Headache Treatment Protocol Essay Assignment Paper

The National Institute for Health and Care Excellence (NICE) has published a headache guideline for those aged over 12 years. The guideline, dated 2012, updated in 2015, includes treatment for migraine.Headache Treatment Protocol Research Paper

The guideline is based on scientific evidence and is intended for primary care where most headaches can safely be diagnosed and managed. If specialist advice is necessary, the guideline recommends referral to a GP with a special interest in headache or a consultant neurologist with similar interest. The guideline highlights special considerations for women with migraine including choice of contraception, management during pregnancy and management of migraine associated with the menstrual period.Headache Treatment Protocol Research Paper

For diagnosis of headache, the guideline says that, at the first consultation, the doctor should ask for a description of the headache and any other symptoms. The doctor will want to ensure that the headache is not due to a serious underlying cause. The doctor may ask for completion of a diary over eight weeks to gather more detailed information about headaches and help them make the diagnosis.

The guideline says that, if a GP makes a diagnosis of migraine, further investigation is not usually required. A brain scan is not indicated solely to reassure the patient or the doctor. Adverse affects from scanning include exposure to radiation.Headache Treatment Protocol Research Paper

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NICE guideline recommendations for migraine

The guideline recommends that for relief from a migraine attack, a healthcare professional should offer a triptan together with either a non-steroidal anti-inflammatory drug (NSAID) or paracetamol to help relieve migraine. If it is preferred to take only one drug, they may offer a trip tan, an NSAID, high‑dose aspirin or paracetamol. They may also offer you an anti-sickness medicine. All of these drugs are oral drugs. If you are unable to take oral drugs, or they do not work well, you should be offered metoclopramide or prochlorperazine which are non-oral drugs. You may also be offered a non‑oral NSAID or triptan. You should not be offered an ergot or an opioid to treat migraine, and those aged under 16 should not be offered aspirin.

The guideline recommends that for treatment to help prevent future migraine your healthcare professional should offer topiramate or propranolol. You may be offered amitriptyline as a treatment option, depending on your preferences, any other health problems and the possible side effects of the drug. Topiramate can cause birth defects and this should be discussed if there is the possibility of pregnancy. Contraception should be checked and changed if necessary, because topiramate can reduce the effectiveness of some types of contraceptive drugs. If neither topiramate nor propranolol are suitable or work well, you may be offered a course of up to 10 sessions of acupuncture.Headache Treatment Protocol Research Paper

The guideline says that women with menstrual-related migraine may be offered frovatriptan or zolmitriptan to help prevent migraine. Women with migraine with aura should not usually be offered the combined pill for contraception. During pregnancy, your healthcare professional should offer paracetamol to relieve migraine. They may offer a triptan or an NSAID after discussing the risks and benefits of taking these drugs during pregnancy.

Migraine is a primary headache disorder characterized by recurrent attacks. Acetaminophen, non steroidal anti-inflammatory drugs, trip tans, anti emetics, ergot alkaloids, and combination analgesics have evidence supporting their effectiveness in the treatment of migraine. Acetaminophen and non steroidal anti-inflammatory drugs are first-line treatments for mild to moderate migraines, whereas trip-tans are first-line treatments for moderate to severe migraines. Although trip-tans are effective, they may be expensive. Other medications such as hydroelectrically and anti emetics are recommended for use as second- or third-line therapy for select patients or for those with refractory migraine. The pharmacologic properties, potential adverse effects, cost, and routes of administration vary widely, allowing therapy to be individualized based on the pattern and severity of attacks. Several treatment principles, including taking medication early in an attack and using a stratified treatment approach, can help ensure that migraine treatment is cost-effective.

Migraine is a primary headache disorder characterized by recurrent attacks. Approximately 44.5 million U.S. adults (18% to 26% of women and 6% to 9% of men) have experienced a migraine, according to 2009 data.1 Estimated annual U.S. direct costs for migraine are more than $17 billion; the costs of lost productivity and reduced quality of life are significantly higher.2 More than one-half of migraines are treated in primary care, and they are the fourth most common cause of emergency department visits.3

Chronic migraine is a distinct and relatively recently defined sub-type of Chronic Daily Headache. The International Headache Society defines chronic migraine as more than fifteen headache days per month over a three month period of which more than eight are migrainous, in the absence of medication over use. Episodic migraine is the other migraine sub-type, which is defined as less than 15 headache days per month.^{1Headache Treatment Protocol Research Paper}

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Impact of chronic migraine

It is estimated that this condition affects fewer than 1% of the population, but this still means that there over 610,000 chronic migraine sufferers in the UK.² Due to the nature and length of time that the sufferer is affected, people with chronic migraine experience significantly more time absent from work, school, leisure, housework and social activities than episodic migraine patients.³ Efficiency is also reduced due to chronic migraine, resulting in a more than 50% reduction in productivity from work or school.^3,4 This is often described as a migraine ‘hangovers by sufferers.

The impact of chronic migraine can be very disabling.⁵ Being incapacitated for over half the month sometimes means that people are unable to work at all, with some claiming disability living allowance. Unfortunately, in many cases, current therapies are not enough to prevent or reduce the impact that chronic migraine has on people’s lives. This can lead to sufferers frequently becoming depressed and unable to cope.

The World Health Organization (WHO) has recognized the impact of migraine worldwide and categorized it as the same level of disability as dementia, quadriplegia and acute psychosis. Furthermore WHO classified chronic migraine as more disabling than blindness, paraplegia angina or rheumatoid arthritis.⁶

Some estimates put the cost of migraine, just in terms of medications at £150 million annually in the UK, but the overall cost is much more than that. An estimated 25 million working days are lost due to migraine, and at average gross weekly pay of £450, this costs the UK £2.25 billion per annul.^{7Headache Treatment Protocol Research Paper}

Causes of chronic migraine

Just like episodic migraine there is no single cause for chronic migraine. Some people find that they have defined triggers such as caffeine, bright lights, hormone, food or sleep deprivation.

However for some people there is a steady progression in headache frequency, especially in long term sufferers. This can lead to the migraines becoming so frequent that they cross the threshold of more than 15 days per month and become defined as chronic migraine.⁸

Every year between 2.5 and 4.6% of people with episodic migraine experience progression to chronic migraine. The good news is that approximately the same proportion regress from chronic to episodic migraine spontaneously.^8,9

Treatment for chronic migraine

Many of the therapies prescribed for chronic migraine are the same as those prescribed for episodic migraine. These include both prescription and over the counter painkillers and as well as migraine specific drugs such as trip tans. These are known as abortive or acute medications.

A combination of lifestyle changes and understanding the migraine triggers is important. There are also preventive treatments available for chronic migraine, but these are often associated with side effects, and many people cannot tolerate them for long periods of time.^{10Headache Treatment Protocol Research Paper}

Medication overuse

It has been shown that up to 73% of chronic migraine patients over use headache medications. This may result in further complications, so it is important that if use of acute medication becomes daily, then help should be sought from their GP or neurologist.⁹

Currently there is no known cure for chronic migraine, although there are some new treatment options under investigation for the prevention of some types of migraine including chronic migraine.^10,11

Specialist migraine/headache clinics

People with chronic migraine are three times more likely to consult their GPs compared to episodic migraine. In the UK 43% of people with chronic migraine visit a neurologist or headache specialist compared to only 18% of people with episodic migraine.¹²

Furthermore patients with chronic migraine are nearly four times more likely to end up visiting the accident and emergency department in any three month period, than those with episodic migraine.¹²

As more and more is understood about the different types of chronic daily headache and chronic migraine in particular, the role of the neurologist and specialist migraine clinics is becoming increasingly important.

Further investigations into chronic migraine may be required as well as tailored treatment plan to try to minimize the frequency and severity of attacks. People with chronic migraine also need specialist therapies that should only be prescribed whilst under the care of a neurologist.Headache Treatment Protocol Research Paper

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