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Clinical case scenarios

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1 Clinical case scenarios
Headaches Clinical case scenarios for group discussion ABOUT THIS PRESENTATION: This clinical case scenario slide set has been developed to support education and learning about the NICE clinical guideline on Headaches. This resource has been developed to illustrate the application of the recommendations in ‘Headaches’ (NICE clinical guideline 150) in practice and should only be used to support learning. Patients' needs should be assessed holistically, and it is acknowledged that they may have needs beyond the scope of these case studies. These cases do not reflect treatment plans for actual patients and should not be used as such. If an individual clinician has any queries or concerns about the relationship between NICE guidance and this educational resource they should always refer to the original guidance published by NICE, and this should in all cases be regarded as the only definitive statement of the guidance. The NICE clinical guideline may be found at The Headaches guideline has been written for healthcare professionals working in all settings in the NHS where care is provided for young people (aged 12 years and older) and adults with headache. Documents you may wish to download for your audience to refer to: NICE version: NICE headaches pathway: Diagnosis poster: GMC good practice in prescribing medicines – guidance for doctors: Joint standing committee on medicines - prescribing advice: Home oxygen ordering form (case 3 only): This slide set contains 58 slides. Depending upon time available you may only wish to use one or two cases. The slide set can be adapted to meet your requirements. DISCLAIMER This clinical case scenario slide set is an implementation tool and should be used alongside the published guidance. This information does not supersede or replace the guidance itself. PROMOTING EQUALITY Implementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have regard to promoting equality of opportunity. Nothing in this guidance should be interpreted in a way which would be inconsistent with compliance with those duties. September 2012 NICE clinical guideline 150

2 What this presentation covers
Introduction to clinical case scenarios Background NICE Pathway The cases NHS Evidence Find out more NOTES FOR PRESENTERS: In this presentation we will start by introducing clinical case scenarios. We will then present a background to headaches and the headaches clinical guideline Next, we will present the cases Links to NHS Evidence and the NICE Pathway are provided. Finally, we will end the presentation with further information about the support provided by NICE.

3 Clinical case scenarios
Each scenario includes details of the patient’s initial presentation The clinical decisions about diagnosis and management are then examined using a question and answer approach Relevant recommendations from the NICE guideline are quoted in the notes and additional information and detail from the full guideline is added to answers These clinical case scenarios form part of a package of education and learning materials which include an Academic detailing aid and Diagnosis poster to support CG150, Headaches. NOTES FOR PRESENTERS: Clinical case scenarios are an educational resource that can be used for individual or group learning. Each question should be considered by the individual or group before referring to the answers. These 4 clinical case scenarios have been put together to improve your knowledge of headaches and its application in practice. They illustrate how the recommendations from ‘Headaches’ (NICE clinical guideline 150) can be applied to the care of patients presenting with previously diagnosed headache to GPs and practice nurses. This clinical case scenario slide set is provided to support learning in a group setting. A pdf version is also available to support individual learning. You will need to refer to the NICE clinical guideline to help you decide what steps you would need to follow to diagnose and manage each case, so make sure that users have access to a copy (either online at or as a printout). You may also want to refer to the headaches NICE pathway (http://pathways.nice.org.uk/headaches) and the diagnosis poster (http://guidance.nice.org.uk/CG150/DiagnosisPoster/pdf/English). Each case scenario includes details of the person’s initial presentation, their medical history and their clinician’s summary of the situation after examination. The clinical decisions about diagnosis and management are then examined using a question and answer approach. Relevant recommendations from the NICE guideline are quoted in the text (after the answer), with corresponding recommendation numbers. Information and detail from the full guideline (http://guidance.nice.org.uk/CG150/Guidance) has been included in the answers and the 'supporting information' boxes. The language used when responding to the hypothetical patients has been written in such a way to ensure that the guideline recommendations are reflected accurately and the learning objectives are achieved. In practice it is acknowledged when providing patients with information, clinicians will deliver this in a way which meets the patients' needs. In addition, it is noted that many patients will have holistic needs which go beyond the scope of these fictional cases and therefore these cases should not be used as treatment plans for any patients. These clinical case scenarios form part of a package of education and learning tools developed to support implementation of the Headaches guideline. Other tools within the package are: Diagnosis poster: This will provide quick reference diagnosis support for clinicians Academic detailing aid: This is designed for use by experienced prescribing and medicines management personnel to support discussion with prescribers on medicines for management of acute migraine

4 Background: Headaches
Headaches one of the most common neurological problems presented to GPs and neurologists. Most common primary headache disorders are tension-type headache, migraine and cluster headache Improved recognition of primary headaches will help the generalist clinician to manage headaches more effectively, allow better targeting of treatment and potentially improve quality of life and reduce unnecessary investigations for people with headache NOTES FOR PRESENTERS: Headaches are one of the most common neurological problems presented to GPs and neurologists. They are painful and debilitating for individuals, an important cause of absence from work or school and a substantial burden on society. Headache disorders are classified as primary or secondary. The aetiology of primary headaches is not fully understood and they are classified according to their clinical pattern. The most common primary headache disorders are tension-type headache, migraine and cluster headache. Secondary headaches are attributed to underlying disorders and include, for example, headaches associated with medication overuse, giant cell arteritis, raised intracranial pressure and infection. Medication overuse headache most commonly occurs in those taking medication for a primary headache disorder. The major health and social burden of headaches is caused by the primary headache disorders and by medication overuse headache. The NICE clinical guideline on headaches makes recommendations on the diagnosis and management of the most common primary headache disorders in young people (12 years and older) and adults. Many people with headache do not have an accurate diagnosis of headache type. Healthcare professionals can find the diagnosis of headache difficult, and both people with headache and their healthcare professionals can be concerned about possible underlying causes. Improved recognition of primary headaches will help the generalist clinician to manage headaches more effectively, allow better targeting of treatment and potentially improve quality of life and reduce unnecessary investigations for people with headache. The NICE clinical guideline on headaches and these clinical case scenarios assumes that prescribers will use a drug’s summary of product characteristics to inform decisions made with individual patients. Drug dosages are specified in recommendations where the dosage for that indication is not included in the British National Formulary (BNF). The guideline recommends some drugs for indications for which they do not have a UK marketing authorisation at the date of publication, if there is good evidence to support that use. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. The patient (or their parent or carer) should provide informed consent, which should be documented. See the General Medical Council’s Good practice in prescribing medicines – guidance for doctors and the prescribing advice provided by the Joint Standing Committee on Medicines (a joint committee of the Royal College of Paediatrics and Child Health and the Neonatal and Paediatric Pharmacists Group) for further information. Where recommendations have been made for the use of drugs outside their licensed indications (‘off- label use’), these drugs are marked with a footnote in the recommendations.

5 Click here to go to NICE Pathways website
The NICE Headaches Pathway shows all the recommendations in the Headaches guideline Click here to go to NICE Pathways website NOTES FOR PRESENTERS: The recommendations from this guideline have been incorporated into a NICE Headaches pathway, which is available from If you are showing this presentation when connected to the internet, click on the orange button to go straight to the NICE Pathways website. The front page includes a two minute video giving an overview of the features and content within the site, as well as the list of topics covered. NICE Pathways: guidance at your fingertips Our new online tool provides quick and easy access, topic by topic, to the range of guidance from NICE, including quality standards, technology appraisals, clinical and public health guidance and NICE implementation tools. NICE pathways are simple to navigate and allow you to explore in increasing detail NICE recommendations and advice, giving you confidence that you are up to date with everything we have recommended.

6 Learning objectives The learning objectives for these clinical case scenarios are to improve knowledge on: how to manage acute migraine best practice for migraine prophylaxis (including migraine prophylaxis for women and girls of childbearing potential) treating cluster headaches, including the key points about ordering home and ambulatory oxygen where to find information for patients on acute migraine, migraine prophylaxis and cluster headaches.

7 Case scenario 1 Joseph, acute migraine (paediatric)

8 Presentation Joseph is a 14-year-old boy. He attends your clinic accompanied by his mum, Claire. He presents with a 2-month history of headaches that he describes as “banging” and that make his head “very very sore”. He says that in the past 2 months he has had 6 of these headaches. He also says that light hurts his eyes when he has the headaches. He does not feel nauseous or vomit during the headaches. Claire tells you that when Joseph has the headaches he is unable to go to school and that the headaches last from 2 to 4 hours. She gives Joseph paracetamol and if that doesn’t work she also gives him ibuprofen. Joseph reports that this combination of medication helps but that it still hurts a lot until the headache eventually goes completely. Joseph and Claire ask if Joseph’s headaches are migraines and if there is anything more he can take to ease the pain and reduce the amount of time he is taking off school.

9 1.1 Question Based on the history provided, and using the diagnosis poster as a quick reference to recommendations in section 1.1 and 1.2 of the guideline, you diagnose migraine without aura. Claire asks what this means for Joseph. How would you answer this? NOTES FOR PRESENTERS: The diagnosis poster can be accessed here:

10 1.1 Answer You would explain the diagnosis to Claire and Joseph and reassure them that a serious underlying cause is unlikely, based on Joseph’s history and your examination of him, which showed no abnormalities. You would tell them that migraines are a well-recognised problem although what causes them is not known for certain. You would reassure Claire and Joseph that you appreciate the large impact the headaches are having on Joseph’s life. You would give them written information about migraine in a format suitable for both, and include information about support organisations (see information in notes). Given that Joseph is likely to have recurrent migraines that will need treatment, you would explain the risk of medication overuse headache. NOTES FOR PRESENTERS: Relevant recommendations Include the following in discussions with the person with a headache disorder: a positive diagnosis, including an explanation of the diagnosis and reassurance that other pathology has been excluded and the options for management and recognition that headache is a valid medical disorder that can have a significant impact on the person and their family or carers. [1.3.4] Give the person written and oral information about headache disorders, including information about support organisations. [1.3.5] Explain the risk of medication overuse headache to people who are using acute treatments for their headache disorder. [1.3.6] Supporting information The following organisations provide information and support for people with migraine and are listed in NICE ‘Information for the public’ (http://publications.nice.org.uk/IFP150): Migraine Action, The Migraine Trust,

11 1.2 Question For acute management of Joseph’s migraine, you would tell Joseph and Claire that Joseph could have nasal sumatriptan, to take along with a non steroidal anti-inflammatory or paracetamol. However, Claire is concerned about Joseph taking 2 drugs and asks if there is an option for him to take just 1 drug. How would you answer this? At the time of publication of these cases (September 2012), only nasal sumatriptan had a UK marketing authorisation for this indication in people aged under 18 years

12 1.2 Answer You would tell Claire and Joseph that adding nasal sumatriptan, to paracetamol or a non steroidal anti-inflammatory would be the most effective option for relieving his migraines, but that Joseph could try taking just nasal sumatriptan to see whether it works better than paracetamol or ibuprofen. You would explain that the triptan would come as a nasal spray because it is not usually prescribed in tablet or capsule form for people aged under 18. You would tell Claire and Joseph that the other option would be monotherapy with either paracetamol or NSAID and you would ensure that the dose was optimised. However, since Joseph has already tried both of these drugs and they didn’t work well enough, triptan would be a suitable option for him to try next. NOTES FOR PRESENTERS: Relevant recommendations Offer combination therapy with an oral triptan1 and an NSAID, or an oral triptan1 and paracetamol, for the acute treatment of migraine, taking into account the person's preference, comorbidities and risk of adverse events. For young people aged 12–17 years consider a nasal triptan in preference to an oral triptan1. [1.3.10] For people who prefer to take only one drug, consider monotherapy with an oral triptan1, NSAID, aspirin2 (900 mg) or paracetamol for the acute treatment of migraine, taking into account the person's preference, comorbidities and risk of adverse events. [1.3.11] Related recommendation Do not offer ergots or opioids for the acute treatment of migraine. [1.3.14] Footnotes 1 At the time of publication (September 2012), triptans (except nasal sumatriptan) did not have a UK marketing authorisation for this indication in people aged under 18 years. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. The patient (or their parent or carer) should provide informed consent, which should be documented. See the General Medical Council’s Good practice in prescribing medicines – guidance for doctors and the prescribing advice provided by the Joint Standing Committee on Medicines (a joint committee of the Royal College of Paediatrics and Child Health and the Neonatal and Paediatric Pharmacists Group) for further information. 2 Because of an association with Reye’s syndrome, preparations containing aspirin should not be offered to people aged under 16 years.

13 1.3 Question Claire asks what they should do if the nasal triptan doesn’t work and whether there are there alternative medications. a) How would you answer this? b) What tool could you use to help assess the effectiveness of the nasal triptan

14 1.3 Answer You would explain that Joseph should try the sumatriptan nasal spray for at least 3 headaches because it isn’t possible to tell whether it’s working based on just 1 headache. If it still doesn’t work well enough then they should return to you and you would offer combination therapy with nasal sumatriptan, and a non steroidal anti-inflammatory. You explain that it is a case of finding out which type of treatment works best for Joseph. You could give Joseph a headache diary containing prompts for him to record the frequency, duration and severity of his headaches as well as his response to the triptan. You would explain to Joseph and Claire that keeping the diary will help them to learn more about his migraines (See next slide) NOTES FOR PRESENTERS: Relevant recommendation When prescribing a triptan1, start with the one that has the lowest acquisition cost; if this is consistently ineffective, try one or more alternative triptans. [1.3.12] Footnote 1 At the time of publication (September 2012), triptan (except nasal sumatriptan) did not have a UK marketing authorisation for this indication in people aged under 18 years. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. The patient (or their parent or carer) should provide informed consent, which should be documented. See the General Medical Council’s Good practice in prescribing medicines – guidance for doctors and the prescribing advice provided by the Joint Standing Committee on Medicines (a joint committee of the Royal College of Paediatrics and Child Health and the Neonatal and Paediatric Pharmacists Group) for further information.

15 1.3 Answer (headache diary)
Headache diaries are more accurate than recall and allow patterns of events to be more clearly seen. They also play an important role in acknowledging the impact of headache. Keeping the diary will help the patient to learn more about their migraines, for example whether they occur in patterns and whether they are triggered by anything in particular. The diary will also enable them to record any changes in how often the migraines happen, how painful they are, how well the treatments for them are working and any side effects from the treatments. You would use this information in the standard review you carry out after starting or changing treatment. NOTES FOR PRESENTERS: Relevant recommendation Consider using a headache diary: to record the frequency, duration and severity of headaches to monitor the effectiveness of headache interventions as a basis for discussion with the person about their headache disorder and its impact. [1.3.1]

16 1.4 Question Claire and Joseph thank you for your help and leave. As you are reflecting on Joseph's case, you think about other treatment options that might be suitable for Joseph if the triptan nasal spray doesn’t work well enough for him. What other treatment options would be available?

17 1.4 Answer You could try combination of the nasal sumatriptan with paracetamol. Alternatively you might then consider trying a different formulation of nasal triptan, triptan tablets or melts, but you would prefer not to prescribe these for Joseph because they are usually only given to people aged 18 and over. In addition to different formulations of nasal triptan, or triptan tablets or melts, you might consider adding an anti-emetic to Joseph’s treatment, taking into account the risk of side effects and Joseph and Claire’s preferences. NOTES FOR PRESENTERS: Relevant recommendations Offer combination therapy with an oral triptan1 and an NSAID, or an oral triptan1 and paracetamol, for the acute treatment of migraine, taking into account the person's preference, comorbidities and risk of adverse events. For young people aged 12–17 years consider a nasal triptan in preference to an oral triptan1. [1.3.10] When prescribing a triptan2, start with the one that has the lowest acquisition cost; if this is consistently ineffective, try one or more alternative triptans. [1.3.12] Consider an anti-emetic in addition to other acute treatment for migraine even in the absence of nausea and vomiting. [1.3.13] Supporting information (pages 167–168 of full guideline) An anti-emetic may have an effect on migraine itself and is a useful adjunct even if the patient does not have significant nausea and vomiting. Anti-emetics can trigger extrapyramidal side effects. The risk of these is higher in people aged under 20 years. There may be practical difficulties ingesting a number of drugs together. This may trigger more nausea and vomiting. The decision to add an anti-emetic is likely to depend on patient preference and experience of benefit without anti-emetic. Many will find it preferable and easier to use fewer drugs. Footnotes 1 At the time of publication (September 2012), triptans (except nasal sumatriptan) did not have a UK marketing authorisation for this indication in people aged under 18 years. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. The patient (or their parent or carer) should provide informed consent, which should be documented. See the General Medical Council’s Good practice in prescribing medicines – guidance for doctors and the prescribing advice provided by the Joint Standing Committee on Medicines (a joint committee of the Royal College of Paediatrics and Child Health and the Neonatal and Paediatric Pharmacists Group) for further information. 2 At the time of publication (September 2012), triptan (except nasal sumatriptan) did not have a UK marketing authorisation for this indication in people aged under 18 years. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. The patient (or their parent or carer) should provide informed consent, which should be documented. See the General Medical Council’s Good practice in prescribing medicines – guidance for doctors and the prescribing advice provided by the Joint Standing Committee on Medicines (a joint committee of the Royal College of Paediatrics and Child Health and the Neonatal and Paediatric Pharmacists Group) for further information. At the time of publication of these cases (September 2012), only nasal sumatriptan had a UK marketing authorisation for this indication in people aged under 18 years

18 Case scenario 2 Anaka, migraine prophylaxis

19 Presentation Anaka is a 28-year-old woman who was diagnosed with migraine with aura 6 months ago. She has, on average, 1 migraine attack per week, for which she takes triptan, an NSAID and an anti- emetic. Because Anaka has migraine about 4 times per month, she is unlikely to develop medication overuse headache. You are therefore happy with her current treatment plan. However, during an attack, she is unable to work or continue her normal daily activities. She also worries a lot about when the next attack is going to happen and their frequency causes her to take a lot of time off work. NOTES FOR PRESENTERS: Relevant recommendation Be alert to the possibility of medication overuse headache in people whose headache developed or worsened while they were taking the following drugs for 3 months or more: triptans, opioids, ergots or combination analgesic medications on 10 days per month or more or paracetamol, aspirin or an NSAID, either alone or in any combination, on 15 days per month or more. [1.2.7]

20 2.1 Question You note from Anaka's records that other than the medication mentioned above she is not taking any other forms of medication. You want to confirm that she is not a taking combined hormonal contraceptive for contraception purposes. Why is this?

21 2.1 Answer There is an increased risk of ischaemic stroke in people with migraine with aura. This risk is increased in women using combined hormonal contraception. Anaka confirms that she currently uses contraception but not a combined hormonal contraceptive. NOTES FOR PRESENTERS: Relevant recommendation Do not routinely offer combined hormonal contraceptives for contraception to women and girls who have migraine with aura. [1.3.22] Supporting information Women with migraine with aura (pages 327–328 of full guideline) It is important to note that recommendation refers to the use of combined hormonal contraceptives for contraceptive purposes only. The World Health Organization, 2009 (medical eligibility criteria) recommends that the oral contraceptive pill should not be used in women with migraine with aura at any age. The UK eligibility criteria (UKMEC), 2009 and UK Faculty of Sexual and Reproductive Health, both recommend that the use of combined hormonal contraceptive methods represent an unacceptable risk for women with migraine with aura. References/further sources of information: Department of Reproductive Health WHO. Medical eligibility criteria for contraceptive use. 4th edition. World Health Organization; 2009 Faculty of Sexual and Reproductive Healthcare. UK Medical Eligibility Criteria for contraception use [Last accessed: 13 July 2012] Faculty of Sexual and Reproductive Healthcare Clinical Effectiveness Unit RCoOaG. Clinical guidance; combined hormonal contraception 2011 (updated 2012). Accessible at

22 2.2 Question Anaka asks if there is anything that can be done to reduce the frequency of her migraine attacks.

23 2.2 Answer You would tell Anaka about the option of prophylactic treatment. Explain that prophylactic treatments prevent, rather than cure, a condition, and that for migraines they aim to reduce the frequency, severity and duration of the attacks. You explain the risks and benefits of prophylactic treatment – ensuring she understands her risk of migraine recurrence and severity, with and without prophylaxis, and her risk of adverse effects. NOTES FOR PRESENTERS: Relevant recommendation Discuss the benefits and risks of prophylactic treatment for migraine with the person, taking into account the person’s preference, comorbidities, risk of adverse events and the impact of the headache on their quality of life. [1.3.16]

24 2.3 Question The NICE guideline recommends offering topiramate or propranolol for the prophylactic treatment of migraine. When discussing the most suitable prophylaxis for Anaka what important information do you need to tell her about topiramate?

25 2.3 Answer Given that Anaka is of child bearing potential, it is important for her to be aware that topiramate is associated with a risk of fetal malformations. Additionally, as Anaka has confirmed that she is currently using contraception, she needs to be aware that there is potential for topiramate to impair the effectiveness of hormonal contraceptives. With Anaka's consent you arrange an appointment for her with the contraceptive service so she can talk about the options for suitable contraception if she were to take topiramate. NOTES FOR PRESENTERS: Relevant recommendation Offer topiramate1 or propranolol for the prophylactic treatment of migraine according to the person’s preference, comorbidities and risk of adverse events. Advise women and girls of childbearing potential that topiramate is associated with a risk of fetal malformations and can impair the effectiveness of hormonal contraceptives. Ensure they are offered suitable contraception. [1.3.17] Supporting information Contraception for women and girls taking topiramate (page 217 of full guideline) Further detail on contraception for women and girls taking topiramate is available in The epilepsies NICE clinical guideline 137, The diagnosis and management of the epilepsies in adults and children in primary and secondary care. There is a section specifically concerning Women and girls with epilepsy. This guideline refers to the BNF (www.bng.org) and Summary of Product Characteristics (SPC) (www.medicines.org.uk/emc) Further sources of information: Faculty of Sexual and Reproductive Healthcare Clinical Effectiveness Unit RCoOaG, (2012) Drug interactions with hormonal contraception. Available from Faculty of Sexual and Reproductive Healthcare Clinical Effectiveness Unit RCoOaG (2010) CEU statement: antiepileptic drugs and contraception. Available from: Footnotes 1 At the time of publication (September 2012), topiramate did not have a UK marketing authorisation for this indication in people aged under 18 years. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. The patient (or their parent or carer) should provide informed consent, which should be documented. See the General Medical Council’s Good practice in prescribing medicines – guidance for doctors and the prescribing advice provided by the Joint Standing Committee on Medicines (a joint committee of the Royal College of Paediatrics and Child Health and the Neonatal and Paediatric Pharmacists Group) for further information.

26 2.4 Question Following consultation with the contraceptive service, Anaka decides that she does not want to use any of the contraceptives that were recommended as suitable and reliable for use with topiramate. You therefore suggest propranolol for migraine prophylaxis. a) How would you assess the effectiveness of the propranolol? b) When would you review the need to continue this prophylaxis?

27 2.4 (a) Answer a) You would provide Anaka with a headache diary that contains prompts to record the frequency, duration and severity of her headaches as well as her response to the propranolol. Headache diaries are more accurate than relying on a person’s memory, and allow patterns of events to be more clearly seen. Diaries also play an important role in acknowledging the impact of headaches. You would advise Anaka to complete the diary in order to: understand any patterns or triggers that may cause her symptoms; be more alert to changes in the regularity or severity of her attacks; and learn the effectiveness of any new medications she takes. It will also help inform the standard review process, to assess the treatment’s effectiveness and the presence of side effects after starting or changing a treatment plan. See next slide for answer 2.4 (b) NOTES FOR PRESENTERS: Relevant recommendations Offer topiramate1 or propranolol for the prophylactic treatment of migraine according to the person’s preference, comorbidities and risk of adverse events. Advise women and girls of childbearing potential that topiramate is associated with a risk of fetal malformations and can impair the effectiveness of hormonal contraceptives. Ensure they are offered suitable contraception. [1.3.17] Consider using a headache diary: to record the frequency, duration and severity of headaches to monitor the effectiveness of headache interventions as a basis for discussion with the person about their headache disorder and its impact. [1.3.1] Footnote 1 At the time of publication (September 2012), topiramate did not have a UK marketing authorisation for this indication in people aged under 18 years. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. The patient (or their parent or carer) should provide informed consent, which should be documented. See the General Medical Council’s Good practice in prescribing medicines – guidance for doctors and the prescribing advice provided by the Joint Standing Committee on Medicines (a joint committee of the Royal College of Paediatrics and Child Health and the Neonatal and Paediatric Pharmacists Group) for further information.

28 2.4 (b) Answer b) Continuing treatment when it is no longer needed puts the person at risk of having side effects and drug interactions. Experts agree that many people can stop prophylaxis after 6 months of treatment and continue to benefit from the prophylactic treatment. Therefore, you would review Anaka’s need to continue prophylactic treatment at 6 months. NOTES FOR PRESENTERS: Relevant recommendation Review the need for continuing migraine prophylaxis 6 months after the start of prophylactic treatment. [1.3.20].

29 2.5 Question Anaka asks if there is anything else she can do or take, such as a natural remedy, which could help reduce her migraine intensity. How would you address this?

30 2.5 Answer You would tell Anaka that taking riboflavin (400 mg once a day) may help to reduce her migraine frequency and intensity. You would tell her that products containing riboflavin can be purchased from pharmacies and health food stores. You could also tell Anaka that if propranolol is unsuitable or ineffective you will consider offering her a course of acupuncture. NOTES FOR PRESENTERS: Relevant recommendations Advise people with migraine that riboflavin (400 mg1 once a day) may be effective in reducing migraine frequency and intensity for some people. [1.3.21] If both topiramate2 and propranolol are unsuitable or ineffective, consider a course of up to 10 sessions of acupuncture over 5–8 weeks or gabapentin3 (up to 1200 mg per day) according to the person’s preference, comorbidities and risk of adverse events. [1.3.18] Additional information Products containing riboflavin can be purchased from pharmacies and reputable health food stores. Footnotes 1 At the time of publication (September 2012), riboflavin 400 mg did not have a UK marketing authorisation for this indication but is available as a food supplement. When advising this option, the prescriber should take relevant professional guidance into account. See the General Medical Council’s Good practice in prescribing medicines – guidance for doctors and the prescribing advice provided by the Joint Standing Committee on Medicines (a joint committee of the Royal College of Paediatrics and Child Health and the Neonatal and Paediatric Pharmacists Group) for further information. 2 At the time of publication (September 2012), topiramate did not have a UK marketing authorisation for this indication in people aged under 18 years. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. The patient (or their parent or carer) should provide informed consent, which should be documented. See the General Medical Council’s Good practice in prescribing medicines – guidance for doctors and the prescribing advice provided by the Joint Standing Committee on Medicines (a joint committee of the Royal College of Paediatrics and Child Health and the Neonatal and Paediatric Pharmacists Group) for further information. 3 At the time of publication (September 2012), gabapentin did not have a UK marketing authorisation for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. The patient (or their parent or carer) should provide informed consent, which should be documented. See the General Medical Council’s Good practice in prescribing medicines – guidance for doctors and the prescribing advice provided by the Joint Standing Committee on Medicines (a joint committee of the Royal College of Paediatrics and Child Health and the Neonatal and Paediatric Pharmacists Group) for further information.

31 2.6 Question Anaka tells you that her mum also takes treatment to prevent migraines, but that she takes amitriptyline. Anaka says amitriptyline works for her mum and asks why she has not been offered it. How would you answer this question?

32 2.6 Answer You would tell her that, following a recent review, NICE (a national organisation that advises the NHS about the effective use of drugs) recommended that prophylaxis with topiramate or propranalol should be offered first and if those did not work then acupuncture or gabapentin should be offered. NICE recommended that if someone was already having treatment with amitriptyline and it was working then they could continue with that treatment. NOTES FOR PRESENTERS: Relevant recommendations For people who are already having treatment with another form of prophylaxis such as amitriptyline1, and whose migraine is well controlled, continue the current treatment as required. [1.3.19] Footnotes 1 At the time of publication (September 2012), amitriptyline did not have a UK marketing authorisation for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. The patient (or their parent or carer) should provide informed consent, which should be documented. See the General Medical Council’s Good practice in prescribing medicines – guidance for doctors and the prescribing advice provided by the Joint Standing Committee on Medicines (a joint committee of the Royal College of Paediatrics and Child Health and the Neonatal and Paediatric Pharmacists Group) for further information.

33 2.7 Question If Anaka wants to become pregnant in the future, but still needs migraine prophylaxis, what should you do?

34 2.7 Answer Migraine without aura often improves during pregnancy. However, migraine with aura is more likely to continue throughout pregnancy. If Anna becomes pregnant you should therefore assess whether she needs prophylaxis during her pregnancy. If she does, then you would seek specialist advice. This could be advice over the telephone to avoid delaying a prescription that would otherwise require a referral. You would also review and discuss her use of triptan, NSAIDs and anti- emetics, because of the risks associated with these medications during pregnancy. NOTES FOR PRESENTERS: Relevant recommendations Seek specialist advice if prophylactic treatment for migraine is needed during pregnancy. [1.3.25] Offer pregnant women paracetamol for the acute treatment of migraine. Consider the use of a triptan1 or an NSAID after discussing the woman’s need for treatment and the risks associated with the use of each medication during pregnancy. [1.3.24] Footnotes 1 At the time of publication (September 2012), triptan (except nasal sumatriptan) did not have a UK marketing authorisation for this indication in people aged under 18 years. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. The patient (or their parent or carer) should provide informed consent, which should be documented. See the General Medical Council’s Good practice in prescribing medicines – guidance for doctors and the prescribing advice provided by the Joint Standing Committee on Medicines (a joint committee of the Royal College of Paediatrics and Child Health and the Neonatal and Paediatric Pharmacists Group) for further information.

35 2.8 Question Anaka asks you if there is any reading she can do to learn more about her condition. a) In your discussion with Anaka, what information and support would you provide as a minimum? b) What further information would you provide to Anaka?

36 2.8 Answer a) As a minimum, you would explain to Anaka about her diagnosis and reassure her that other pathology has been excluded. You would reassure Anaka that this type of headache is a well- recognised problem and that you understand that it is having a big impact on her life. b) You would provide Anaka with information (in a format suitable for her) about headache disorders, including information about support groups (see supporting information in notes). NOTES FOR PRESENTERS: Relevant recommendation Include the following in discussions with the person with a headache disorder: a positive diagnosis, including an explanation of the diagnosis and reassurance that other pathology has been excluded and the options for management and recognition that headache is a valid medical disorder that can have a significant impact on the person and their family or carers. [1.3.4] Give the person written and oral information about headache disorders, including information about support organisations. [1.3.5] Explain the risk of medication overuse headache to people who are using acute treatments for their headache disorder. [1.3.6] Supporting information The following organisations provide information and support for people with migraine and are listed in NICE ‘Information for the public’ (http://publications.nice.org.uk/IFP150): Migraine Action, The Migraine Trust,

37 Case scenario 3 Malcolm, cluster headache

38 Presentation Malcolm is a 31-year-old man. He has a history of severe headaches, which he says cause him the worst pain he’s ever felt. When he gets these headaches, he has pain on 1 side of his head, around his eye and along the side of his face. He also experiences drooping or swelling of the eyelid, watery eye and nasal congestion, on the same side as the headache Malcolm experienced the severe headache for the first time 2 weeks ago for which he went to accident and emergency, where he was given a CT scan. The CT scan was normal and you have been asked to evaluate Malcolm. Malcolm tells you that, since his first severe headache 2 weeks ago, he has experienced 6 more headaches. He says that on average his severe headaches last from 30 to 90 minutes. Based on Malcolm's history and using the diagnosis poster as a quick reference to recommendations in section 1.1 and 1.2 of the guideline you diagnose him with cluster headache. NOTES FOR PRESENTERS: It is acknowledged that this diagnosis process is likely to be more complex than this case represents however, for the purpose of the case scenario diagnosis has been simplified. The diagnosis poster can be accessed here:

39 3.1 Question What advice and support can you offer Malcolm about his diagnosis?

40 3.1 Answer At a minimum, you would explain the diagnosis and reassure Malcolm that other pathology has been excluded. You would also talk about the options for management (see case continued) and reassure him that you recognise these severe headaches are having a big impact on him. You would also provide Malcolm with information about cluster headache in a format suitable for him and include information about support organisations (see information in notes) NOTES FOR PRESENTERS: Relevant recommendation Include the following in discussions with the person with a headache disorder: a positive diagnosis, including an explanation of the diagnosis and reassurance that other pathology has been excluded and the options for management and recognition that headache is a valid medical disorder that can have a significant impact on the person and their family or carers. [1.3.4] Give the person written and oral information about headache disorders, including information about support organisations. [1.3.5] Supporting information The following organisations provide information and support for people with migraine and are listed in NICE ‘Information for the public’ (http://publications.nice.org.uk/IFP150): OUCH(UK),

41 3.2 Question When you ask Malcolm about how his attacks have been since his admission to the emergency department, he becomes upset and says that that they are very painful. He asks if there is any more that can be done to reduce the pain during attacks. What interventions could help Malcolm during an attack?

42 3.2 Answer You would offer Malcolm subcutaneous or nasal triptan. You need to make Malcolm aware that the nasal triptan does not have UK marketing authorisation for this indication (correct at time of publication of these case scenarios in September 2012). Malcolm is concerned about injecting himself; therefore, you decide to offer him nasal triptan. You document that Malcolm has consented to this treatment. You highlight that, if he is not receiving adequate relief with the nasal triptan, you will meet with Malcolm again and talk about subcutaneous triptan. See next slide for answer 3.2 continued NOTES FOR PRESENTERS: Relevant recommendation Offer oxygen or a subcutaneous1 or nasal triptan2 for the acute treatment of cluster headache. [1.3.27] Footnotes  1 At the time of publication (September 2012), subcutaneous triptan did not have a UK marketing authorisation for this indication in people aged under 18 years. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. The patient (or their parent or carer) should provide informed consent, which should be documented. See the General Medical Council’s Good practice in prescribing medicines – guidance for doctors and the prescribing advice provided by the Joint Standing Committee on Medicines (a joint committee of the Royal College of Paediatrics and Child Health and the Neonatal and Paediatric Pharmacists Group) for further information. 2 At the time of publication (September 2012), nasal triptan did not have a UK marketing authorisation for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. The patient (or their parent or carer) should provide informed consent, which should be documented. See the General Medical Council’s Good practice in prescribing medicines – guidance for doctors and the prescribing advice provided by the Joint Standing Committee on Medicines (a joint committee of the Royal College of Paediatrics and Child Health and the Neonatal and Paediatric Pharmacists Group) for further information.

43 3.2 Answer continued You would also assess Malcolm's medical history and note that he has no history of respiratory disease or COPD. You would offer Malcolm home and ambulatory oxygen. As required, you would explain that during an attack he will need to use a non-rebreathing mask and reservoir bag, and that the oxygen will be running at a flow rate of at least 12 litres per minute. The home oxygen is for use if he has an attack at home. The ambulatory oxygen is for him to take out and use if he has an attack while he is away from home (recognising that attacks happen at unpredictable intervals). You would explain that this will allow him to treat his attack at the earliest opportunity. NOTES FOR PRESENTERS: Relevant recommendation When using oxygen for the acute treatment of cluster headache: use 100% oxygen at a flow rate of at least 12 litres per minute with a non‑rebreathing mask and a reservoir bag and arrange provision of home and ambulatory oxygen. [1.3.28]

44 3.3 Question You are prescribing Malcolm the nasal triptan. How much should you prescribe?

45 3.3 Answer Because of the frequent nature of attacks during a bout of cluster headaches, it is important that Malcolm has an adequate supply of medication to reduce the pain. You would calculate this according to his history of cluster bouts and based on the manufacturer’s maximum daily dose. NOTES FOR PRESENTERS: Relevant recommendation When using a subcutaneous1 or nasal triptan2, ensure the person is offered an adequate supply of triptans calculated according to their history of cluster bouts, based on the manufacturer’s maximum daily dose. [1.3.29] Be alert to the possibility of medication overuse headache in people whose headache developed or worsened while they were taking the following drugs for 3 months or more: triptans, opioids, ergots or combination analgesic medications on 10 days per month or more or paracetamol, aspirin or an NSAID, either alone or in any combination, on 15 days per month or more. [1.2.7] Footnotes 1 At the time of publication (September 2012), subcutaneous triptan did not have a UK marketing authorisation for this indication in people aged under 18 years. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. The patient (or their parent or carer) should provide informed consent, which should be documented. See the General Medical Council’s Good practice in prescribing medicines – guidance for doctors and the prescribing advice provided by the Joint Standing Committee on Medicines (a joint committee of the Royal College of Paediatrics and Child Health and the Neonatal and Paediatric Pharmacists Group) for further information. 2 At the time of publication (September 2012), nasal triptan did not have a UK marketing authorisation for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. The patient (or their parent or carer) should provide informed consent, which should be documented. See the General Medical Council’s Good practice in prescribing medicines – guidance for doctors and the prescribing advice provided by the Joint Standing Committee on Medicines (a joint committee of the Royal College of Paediatrics and Child Health and the Neonatal and Paediatric Pharmacists Group) for further information.

46 3.4 Question How will you order the oxygen for Malcolm?

47 3.4 Answer To order the oxygen you must complete a home oxygen order form (HOOF). There are sections for ambulatory oxygen and long term or short burst oxygen. At the time of publication of these case scenarios (September 2012) the HOOF was available at oxygen-order-form. The current HOOF contains cluster headache as an indication. As well as ordering the oxygen, it is important to order the non- rebreathing mask (cushioned). It is essential that all the necessary equipment has been delivered to Malcolm to make sure he receives the prescribed oxygen. NOTES FOR PRESENTERS: In order to facilitate learning you may wish to download the HOOF form for the group to use whilst working through this case Additional information Oxygen supply companies differ by region. For more information see Some supply companies can only accept orders for oxygen at 15 litres per minute. The wording of the guideline recommendation 'use 100% oxygen at a flow rate of at least 12 litres per minute' allows for ordering more than 12 litres per minute if the supplier is unable to deliver 12 litres per minute.

48 3.5 Question What prophylaxis for cluster headache could you offer Malcolm?

49 3.5 Answer In order to reduce the frequency, severity and duration of attacks, you consider offering Malcolm verapamil. However, because of your lack of experience in using verapamil for cluster headache, you consult a colleague who is a GP with a special interest in headaches or neurology (or a consultant neurologist) for guidance in using this medication before prescribing it. NOTES FOR PRESENTERS: Relevant recommendation Consider verapamil1 for prophylactic treatment during a bout of cluster headache. If unfamiliar with its use for cluster headache, seek specialist advice before starting verapamil, including advice on electrocardiogram monitoring. [1.3.31] Supporting information (page 236 of full guideline) Verapamil may cause cardiac conduction problems. ECG monitoring is required before every increase in verapamil dosage and monitoring is also required at intervals if the person remains on verapamil Footnotes  1 At the time of publication (September 2012), verapamil did not have a UK marketing authorisation for this indication in people aged under 18 years. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. The patient (or their parent or carer) should provide informed consent, which should be documented. See the General Medical Council’s Good practice in prescribing medicines – guidance for doctors and the prescribing advice provided by the Joint Standing Committee on Medicines (a joint committee of the Royal College of Paediatrics and Child Health and the Neonatal and Paediatric Pharmacists Group) for further information.

50 3.6 Question What medications would you not offer Malcolm for the acute management of his cluster headache attacks?

51 3.6 Answer You would not offer paracetamol, NSAIDS, oral triptans, ergots or opioids as there is no evidence to suggest that they would have any clinical benefit in the treatment of cluster headache. NOTES FOR PRESENTERS: Relevant recommendation Do not offer paracetamol, NSAIDS, opioids, ergots or oral triptans for the acute treatment of cluster headache. [1.3.30]

52 Case scenario 4 Nisha, acute migraine (adult)

53 Presentation You are an out-of-hours GP and have been called out to visit Nisha. Nisha is a 48-year-old woman who was diagnosed with episodic migraine 10 years ago. She is taking topiramate for prophylaxis and takes an NSAID and oral triptan for acute treatment. Nisha currently has a severe migraine with aura that started 60 minutes ago. She took her usual oral triptan and NSAID 50 minutes ago and her migraine has not responded. Nisha has also vomited 6 times during this attack; once just after taking the oral medication.

54 4.1 Question What other acute migraine treatment can you offer Nisha?

55 4.1 Answer Given that the oral preparations of NSAID and triptan were not effective for Nisha, you offer her intramuscular metoclopramide or prochlorperazine. You also consider offering Nisha a non-oral NSAID or triptan; however, you decide against this because Nisha has recently taken both of these. NOTES FOR PRESENTERS: Relevant recommendations For people in whom oral preparations (or nasal preparations in young people aged 12–17 years) for the acute treatment of migraine are ineffective or not tolerated: offer a non-oral preparation of metoclopramide or prochlorperazine1 and consider adding a non-oral NSAID or triptan2 if these have not been tried. [1.3.15] Supporting information (page of full guideline) Anti-emetics are effective for symptom relief, regardless of whether the person has nausea or vomiting. Reasons for oral treatment not being appropriate could include vomiting, previous attempt at oral treatment which has been ineffective. If the individual has already taken an NSAID or triptan with unsatisfactory response, do not re-administer the same drug parenterally in addition to the antiemetic. Footnotes 1 At the time of publication (September 2012), prochlorperazine did not have a UK marketing authorisation for this indication (except for the relief of nausea and vomiting).The prescriber should follow relevant professional guidance, taking full responsibility for the decision. The patient (or their parent or carer) should provide informed consent, which should be documented. See the General Medical Council’s Good practice in prescribing medicines – guidance for doctors and the prescribing advice provided by the Joint Standing Committee on Medicines (a joint committee of the Royal College of Paediatrics and Child Health and the Neonatal and Paediatric Pharmacists Group) for further information. 2 At the time of publication (September 2012), triptan (except nasal sumatriptan) did not have a UK marketing authorisation for this indication in people aged under 18 years. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. The patient (or their parent or carer) should provide informed consent, which should be documented. See the General Medical Council’s Good practice in prescribing medicines – guidance for doctors and the prescribing advice provided by the Joint Standing Committee on Medicines (a joint committee of the Royal College of Paediatrics and Child Health and the Neonatal and Paediatric Pharmacists Group) for further information.

56 Click here to go to the NHS Evidence website
Visit NHS Evidence for the best available evidence on all aspects of Headaches Click here to go to the NHS Evidence website NOTES FOR PRESENTERS: If you are showing this presentation when connected to the internet, click on the blue button to go straight to the NHS Evidence website. For the home page go to

57 Find out more Visit www.nice.org.uk/guidance/CG150 for: the guideline
Information for the public costing statement and template audit support baseline assessment tool academic detailing aid diagnosis poster NOTES FOR PRESENTERS: You can download the guidance documents from the NICE website. The NICE guideline – all the recommendations. Information for the public – a summary of the guideline recommendations written for the public. The full guideline – all the recommendations, details of how they were developed, and reviews of the evidence they were based on. NICE has developed tools to help organisations implement this guideline, which can be found on the NICE website. Costing statement and template – details of the likely costs and savings when the cost impact of the guideline is not considered to be significant. Clinical audit support – for monitoring local practice. Baseline assessment tool – for assessing compliance against the guideline. Academic detailing aid – for use by experienced prescribing and medicines management personnel to support discussion with prescribers on medicines for management of acute migraine. Diagnosis poster – provides quick reference diagnosis support for clinicians

58 What do you think? Did the implementation tool you accessed today meet your requirements, and will it help you to put the NICE guidance into practice? We value your opinion and are looking for ways to improve our tools. Please complete this short evaluation form. If you are experiencing problems accessing or using this tool, please NOTES FOR PRESENTERS: Additional information: This final slide is not intended to be part of the presentation. It asks for feedback on whether this implementation tool meets your requirements and whether it will help you to put this NICE guidance into practice: your opinion would be appreciated. To open the links in this slide set, right click over the link and choose ‘open link’. To open the links in this slide set right click over the link and choose ‘open link’


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