Czech headache guidelines for general practitioners

Jolana Marková Thomayer University Hospital Prague

Guideline concept

Guideline goal: Improve headache management by first-line physicians

Improvement diagnosis using appropriate tools Improve treatment

Increase awareness and interest of general practitioners in headache

Initiative of Czech GP society

Guideline preparation

GP addressed CHS Identification of major issues to be covered

(based on GPs’ needs) Creation of joint team (GPs and neurologists) to

work on guidelines Guideline draft

Assessment by neurologists Assessment by GPs (not team members)

Final version of guidelines

Guideline implementation

Establishmentof guideline team

First draft andpublic discussion

Final versionof guideline

Introduction of guidelines at the congress of GPsociety

Implementationof guideline

Managementaudit andfeedback to GPs

Implementationof findings andguidelineup-date

Expectations of specialists

Neurologists' expectations: Higher awareness among first-line

physicians Improved diagnosis Improved management

Patients visit the specialist better diagnosed,in a shorter time after the appearance of headache

Headache

Classification and Diagnostic Criteria for Headache Disorders (IHS)

Primary headache disorders 1–4

Secondary headache disorders 5–12

Cranial Neuralgias 13-14

Headache Important features in headache history:

Attack onset Pain location Attack duration Attack frequency and timing Pain severity Pain quality Associated features

Headachealarms

Headache alarms

• Sudden-onset severe headache• Accelerating pattern of headache• Headache begins after the age of 50• Severe headache with fever and vomiting• Headache with focal neurological symptoms• Headache in patient with cancer or HIV

Primary Headaches

• Migraine• Tension-type headache• Cluster headache• Trigeminal autonom. cephalalgias

• Headache attributed to head and/or neck trauma• Headache attributed to vascular disorder• Headache attributed to non-vascular intracranial disorder• Headache attributed to a substance or its

withdrawal• Headache attributed to infection

Secondary Headaches

• Headache attributed to homeostasis disorder• Headache or facial pain attributed to disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other cranial structure• Headache attributed to psychiatric disorder• Cranial neuralgias

Secondary Headaches

Focus on practical applicability in first-line.

• Diagnosis of migraine• Treatment

• Acute migraine attack• Prophylactic treatment

• Follow up

Migraine

Not only headache – combination of neurological, gastrointestinal and autonomic changes

Prodrome phaseAuraHeadache and asssociated symptomsHeadache resolution phase

Migraine-phases

Complex of focal neurological symptoms- positive or negative phenomenaPrecedes or accompanies an attackLast less than 60 minutesVisual ( scotoma,color shapes,migration)SensoryMotorLanguage disturbances

Migraine- Aura

Unilateral – hemicraniaSevere intensityThrobbing, pulsating characterAggravated by physical activityAccompanied with nausea, vomitingPhotophobia, phonophobia

Depression,fatigue, anxiety, irritabily are common in migraine patients

Migraine - headache

ACUTE ATTACK TREATMENT:

• Mild forms: NSAID, ASA, Paracetamol and/or combinations with prokinetics• Moderate forms: Triptans• Severe forms: Triptans (incl. nasal spray, inj.) and prophylaxis

Migraine – therapy

Since generic sumatriptan entered the Czech market it has been used widely by the majority of migraine patients.

Generic entry has also enabled GPs to prescribe effective medication at a lower price level.

Migraine – therapy

PROPHYLACTIC TREATMENT:• Anticonvulsants (valproic acid, topiramat)• Beta-blockers• Calcium channel blockers• Antidepressants (tricyclics, SSRI)

Prophylactic treatment remains fully under the neurologist's competence. Indication is consistent with IHS criteria.

Migraine – therapy

Introduction of adapted, simple questionnaire for use in first-line.

Own development as:• MIDAS perceived as rather complicated for

patients and physicians

• Interpretation often imprecise

Migraine – diagnosis

Diagnostic scheme – migraine

Impact of migraine questionnaireto assess disability level

“How much does headache negatively influenceyour daily activities (work, school, social activities, housework)”

Slightly, not much (mild migraine)Treatment: ASA, Paracetamol, NSAID, combination with

prokinetics

Moderately (moderate migraine) Treatment: Triptans

Significantly (severe migraine)Treatment: Triptans and prophylactics. Patient indicated for

specialist consultation.

Pressing/tightening qualityMild or moderate intensityBilateral locationNo aggravation by walking stairsNo nausea or vomitingOften depression

High lifetime prevalence (70–90%)

Tension – type headache

Acute treatment analgesics, NSAIDs, muscle relaxants

Prophylactic treatment antidepressants

– tricyclics, SSRI non-pharmacological treatment – relaxation, physical therapy techniques

Tension – type headache

Subarachnoid hemorrhage

• sudden-onset severe headache• stiff neck• nausea, vomiting• alteration of consciousness• often beginning during physical activity

• urgent admission to hospital• CT, lumbal puncture• neurosurgeon – consultation

• angiography• intervention • pharmacological treatment to prevent complications

Subarachnoid hemorrhage

Headache in stroke patients

Various combinations of headache, focal neurological deficits and alteration of consciousness

• ischemic stroke • hemorrhagic stroke

Admission to hospital is needed in the shortest possible time in every stroke patient.

Headache in patientswith brain tumor

• pain quality similar to tension-type headache, bilateral• neurological focal symptoms, epileptic seizure as an initial symptom • elevated intracranial pressure • personality changes

CT, MRI, neurosurgery

Medication overuse headache

Headache often increase in frequency Patients develop a pattern of daily or nearly

daily headache with increasing medication use Simple analgetics, combined analgetics, NSA,

ergots, triptans, opioids High depression comorbidity Headache now is caused by medication

overuse

Medication overuse headache

Headache present on more than 15days/month Pain is dull, presssing-tightening quality, mild or moderate intensity bilateral location no aggravation by walking stairs Substance intake on (10-15) days /months on a

regular basis for 3 months Headache has developed or markedly

worsened during substance overuse

Medication overuse headache

Treatment Patient wants to stop with overuse stop substance intake completedly-

detoxification pain control with parenteral therapy estabilishment of effective prophylactic

treatment patient education estabilishment of outpatient methods of pain

control

Cervicogenic headache

Occipital or suboccipital pain Neck tendrness a muscle spasms that may

produce pain Limitation of movementr or unusual postures Sensory abnormalities in the distribution of the

upper cervical roots

Cervicogenic headache

Clinical, laboratory or imaging evidence of a disorder or lesion within the cervical spine or soft tissues of the neck

Headache is mostly unilateral Mild or moderate intensity nausea or vomiting sometimes No photo or phonophobia Sometimes vertigo or instability

Cervicogenic headache

Treatment

NSA, myorelaxants, analgetics- only a short time

Antidepressants – tricyclics, SSRI Physioterapy Long term living style improvement

Traumatic and post-traumatic headache

Acute posttraumatic headache Chronic posttraumatic headache Whiplash injury Headache attributed to traumatic intracranial

haematoma – epidural, subdural

Traumatic and post-traumatic headache

Headache accompanied by other symptoms

Dizziness Difficulty in concentration Personality changes Sleep disturbances Anxiety Depression Vertigo

Traumatic and post-traumatic headache

Diagnostic methods Clinical neurological examination Imaging – RTG, CT, MRI

Treatment Transport to the hospital Neurosurgery Intensive care

Thank you for your attention