.

57. New MIPCA algorithm Follow-up consultation and treatment

58. Aspirin/NSAID (large dose) Aspirin/paracetamol plus anti-emetic Oral triptan Initial treatment Follow-up treatment Oral triptan Alternative oral triptan Nasal spray/subcutaneous triptan Rescue If unsuccessful Consider prophylaxis + acute treatment for breakthrough migraine attacks Frequent headache (i.e.  4 attacks per month) Consider referral Chronic daily Headache (CDH)? Migraine If unsuccessful Initial treatment Copyright MIPCA 2002, all rights reserved If management unsuccessful Dowson AJ et al. Curr Med Res Opin 2002;18:414-39.

59. ‘10 Commandments’ of headache management

60. Screening/diagnosis 1.Almost all headaches are benign and should be managed in general practice. (However, monitor for sinister headaches and refer if necessary.) Copyright MIPCA 2002, all rights reserved

61. 2.Use questions / a questionnaire assessing impact on daily living for diagnostic screening and to aid management decisions. (Any episodic, high impact headache should be given a default diagnosis of migraine.) Screening/diagnosis Copyright MIPCA 2002, all rights reserved

62. Management 3.Share migraine management between the doctor, the nurse and patient. (The patient taking control of their management and the doctor/nurse providing education and guidance.) Copyright MIPCA 2002, all rights reserved

63. Management 4.Provide individualised care for migraine and encourage patients to treat themselves. (Migraine attacks in and between individuals are highly variable in frequency, duration, symptomatology and impact.) Copyright MIPCA 2002, all rights reserved

64. Management 5.Follow-up patients, preferably with migraine diaries. (Invite the patient to return for further management and apply a proactive policy.) Copyright MIPCA 2002, all rights reserved

65. Management 6.Adapt migraine management to changes that occur in the illness and its presentation over the years. (e.g. migraine may change to chronic daily headache over time.) Copyright MIPCA 2002, all rights reserved

66. Treatments 7.Provide acute medication to all migraine patients and recommend it is taken as early as possible in the attack. (Triptans are the most effective acute medications for migraine. Avoid the use of drugs that may cause analgesic-dependent headache, e.g. regular analgesics, codeine and ergotamine.) Copyright MIPCA 2002, all rights reserved

67. Treatments 8.Prescribe prophylactic medications to patients who have four or more migraine attacks per month or who are resistant to acute medications. (First-line prophylactic medications are beta-blockers, sodium valproate and amitriptyline.) Copyright MIPCA 2002, all rights reserved

68. Treatments 9.Monitor prophylactic therapy regularly. Copyright MIPCA 2002, all rights reserved

69. Treatments 10.Ensure that the patient is comfortable with the treatment recommended and that it is practical for their lifestyle and headache presentation. Copyright MIPCA 2002, all rights reserved

70. Conclusions New MIPCA guidelines Diagnostic algorithm Management algorithm 10 principles of management

71. The future Heather MacBean Nurse Practitioner Holmes Chapel Cheshire

72. Discussion: How can nurses use the new MIPCA guidelines? Dr Andrew Dowson

73. Pharmacist Community nurse Optician Dentist Complementary practitioner Patient Primary care physician Practice nurse Physician with expertise in headache: GP; PCT; specialist Ancillary staff Primary care Specialist care Associate teamCore team Copyright MIPCA 2002, all rights reserved Dowson AJ et al. Curr Med Res Opin 2002;18:414-39.

74. Proposals The nurse is the first point of contact for the patient in the core team The nurse can handle the patient’s initial assessments before they see the GP –Screening The nurse can conduct assessments of impact –Diagnosis and individualised care The nurse is the first point of contact for follow-up –Headache diaries –Impact assessments –Repeat prescriptions / Switching therapies

75. Screening procedures Taking a careful history is essential –Use of a headache history questionnaire is recommended Patient education –Advice, leaflets, websites and patient organisations Patient buy in –Patients to take charge of their own management –Effective communication between patient and physician

76. Assessing impact on daily living

77. Diagnosis 1.What is the impact of the headache on the sufferer’s daily life?

79. Patient presenting with headache Migraine/CDH low High Q1. What is the impact of the headache on the sufferer’s daily life? ETTH Q2. How many days of headache does the patient have every month? > 15  15 CDH Q3. For patients with chronic daily headache, on how may days per week does the patient take analgesic medications? <2 22 Not analgesic dependent Analgesic dependent Migraine Q4. For patients with migraine, does the patient experience reversible sensory symptoms associated with their attacks? With aura Without aura YesNo Exclude sinister Headache (<1%) Consider short-lasting Headaches Copyright MIPCA 2002, all rights reserved Nurse

80. Management individualised for each patient Assess illness severity Attack frequency and duration Pain severity Impact on daily living –MIDAS/HIT questionnaires Non-headache symptoms Patient factors –History, preference and other illnesses

81. Assessment of severity Mild-to-moderate migraineModerate-to-severe migraine Headaches mild-to- moderate in intensity Headaches moderate or severe in intensity Non-headache symptoms not severe in intensity Significant non-headache symptoms, possibly severe Impact not significant: MIDAS Grade I or II HIT Grade 1 or 2 Significant impact: MIDAS Grade III or IV HIT Grade 3 or 4

82. Follow-up procedures Instigate proactive long-term follow-up procedures Monitor the outcome of therapy –Headache diaries –Impact questionnaires (MIDAS/HIT) Make appropriate treatment decisions

83. Follow-up treatment decisions Acute medications –Patients effectively treated should continue with the original therapy –Patients who fail on original therapy should be offered other therapies (switching) Prophylactic medications –Ensure medication is provided for an adequate time period (up to 3 months) –If effective, treatment can continue for 6 months, after which it may be stopped –If ineffective, another prophylactic medication may be tried –Usual contraindications apply Patients refractory to repeated acute and prophylactic medications should be referred to a specialist