1. Czech headache guidelines for general practitioners Jolana Marková Thomayer University Hospital Prague

2. 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

3. 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

4. Guideline implementation Establishment of guideline team First draft and public discussion Final version of guideline Introduction of guidelines at the congress of GP society Implementation of guideline Management audit and feedback to GPs Implementation of findings and guideline up-date

5. 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

6. Headache Classification and Diagnostic Criteria for Headache Disorders (IHS) Primary headache disorders1–4 Secondary headache disorders5–12 Cranial Neuralgias 13-14

7. Headache  Important features in headache history: Attack onset Pain location Attack duration Attack frequency and timing Pain severity Pain quality Associated features

8. Headache alarms

9. 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

10. Primary Headaches Migraine Tension-type headache Cluster headache Trigeminal autonom. cephalalgias

11. 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

12. 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

13. Focus on practical applicability in first-line. Diagnosis of migraine Treatment Acute migraine attack Prophylactic treatment Follow up Migraine

14. Not only headache – combination of neurological, gastrointestinal and autonomic changes Prodrome phase Aura Headache and asssociated symptoms Headache resolution phase Migraine-phases

15. Complex of focal neurological symptoms- positive or negative phenomena Precedes or accompanies an attack Last less than 60 minutes Visual ( scotoma,color shapes,migration) Sensory Motor Language disturbances Migraine- Aura

16. Unilateral – hemicrania Severe intensity Throbbing, pulsating character Aggravated by physical activity Accompanied with nausea, vomiting Photophobia, phonophobia Depression,fatigue, anxiety, irritabily are common in migraine patients Migraine - headache

17. 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

18. 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

19. 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

20. 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

21. Diagnostic scheme – migraine

22. Impact of migraine questionnaire to assess disability level “How much does headache negatively influence your 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.

23. Pressing/tightening quality Mild or moderate intensity Bilateral location No aggravation by walking stairs No nausea or vomiting Often depression High lifetime prevalence (70–90%) Tension – type headache

24. Acute treatment analgesics, NSAIDs, muscle relaxants Prophylactic treatment antidepressants – tricyclics, SSRI non-pharmacological treatment – relaxation, physical therapy techniques Tension – type headache

25. Subarachnoid hemorrhage sudden-onset severe headache stiff neck nausea, vomiting alteration of consciousness often beginning during physical activity

26. urgent admission to hospital CT, lumbal puncture neurosurgeon – consultation angiography intervention pharmacological treatment to prevent complications Subarachnoid hemorrhage

27. 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.

28. Headache in patients with 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. Cervicogenic headache Treatment  NSA, myorelaxants, analgetics- only a short time  Antidepressants – tricyclics, SSRI  Physioterapy  Long term living style improvement

35. Traumatic and post-traumatic headache  Acute posttraumatic headache  Chronic posttraumatic headache  Whiplash injury  Headache attributed to traumatic intracranial haematoma – epidural, subdural

36. Traumatic and post-traumatic headache Headache accompanied by other symptoms  Dizziness  Difficulty in concentration  Personality changes  Sleep disturbances  Anxiety  Depression  Vertigo

37. Traumatic and post-traumatic headache Diagnostic methods  Clinical neurological examination  Imaging – RTG, CT, MRI Treatment  Transport to the hospital  Neurosurgery  Intensive care

39. Thank you for your attention Thank You for Your Attention