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Headache & migraine: new NICE guideline

In September, the National Institute for Health & Clinical Evidence (NICE) published a guideline offering "evidence-based advice on the diagnosis and management of tension-type headache, migraine (including migraine with aura and menstrual-related migraine), cluster headache and medication overuse headache in young people (aged 12 years and older) and adults."

The guidance includes a series of interlocking components.  So there is the full 360 page guideline itself (and this doesn't include the 630 pages of appendices).  Happily there is also a very useful 38 page summary of the guideline, a good 1 page diagnosis 'poster', web-based advice for health professionals, and also clear web-based advice for the general public.   

NICE's highlighted "key facts" include the comments that

  • More than 10 million people in the UK experience regular or frequent headaches, making them one of the most common health complaints.
  • Headache accounts for 1 in 25 (4%) of primary care consultations and up to 30% of neurology out-patient appointments. Current practice suggests that 97% of people with headache are managed in primary care.
  • More than 100,000 people are absent from work or school because of migraines every working day - this totals around 25 million days a year.
  • Cluster headache is a type of primary headache, which typically causes intense pain around one eye. It presents in clusters for a month or two at around the same time of year. Around 1 in 1,000 people are believed to experience these at some point in their lives. Over-the-counter medications tend not to ease symptoms, but there are several treatments (including preventative options) recommended in the new NICE guideline.
  • The guideline's authors (and the associated press publicity) made a lot of the difficulties caused by medication-overuse headaches, so Professor Martin Underwood was quoted as saying “We have effective treatments for common headache types. However, taking these medicines for more than ten or fifteen days a month can cause medication overuse headache, which is a disabling and preventable disorder.  Patients with frequent tension-type headaches or migraines can get themselves into a vicious cycle, where their headaches are getting increasingly worse, so they take more medication which makes their pain even worse as they take more medication.  I hope this guideline will improve awareness of medication overuse headache both in primary care and among the general public ... "  And the press release commented "While common over-the-counter treatments are effective for easing the pain of occasional headaches, it has been estimated that up to 1 in 50 people experience headaches caused by medication overuse and that women are five times more likely to get them than men. They occur when people take painkillers or triptan drugs too often for tension-type (“every day”) headaches or migraine attacks."

    Gillian Leng, deputy chief-executive of NICE, expanded on these issues commenting "Although headache is the most common neurological problem seen by GPs and neurologists, many people are not receiving correct or timely diagnoses. The key features of medication overuse and the symptoms that distinguish the types of primary headache can be overlooked and concerns from patients about possible underlying causes can lead to unnecessary hospital investigations. These can mean people experience delays in receiving adequate pain relief from what can be an extremely disabling condition.  Our guideline outlines the assessments and treatments that people should expect to receive for primary headaches and medication overuse. We hope that this will help GPs and other healthcare professionals to correctly diagnose the type of headache disorder and better recognise patients whose headaches could be caused by their over-reliance on medications.  Regarding medication overuse, NICE advises the NHS to be alert to the possibility in people whose headache developed or worsened while they were taking the following drugs for three months or more:  * Triptans, opioids, ergots or combination analgesic medications on 10 days per month or more, or * Paracetamol, aspirin and an NSAID [non-steroidal anti-inflammatory drug, e.g. ibuprofen], either alone or any combination, on 15 days per month or more.  In addition, the NICE guideline advises healthcare professionals not to refer their patients for brain scans (neuroimaging) solely for reassurance. Many referrals will be unnecessary with improved diagnostic assessments." 

    Good, helpful information and advice ...

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