BNSSG Chronic Headache Pathway

Introduction Headache is common, affecting over 90% of the general population in the UK, accounting for 4.4% of consultations in primary care and 30% of neurology OP consultations. GPs refer 2-3% of patients consulting for headache to secondary care to exclude secondary headache. Most primary headaches can be managed in primary care and investigations are rarely needed. (SIGN, 2007) The lifetime prevalence of migraine is 25% in women and 8% in men. In a practice of 2000 patients there are likely to be 5 newly diagnosed patients p.a. and 40 consultations for existing migraine. (Prodigy 2006) Demand for neurology outpatient appointments has historically been greater than capacity across the Bristol, North Somerset and South Gloucestershire (BNSSG) health community. This has led to difficulty in maintaining maximum waiting times for GP referrals, delays to follow up appointments and long waiting times for non-GP (tertiary) referrals. A review of GP referrals to Neurology in August 2006 found that headache was the most common reason for referral (24% of referrals). The majority of patients with headaches are referred for a CT scan at the first neurology outpatient appointment. This pathway reinforces the use of GPs direct access to CT scanning for patients with headache at NBT, UBHT and WAHT, which previously has not been widely used. Where the aim of GP referral is to exclude the presence of a tumour, a number of neurology outpatient appointments can potentially be avoided by the GP referring directly for a CT scan. If a patient subsequently requires referral to neurology, having the CT scan results available for the first outpatient appointment will support early decision making by the Consultant.

Annex A

Quick reference Pathway

Annex B Annex C

Supporting Clinical Information and Detailed Pathways for Migraine, Medication Overuse Headache and Chronic Daily Headache Supporting Information for Commissioners

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PEC Paper

Page 1 of 10

Annex A. Quick reference care pathway

Patient presents with chronic headache 1 1 Patient presents with chronic headache 1 Patient presents with chronic headache

Diagnosis based on history and physical examination (BP, head and neck, neurological system)

Diagnosis based on history and physical examination (BP, head and neck, neurological system)

Diagnosis based on history and physical examination (BP, head and neck, neurological system)

Migraine
Recurrent episodic moderate or severe headaches, unilateral and/or pulsating, lasting 4 to 72 hrs, associated with gastrointestinal (and sometimes visual symptoms). Reassurance and identification/ avoidance of predisposing and trigger factors (e.g. stress, depression, menstruation, dietary, exercise)

Medication overuse headache

Patients often use very large quantities of medication and pre-emptive use of medication, headache present on awakening in the morning and increases after physical exertion, diagnosis confirmed only when symptoms improve after medication is withdrawn.

Chronic daily headache

Episodic, mostly lasting no more than several hours, or chronic, occurring on >15 days a month; can be unilateral but more often generalised, typically described as pressure or tightness, commonly spreads into or arises from the neck, lacks specific features associated with migraine.

8 3

12

Identify and stop analgesic causing MOH Consider analgesic to manage pain
Acute 1st line treatment: simple analgesics, or NSAIDs are effective. step up if unresponsive to : anti-migraine drugs (5HT-agonists) 2nd line treatment NB can cause MOH (pathway 2) Do not substitute another analgesic. Warn the patient that headache may become worse/ more severe for a period of days/ weeks before improvement and no analgesic must be taken in period.

Provide reassurance, identify contributory factors and confirm not MOH 13

9 Consider primary prevention as first measure If headache becomes intolerable consider replacing causative analgesic
Opioid analgesics, including codeine are not recommended. Replace causative analgesic with regular NSAID if necessary, unless NSAID is causative/ contra-indicated Regular exercise is of general and potentially considerable benefit Physiotherapy may be appropriate for musculoskeletal symptoms Lifestyle changes, relaxation therapy, cognitive training, yoga and meditation to reduce stress

and/ or consider anti-emetics to manage nausea and vomiting

1st line treatment: buccal prochlorperazine or metoclopramide 2nd line treatment: Domperidone suppositories if vomiting is a problem.

14

10

Consider medication as a second measure for analgesia and prophylaxis and/ or consider prophylaxis for acute prevention
Consider prophylactic treatment if migraine >1 per month Acute 1st line treatment : beta-blockers (e.g. propranolol) or if contraindications (unlicensed 2nd line treatment: pitzofen or amitriptyline indication )

If patient still having headache > 4 weeks, reconsider investigation for migraine or chronic headache go to 3 or 12 11 15

For episodic TTH , occurring on fewer than 2 days per week, aspirin, ibuprofen, paracetamol or NSAIDs. For frequently occurring episodic or chronic TTH try simple analgesic first and step up to amitryptiline (unlicensed indication ) starting at a low dose with increments as side effects permit.

if second-line treatments fail or if diagnosis uncertain consider referral for neurological opinion and/ or directaccess diagnostic CT to exclude secondary headache 7

if second-line treatments fail or if diagnosis uncertain consider referral for neurological opinion and/ or directaccess diagnostic CT to exclude secondary headache 16

Annex B. Supporting clinical information

1. Presentation Headache on 15 days/ month that may be due to a range of underlying mechanisms and may be complicated by, or caused by, drug overdose (Goadsby 2006). 2. History and examination

Diagnosis based on history and physical examination (BP, head and neck and neurological examination). SIGN give the following questions to consider when taking a history: How many different headache types does the patient experience? Separate histories are necessary for each. It is reasonable to concentrate on the most bothersome to the patient, but others should always attract some enquiry in case they are clinically important. Time questions: o why consulting now? o how recent in onset? o how frequent, and what temporal pattern (especially distinguishing between episodic and daily or unremitting) o how long lasting? Character questions: o intensity of pain o nature and quality of pain o site and spread of pain o associated symptoms Cause questions: o predisposing and trigger factors o aggravating and/or relieving factors o family history of similar headache Response questions o what does the patient do during the headache? o how much is activity (function) limited or prevented? o what medication has been used and in what manner? State of health between attacks o completely well, or residual or persisting symptoms o concerns/ anxieties, fears about recurrent attacks, and/ or their cause

Differentiating migraine from tension-type headache from Goadsby 2006 Characteristics Pain features of acute attacks Migraine Throbbing Unilateral Worsening of pain with movement Associated features Nausea or vomiting Photophobia and phonophobia Tension-type headache Boring or squashing Bilateral No effect of head movement None

Characteristics Triggering factors

Migraine Altered sleep patterns (too much or too little) Skipping meals Overexertion Change in stress level (too much or relaxation) Excess afferent stimuli (such as bright lights) Weather change Chemical (delayed headache after alcohol or glyceryl trinitrate) Menstruation

Tension-type headache Psychological stress

Red flags from North Derbyshire guidelines Awoken by headache at night (not awakes with a headache) Worst in the morning Worsened by changes in posture, especially bending Coughing, sneezing, straining or vomiting, exacerbates it Associated with: o vomiting & drowsiness o progressive neurological deficit o cognitive changes papilloedema meningeal irritation: look specifically for neck stiffness, back pain and Kernigs sign new neurological deficit

3.
Patient presents with chronic headache 1

Migraine

Recurrent episodic moderate or severe headaches, unilateral and/or pulsating, lasting 4 to 72 hrs, associated with gastrointestinal (and sometimes visual symptoms). Reassurance and identification/ avoidance of predisposing and trigger factors (e.g. stress, depression, menstruation, dietary, exercise)

Diagnosis based on history and physical examination (BP, head and neck, neurological system)

4.

Consider analgesic to manage pain

Opioids should be avoided. Triptans are not recommended as first line treatment. NSAIDs may cause GI irritation and occasional GI haemorrhage. Do not give if there is a history of peptic ulceration. NSAIDs may worsen asthma, hypertension, renal impairment or heart failure (Prodigy 2006). Acute 1st line treatment: simple analgesics (e.g. paracetamol or NSAIDS e.g. ibuprofen) step up if unresponsive to 5. 2nd line treatment: anti-migraine drugs (5HT-agonists) NB can cause MOH (pathway 2) or triptans Consider anti-emetics to manage nausea and vomiting 1st line treatment: buccal prochlorperazine or metoclopramide Domperidone suppositories if vomiting is a problem.

Migraine
Recurrent episodic moderate or severe headaches, unilateral and/or pulsating, lasting 4 to 72 hrs, associated with gastrointestinal (and sometimes visual symptoms). Reassurance and identification/ avoidance of predisposing and trigger factors (e.g. stress, depression, menstruation, dietary, exercise)

Consider analgesic to manage pain

Acute 1st line treatment: simple analgesics, or NSAIDs are effective. step up if unresponsive to : anti-migraine drugs (5HT-agonists) 2nd line treatment NB can cause MOH (pathway 2)

Soluble preparations are preferred as they act more quickly. (P06) 6. Consider prophylaxis for acute prevention

Consider prophylactic treatment if migraine >1 per month

and/ or consider anti-emetics to manage nausea and vomiting
1st line treatment: buccal prochlorperazine or metoclopramide Domperidone suppositories if vomiting 2nd line treatment: is a problem.

Acute 1st line treatment: beta-blockers (e.g. propranolol)

NB Contraindications for asthma, COPD, peripheral vascular disease or unstable heart failure (P06) or if contraindications 2nd line treatment: amitriptyline/ pitzofen

and/ or consider prophylaxis for acute prevention

Consider prophylactic treatment if migraine >1 per month Acute 1st line treatment : beta-blockers (e.g. propranolol) or if contraindications 2nd line treatment: pitzofen or amitriptyline (unlicensed indication )

Migraine sufferers who are not depressed should be reassured that the drug is intended for prevention of migraine otherwise they may not comply. (P06) 7. Consider referral for direct-access diagnostic CT to exclude secondary headache If second-line treatments of acute symptoms fail or if diagnosis is uncertain, consider referral for neurological opinion and/or refer directly for head CT.

if second-line treatments fail or if diagnosis uncertain consider referral for neurological opinion and/ or directaccess diagnostic CT to exclude secondary headache 7

8.
Patient presents with chronic headache 1

Medication overuse headache (MOH)

Patients often use very large quantities of medication and pre-emptive use of medication, headache present on awakening in the morning and increases after physical exertion, diagnosis confirmed only when symptoms improve after medication is withdrawn. 9. Identify and stop analgesic causing MOH

based on history and physical examination (BP, head and neck, neurological system)

Diagnosis

Do not substitute another analgesic. Warn the patient that headache may become worse/ more severe for a period of days/ weeks before improvement and no analgesic must be taken in period. 10. If headache becomes intolerable

Opioid analgesics, including codeine are not recommended. Replace causative analgesic with regular NSAID if necessary, unless actually NSAID 11. If patient is still having headache > 4 weeks reconsider investigation for migraine or chronic daily headache
Medication overuse headache
Patients often use very large quantities of medication and pre-emptive use of medication, headache present on awakening in the morning and increases after physical exertion, diagnosis confirmed only when symptoms improve after medication is withdrawn.

Go to nodes 3 or 12

Identify and stop analgesic causing MOH

Do not substitute another analgesic. Warn the patient that headache may become worse/ more severe for a period of days/ weeks before improvement and no analgesic must be taken in period.

If headache becomes intolerable consider replacing causative analgesic

Opioid analgesics, including codeine are not recommended. Replace causative analgesic with regular NSAID if necessary, unless NSAID is causative/ contra-indicated

10

If patient still having headache > 4 weeks, reconsider investigation for migraine or chronic headache go to 3 or 12 11

12.
Patient presents with chronic headache 1

Chronic daily headache

Episodic, mostly lasting no more than several hours, or chronic, occurring on >15 days a month; can be unilateral but more often generalised, typically described as pressure or tightness, commonly spreads into or arises from the neck, lacks specific features associated with migraine. 13. Provide reassurance

Diagnosis based on history and physical examination (BP, head and neck, neurological system)

Confirm not medication overuse headache, provide reassurance and identify contributory factors (e.g. stress, depression, musculoskeletal involvement). 14. Consider primary prevention as first measures Regular exercise is of general and potentially considerable benefit Physiotherapy may be appropriate for musculoskeletal symptoms Lifestyle changes, relaxation therapy, cognitive training, yoga and meditation to reduce stress Consider medication as a second measure

Chronic daily headache

Episodic, mostly lasting no more than several hours, or chronic, occurring on >15 days a month; can be unilateral but more often generalised, typically described as pressure or tightness, commonly spreads into or arises from the neck, lacks specific features associated with migraine.

15.

12

Provide reassurance, identify contributory factors and confirm not MOH 13

Opioid analgesics, including codeine are not recommended. For episodic chronic headache, occurring on fewer than 2 days per week, aspirin, ibuprofen, paracetamol or NSAIDs. For frequently occurring episodic or chronic tension type headache try simple analgesic first and step up to amitryptiline starting at a low dose with increments as side effects permit. Withdrawal may be attempted after improvement has been maintained for 4-6 months

Consider primary prevention as first measure

Regular exercise is of general and potentially considerable benefit Physiotherapy may be appropriate for musculoskeletal symptoms Lifestyle changes, relaxation therapy, cognitive training, yoga and meditation to reduce stress

Beware analgesic use > 2 days/ week for headache. 16. Consider referral for direct-access diagnostic CT to exclude secondary headache If second-line treatments of acute symptoms fail or if diagnosis is uncertain, consider referral to secondary care for neurological opinion or direct access CT

14

Consider medication as a second measure for analgesia and prophylaxis

For episodic TTH , occurring on fewer than 2 days per week, aspirin, ibuprofen, paracetamol or NSAIDs. Forfrequently occurring episodic or chronic try TTH simple analgesic first and step up to amitryptiline (unlicensed indication ) starting at a low dose with increments as side effects permit.

15

if second-line treatments fail or if diagnosis uncertain consider referral for neurological opinion and/ or directaccess diagnostic CT to exclude secondary headache 16

Annex C. Supporting information for commissioners

Clinical presentation Speciality Keywords Organisations Author(s) Ownership Accredited by Status Date of publication Date updated Date of review Target professional group Target patient group Adapted from/ references chronic headache neurology chronic headache, tension headache, migraine, CT scan, medication overuse headache Bristol PCT, North Somerset PCT, South Glos PCT NBT, UBHT, Weston Dr Peter Heywood, Dr Duncan Goodland, Elaine Evans, Nathalie Delaney PEC Prescribing Committee (TBC) Final 21 September 2007 n/a January 2009 GPs in BNSSG

Adults >16 years old Excludes 2 week wait referrals, children, and patients with red flag features. SIGN (August 2007) http://www.sign.ac.uk/pdf/headachedraft.pdf BASH (April 2007) http://www.bash.org.uk/ http://216.25.100.131/upload/NS_BASH/BASH_guidelines_2007.pdf Prodigy (June 2006) http://www.cks.library.nhs.uk/migraine and http://cks.library.nhs.uk/headache Goadsby (2006) Recent advances in the diagnosis and management of migraine. BMJ. http://www.bmj.com/cgi/reprint/332/7532/25.pdf

Background

Headache is common, affecting over 90% of the general population in the UK, accounting for 4.4% of consultations in primary care and 30% of neurology OP consultations. GPs refer 2-3% of patients consulting for headache to secondary care to exclude secondary headache. Most primary headaches can be managed in primary care and investigations are rarely needed. (SIGN, 2007) The lifetime prevalence of migraine is 25% in women and 8% in men. In a practice of 2000 patients there are likely to be 5 newly diagnosed patients p.a. and 40 consultations for existing migraine. (Prodigy 2006)

Coding

Neurology 1st OP (400) OPCS U05.1 Computerised tomography of head; U21.2 CT nec (not elsewhere classified)

Presentation

Chronic headache (headache on 15 days/ month that may be due to a range of underlying mechanisms and may be complicated by, or caused by, drug overdose (Goadsby 2006).

History and examination in primary care

Diagnosis based on history and physical examination (BP, head and neck and neurological examination)

Options for diagnosis

Migraine Medication overuse headache (MOH) Chronic daily headache/ tension type headache Other, more rare types of headaches

Management in primary care

See care pathway for detailed primary care management (first and second line treatments) NB Focal migraine is a contraindication to oral contraceptives For further prescribing information, refer to local formulary and BNF.

Direct-to-test diagnostics (Dx)

If unsure of diagnosis and first/ second line treatments fail, possible to refer to direct access CT (available at NBT, UBHT and Weston) Use plain X-ray form to refer to radiology. When booking remember that a CT is equivalent to about 100 chest x-rays and is contraindicated in pregnant women.

Refer to secondary care

BNSSG CT Head Referral Guideline: Recent onset headaches particularly if unexplained aetiology & suggestive of space occupying mass in the cranium. Change in headache pattern. Progressively more severe headaches. Headaches waking patient from sleep. Non-migrainous headache with nausea or vomiting as prominent features. Headaches associated with change in personality or behaviour Headaches with other neurological symptoms or physical signs

In addition, headaches with the following features:

Diagnostics in secondary care (Dx) Treatment (Tx) Follow-up Discharge criteria Self-care Primary prevention Supporting documents

CT (see above)

n/a n/a n/a Manage pain with simple analgesics (see pathway for relevant diagnosis for more information) Identification and avoidance of predisposing and trigger factors (e.g. stress, depression, menstruation, dietary, exercise) and adopting relevant lifestyle changes (e.g. regular exercise, physiotherapy (for musculoskeletal symptoms) Care pathway flowchart Supporting information (including prescribing guidance) Links to relevant patient factsheets and symptom diaries on www.migrainetrust.org (mainly migraine and TTH) and www.patient.co.uk (including MOH)

Evidence summary Glossary Links to

See SIGN (2007) for evidence-base CT computed tomography or computed axial tomography

2 week wait referral form for cancer.

Commissioning info

NBT have unbundled tariffs for neurology and direct access CT: 67 direct access CT, 308 unbundled 1st neurology OP, 235 unbundled FU. UBHT covered within block contract. 390 1st neurology OP, 243 OPFU. 3 elective spells coded as U051 (head CT) in 2006/07 (Bristol PCT) 2146 1st OP attendances neurology (10%) DNA and 3194 FU OP (13% DNA) giving a 1.5 FU:new rate in 2006/07 (Bristol PCT) Audit in August 2006 found that headache was the most common cause for referral (18/95: 95%) Potential increase in demand un-quantified (estimated at 50% of DNAs). Conversion rate from DTT to 1st OP un-quantified (estimated at 20%: although this may be high, as it is estimated that the chance of finding a relevant abnormality on neuro-imaging is as low as 0.2% for patients presenting with stable episodic headache and a normal neurological exam (i.e. those covered by this guidance) (SIGN).

Responsible lead Date added to intranet/ database Distribution

Nathalie Delaney, SIF, Bristol PCT nathalie.delaney@nhs.net October 2007

All GPs in BNSSG PCTs via email and available on care pathway website. Consultation draft available at http://www.avon.nhs.uk/HeadachePathway