Careful diagnosis • Proposal: the IHS diagnostic criteria are too 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
Four-item questionnaire A. Consider sinister headaches 1.What is the impact of the headache on the sufferer’s lifestyle? 2.How many days of headache does the patient have every month?
3.For patients with chronic daily headache, on how many days per week does the patient take analgesic medication? 4.For patients with migraine, does the patient experience reversible sensory symptoms associated with their attacks?
Q1. Headache impact ATTH Q2. No. of headache days per month > 15 < 15 Chronic headache Q3. Analgesic days/week <2 >2 Not analgesic dependent Analgesic dependent Migraine Q4. Reversible sensory symptoms With aura Without aura Yes No Consider sinister headache Consider short-lasting headaches
Management individualized for each patient Assess illness severity • Attack frequency and duration • Pain severity • Impact – MIDAS/HIT questionnaires • Non-headache symptoms • Patient factors – History, preference and other illnesses
Assessment of severity Mild-to-moderate migraine Moderate-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
Provision of individualized treatment plan Evidence-based medicine (Duke database) suggests: • Behavioural therapy recommended for all • Acute therapy recommended for all • Prophylactic therapy recommended for certain patients • Alternative treatments may be useful as adjunctive therapy
Individualizing care – behavioural and physical therapy Recommended therapies • Behavioural: – Biofeedback and relaxation – Stress reduction – Avoidance of triggers – Food intolerances under investigation by MIPCA • Physical – Cervical manipulation – Massage – Exercise
Individualizing care – acute medications • Acute medications should be provided for all patients • Goals: to rapidly relieve the headache and other symptoms, and permit the return to normal activities • Strategy: staged care, patients have a portfolio of medications to treat attacks of differing severities, and have access to rescue medications if the initial therapy fails
Staged care for migraine Migraine diagnosis Severity assessment Mild to moderate migraine Moderate to severe migraine Initial therapy Initial therapy Rescue Rescue If unsuccessful
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- Fall '17