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Development of a Comprehensive Treatment Plan in the Primary Care Settting

Development of a Comprehensive Treatment Plan in the Primary Care Settting - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Neurology, Related


2
Goals of Treatment Plan:
ξMigraine-free in 2 hours or
less
ξMigraine-free for 24 hours
ξTolerability of medications
ξTreatment of comorbid
conditions
ξReduced dependance on
treatment at clinic/ urgent
care/ED
Diagnosis of Migraine or
Probable Migraine
Discuss Behaviors and Comorbid Conditions that May Contribute to Headache
ξ Lifestyle factors (e.g., sleep, activity level, skipping meals, stress)
ξ Be aware of possible headaches triggers (e.g., certain foods, cigarette smoke, lighting, other things in
the environment)
ξ Other behaviors and comorbid conditions (e.g., anxiety/depression, sleep apnea, obesity, cigarette
smoking, medication overuse (OTC, prescription, and illicit drugs, especially cannabis)
Additional Migraine Evaluation
1
ξEvaluate severity, frequency, and disability due to migraine (may use MIDAS)
ξEvaluate previous response to treatment (may use mTOQ-6)
ξEvaluate for headache medication overuse (10-15 times per month for > than 3 months)
Appendix B.
Development of a
Comprehensive Migraine
Treatment Plan in the
Primary Care Setting
Wean off overused
medication.
Medication
Overuse Likely?
Follow Up
ξAdvise patient to use a headache diary to track symptoms/severity, possible triggers, treatments used, and
response to treatment
ξIf starting a new preventive medication, arrange for follow up in about 4-6 weeks
ξInstruct patient to contact the clinic for a change in headache pattern or new symptoms, adverse effects of
medications, or if medications are ineffective
3
Indications for
Preventive Therapy:
ξPatient has 3 or more severe
migraine attacks/month that
fail to respond adequately to
treatment
ξMigraine attacks are severe
(impair the patient’s quality
of life)
ξIn any patient who has > 2
headaches/week that require
pharmacologic intervention
1
Consider referral to a headache
specialist if:
ξAtypical features or change
in headache pattern
ξIf headache becomes chronic
(15 or more days/month)
ξExcessive side effects or lack
of effect in at least 2
preventive medications. For
effective treatment of
chronic migraine, patient
must first wean off opioid
medication, if applicable
Select/Modify the Abortive Treatment Plan
2
FIRST LINE: ORAL TRIPTANS
ξSumatriptan 100 mg, rizatriptan 10 mg, zolmitriptan, almotriptan, or eletriptan. To be taken at
the onset of mild pain
ξAdd naproxen sodium 220 to 440 mg oral unless contraindicated
MODIFICATIONS:
ξFor rapidly progressive, severe, or nocturnal migraine, consider sumatriptan subcutaneous
injection 6 mg
ξConsider naratriptan if other triptans are poorly tolerated.
FOR NON-TRIPTAN RESPONDERS:
ξConsider DHE nasal spray
Initiate Preventive Therapy if Indicated
3
Preventive medications are better tolerated when started slowly and escalated to therapeutic doses.
FIRST LINE: Tricyclic antidepressants (e.g., amitriptyline or nortriptyline 25-75 mg/day) OR beta blockers (e.g.,
propranolol 60-120 mg/day)
SECOND LINE: Antiepileptics (e.g., topiramate 50-200 mg/day or divalproex 500-1500 mg/day). Associated
with a high rate of adverse effects including teratogenicity. Female patients should be cautioned to use
adequate birth control.
Change in
headache pattern or
new symptoms?
Further evaluation
required (outside of
guideline scope)
NO
YES
YES
NO
Last Reviewed: 05/2016
Contact CCKM for questions.
Migraine – Adult – Ambulatory/
Emergency Department Clinical
Practice Guideline
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 05/2016CCKM@uwhealth.org