Abstract
Professor Goadsby
The burden of headache is best seen in the setting of primary care and this is our next subject. Obviously, if we do not translate the benefits of an acute treatment of a common condition into themes appropriate to primary care, we are wasting our time. The next speaker is Dr Andrew Dowson, who cut his teeth in the headache business under the supervision of Dr John Patten in the late 1980s, and in the early 1990s with Dr Michael Gross in Guildford, UK. He subsequently became involved in migraine clinical trials and now runs the King's Headache Service in London. Andrew?
Andrew Dowson
Thank you Peter, and thank you GlaxoWellcome for asking me to give this talk. First, I would like to wish ‘Happy Birthday’ to Imigran. It seems to be growing up quite nicely and I am glad to have Mike Welch's reassurance that the side-effect profile is good and the drug is safe. Given that, it seems strange that triptans are so little used in practice. I want to explore the barriers to getting this care to the general population and will show you some sections from a presentation that we have designed to give messages to primary care at an entry level.
We have challenges both from the patient and from the doctor side of the equation. Many patients have low expectations of their doctors, perhaps because of a poor experience themselves or in their family. It is also often necessary in the UK to take a half-day or more off work to see the doctor and this may be another hurdle to obtaining advice. From the doctor's side of the equation, migraine is often seen as not life-threatening and therefore unimportant. Doctors do not have much interest and it is not well understood because, in medical school and during GP training, education about headache was scanty until recently. We need to come up with some way of bridging this gap between patients and doctors and one way would be to encourage a larger group of professionals to identify the patients in need, directing them then to that professional most likely to improve their quality of life. This is an educational process and if we can create good quality educational experiences we will generate more interest. With better understanding, management will become more appropriate and, hopefully, our patients will get a better quality of life (Table 1).
Challenges and solutions
Here is a programme that we have set up to teach physicians about migraine in the context of meetings arranged to educate on other conditions, such as asthma. The doctors are actually in the meeting for another reason but this presentation is a bonus – an entry level, interesting, thought-provoking presentation on headache – and we hope that, after they go away, they will show more interest than before. We set it up as a web page, so the presentation is very much in the style of multimedia. This enables us to use different forms of presentation that can range from simple slides to audio- and videotapes. We start the programme off with http://www.migraine.com. The ‘www’ signifies Which treatment for What patients, When? In the full presentation, we would use some patient vignette at the beginning and hope that, by the end, the audience would be able to place the patient in the correct treatment group.
The letters of the word ‘migraine’ are used as chapter headings. We only have time to look at one or two of these during this presentation and I will start off with the M, which is used to address the question; ‘Is it really Migraine?’ The use of the International Headache Society (lHS) classification has now become widespread and I would like to thank Dr Jerry Goldstein from San Francisco for leading the way in innovative teaching of this, originally to help us identify populations for clinical trials.
We start with the image of Miss Mona Lisa – this is the image as seen in the Louvre with her inscrutable smile. If she gets a migraine, she will be unhappy; we signify this by changing the picture so that she wears a frown. The fact that the headache can go on for up to 72 h is shown by a clock in the corner that winds around for 3 days. The headaches are generally unilateral, shown by a dot over the right forehead. They have a pulsating quality, at which point a flashing effect occurs with the dot and a throbbing noise is heard on the audio in the lecture hall. As the headache becomes more severe, the dot becomes larger and the intensity of sound increases. It is made worse by routine activities such as walking or climbing stairs and at this point, Lisa starts to move around on the screen.
You and I know that not everybody has all of these symptoms, but it is important to explain this to uninitiated doctors and to let them know that possibly only half the patients will initially have a unilateral headache, etc., although they do need to have at least two of the four major symptoms for the diagnosis. We then return to the picture of Miss Mona Lisa and illustrate the potential associated symptoms, such as light sensitivity (she wears sun-glasses), sound sensitivity (she wears ear muffs) and nausea (she turns green) – and of course a minority of patients can actually vomit (at which point her hand comes to her mouth). Between attacks, we expect patients to return to normal and we show this with a return to the original picture of Miss Mona Lisa with a ring of confidence and the smile returning.
We have found it very successful to use this sort of cartoon to get a serious message across to the uninitiated doctor. We heard earlier about the difference between acute headache as a disease and chronic headache as a syndrome. In general practice, this is the most important dynamic. We need to teach about chronic headache as well as the red flags that suggest that there may be something sinister going on, such as meningitis, cranial arteritis, etc., as an underlying complaint. We try to reassure the doctors that these are actually very uncommon illnesses and need to be put into perspective, because common things occur commonly and most patients with acute headaches will be suffering from migraine.
We do not have time to go through the whole of this presentation and so I will describe just one more letter. That is the I for ‘Impact’ and, of course, during the last decade the big news in headache has been in regard of assessment of patients in terms of impact rather than just looking at the symptoms contained within the IHS classification. A good way to illustrate the impact of migraine is to listen to what patients actually say.
[Three audio clips are presented. The first is of a woman who states; ‘I have an attack about once month, it affects the whole of my body, I need to lie down, it makes me feel sick, I feel dreadful’. The second is of a young man who says; ‘My manager would not accept my private sick note and reported me. After my next attack, I was demoted and transferred’. The third case is a lady who says; ‘Pain-killers take the edge off the attacks but I can't cope. I even had to miss my son's birthday party’.]
We are all familiar with stories about how migraine affects personal life, family life and work. The problem for the GP is that these are all pretty soft end points. There is, however, a further voice-over that can make the GP sit up and listen because of its immediately obvious impact. It is in the style of a newscast and says; ‘In a recent Bandolier article, it has been reported that suicide attempts are higher in migraine sufferers, especially in those with aura. The report continues that almost …’ The article demonstrated that, for those patients who have depression with coexistent migraine, the risk of suicide is more than doubled. This is obviously a very meaningful end point.
The next image, for ‘I’, looks at the impact of migraine from the economic point of view. This has become scientifically acceptable largely due to the work of Buzz Stewart and Richard Lipton. On this slide we show the data collected from the US in the mid-1990s and from the UK in the late 1980s, which, in the case of the UK, predicted that the loss of output of work was worth in the region of £750 million per year. We feel this may be an underestimate and show this by incrementally increasing the size of the flag for the UK when considering the fact that the impact of migraine is not only due to the headache. In fact, most people have this part of the migraine during their own time, for instance at weekends, and the postdrome (although affecting work) is not always considered in the data. Second, because the data were collected over a decade ago and, third, because the prevalence on which the data are based looked at approximately 50% of the true prevalence rate for migraine.
Another way of looking at impact is to consider when patients are most likely to suffer from attacks. We know that the peak prevalence is usually in the mid-thirties, although the peak number of attacks (and therefore impact) is usually about a decade later. These are shown graphically both for men and women.
The final way of looking at impact from migraine is to compare migraine with other conditions that GPs think are quite common. We have taken data from nationally accepted sources for the prevalence of asthma, diabetes and epilepsy and, when added together, these come to less than the currently accepted prevalence rate for migraine.
The others letters for migraine will not be considered in full now but the ‘G’ stands for graphical representations when we look at impact curves and the way these curves may influence decision-making in terms of treatment. ‘R’ is for remedies – the kinds of things people will buy over the counter. The ‘A’ stands for the prescription approaches to migraine treatment where we look in detail at the options with acute and prophylactic agents. The ‘I’ could stand for information on specific prescription agents and the ‘N’ for notable papers, both of which would not be used during the course of this presentation but would be available on a CD ROM. ‘E’ could stand for everyday practice, where we would normally try to reinforce our messages by highlighting which treatment should be used for which patient when returning to our patient vignettes, as described at the beginning of the presentation.
So, how are we going to end up delivering a better standard of care to the men and women in the street of migraine? Probably by utilizing the whole of the primary healthcare team much more effectively. We have a group in the UK called Migraine in Primary Care Advisers (MIPCA) (Table 2). Over 800 of the 36 000 GPs in the UK are members of this organization. There is also a substantial membership of nurses and community pharmacists. Most people with migraine manage themselves and never go to the doctor about their condition. We need, therefore, to have tentacles out in the community to identify those patients in most need and direct them to the nurses and GPs who can start them on effective therapy.
MIPCA (Migraine in Primary Care Advisors)
In Fig. 1, we illustrate the commonly accepted algorithm for approaching migraine management with the group within MIPCA. We consider that acute migraine attacks should be treated mainly with acute medications, whilst chronic headache conditions would predominantly require prophylaxis. The purpose of the algorithm is to select the most appropriate treatment for the individual patient. Most people have tried simple analgesics before they go to a doctor and we really need to know what drugs they have used, in what dose and when. In real life, 90% or more of patients do not access any form of advice for their migraine but have failed with the ‘over the counter’ agents, ending up taking five or six different therapies without success. These may be similar medications but with different names and colours on the packaging. Our contention is that, if appropriate doses of common analgesics are not enough, it would be appropriate to go straight to a migraine-specific therapy such as a triptan. For those people who need a rapid response or in whom vomiting makes oral medication unsuitable, the nasal and subcutaneous formulations are very useful. We have evidence that, if one triptan fails, then a second will probably work. In real life, when patients are treated in the mild phase of the attack, the success rates for the drugs are much higher than those reported in clinical trials and it is fair to say that the introduction of the triptans over the last decade has revolutionized the lives of many migraineurs. [At this point in the presentation, a sketch of a patient repeatedly going in and out of a pharmacy and getting various different ‘over the counter’ therapeutics was shown in the form of a video clip.] The clear message is that there is increasing frustration as none of the therapeutics worked consistently, prior to the development of migraine-specific agents – the triptans.
Flow diagram of patient management options in the treatment of an acute migraine attack as constructed by the Migraine Primary Care Advisors Group (MIPCA). ∗Patients with less frequent but prolonged disabling attacks may warrant prophylaxis if their migraines are unresponsive to oral 5HT1.
Conclusion
Education is the key to delivering migraine care to the population. We need to motivate specific groups of professionals using innovative formats and also to use the consultation as an educational opportunity, especially with regard to the appropriate use of drugs. We must develop ways for patients to control their migraine, rather than allowing it to control them.
Thank you very much.