HeadacheDiagnosis and Management in Primary Care

Approaches to Treatment

•Step care

•Staged care

•Stratified care

MIDASMigraine Disability

•Validated

•Sensitive to change, so good for follow-up

•Link to online version of MIDAS

•http://www.migraine-disability.net/About_Midas/questionnaire5.pdf

HIT-6

•Validated

•Good for differential diagnosis

•Scoring

Mild impairment 50-55Moderate 56-59Severe ≥60

Likelihood Ratiosfor diagnosis of migraine

Positive LRNegative LR

00.8 0.4

Overall Management

Algorithm

MIPCA Diagnostic Screening Algorithm

MIPCA Diagnostic Screening Algorithm•Can we make that

algorithm operate in the background and suggest steps in the Plan?

•Hook it to a Headache Condition Summary?

MIPCA Management

Algorithm

Close-up 1

Close-up 1

Migraine Prophylaxis...

...Migraine Prophylaxis

Headache Action Plans

My choice

Meds

Teaches

Teaches

Diary

Diary

Patient Handouts

PowerChart Opportunities

•Integrate Diagnosis decision aids into history-taking

•Migraine Action Plan integrates PowerChart management orders with patient handout

Migraine Action Plan Potential

•Future patient feedback into chart

•Recent HA pattern

•Treatment response

•Adverse effects

Headache Dashboard

• Medications

• amitriptyline 10 mg 3 hs

• Maxalt MLT 10

• Aleve 220 4 onset, 2 in 30 min

• levothyroxine 125 mcg/d

DiagnosesMigraineInsomniaHypothyroidismCervical Dysplasia 2002 > cryoDysthymia

Allergies & Intolerancessulfa > as a childpenicillin > hivesImitrex SC > chest pain, anxiety (refuses to take again)

Headache Pathway1.Consult: Hx, Tx history, education, buy-in2.Diagnosis: screen for HA type3.Severity assessment: Frequency, Pain severity, Impact on pt’s life, Non-HA symptoms, Patient factors4.Treatment Plan: Establish goals, Behavioral therapy, Acute therapy, Possible prophylactic therapy, Complementary therapy5.Follow-up: Assess outcomes

Paula Pound DOB: 02/11/1967 MRN: 99 88 77 66 5 ph 573-911-9876 email: ppound@cool.com

Headache DiaryHeadache 1 Headache 2 Headache 3

Date / time

Prodrome / aura

Pain (1-10)

Location / type of pain

Other symptoms

Possible triggers

Meds taken

Did med help?

Med side effects

Other therapies

Did another tx help?

Headache Dashboard

• Medications

• amitriptyline 10 mg 3 hs

• Maxalt MLT 10

• Aleve 220 4 onset, 2 in 30 min

• levothyroxine 125 mcg/d

DiagnosesMigraineInsomniaHypothyroidismCervical Dysplasia 2002 > cryoDysthymia

Allergies & Intolerancessulfa > as a childpenicillin > hivesImitrex SC > chest pain, anxiety (refuses to take again)

Headache Pathway1.Consult: Hx, Tx history, education, buy-in2.Diagnosis: screen for HA type3.Severity assessment: Frequency, Pain severity, Impact on pt’s life, Non-HA symptoms, Patient factors4.Treatment Plan: Establish goals, Behavioral therapy, Acute therapy, Possible prophylactic therapy, Complementary therapy5.Follow-up: Assess outcomes

Paula Pound DOB: 02/11/1967 MRN: 99 88 77 66 5 ph 573-911-9876 email: ppound@cool.com

Outcome measuresMidas scores# HA / moMissed work daysNon-HA sxTabular form for temporal trendsBrought into PowerForm by nurse at checkin

Drugs tried, failed, whyTopamaxInderal

Allergies & Intolerancessulfa > as a child Imitrex SC > chest pain, anxiety (refuses to take again)penicillin > hives

Allergies & Intolerancessulfa > as a child

Imitrex SC > chest pain, anxiety (refuses to take again)penicillin > hives

Allergies & Intolerances•sulfa > as a child•Imitrex SC > chest pain, anxiety (refuses to take again)•penicillin > hives

Allergies & Intolerancessulfa > as a childImitrex SC > chest pain, anxiety (refuses to take again) penicillin > hives

Allergies & Intolerancessulfa > as a child

Imitrex SC > chest pain, anxiety (refuses to take again)

penicillin > hives

Allergies & Intolerances•sulfa > as a child•Imitrex SC > chest pain, anxiety (refuses to take again) •penicillin > hives

Algorithm formatting question ...