Migraine Disorders: Rees T

Dowson AJ, Lipscombe S, Sender J, Rees T, Watson D, Anonymous00006. · King's Headache Service, King's College Hospital, London, UK. · Curr Med Res Opin. · Pubmed #12487508 No free full text.

Abstract: Despite repeated initiatives over the past decade, migraine remains under-recognised, under-diagnosed and under-treated in everyday clinical practice. The Migraine in Primary Care Advisors (MIPCA) group has produced new guidelines for migraine management to attempt to rectify this situation. MIPCA is a group of physicians, nurses, pharmacists and other healthcare professionals dedicated to the improvement of headache management in primary care, who have also worked closely with the Migraine Action Association (the UK patients' group) in the development of these guidelines. The principles of the new MIPCA guidelines are: To arrange specific consultations for headache. To institute a system of detailed history taking, patient education and buy-in at the outset of the consultation. To utilise a new screening algorithm for the differential diagnosis of headache, which can be confirmed by further questioning, if necessary. To institute a process of management that is individualised for each patient, using a new algorithm. Assessing the impact on the patient's daily life is a key aspect of diagnosis and management. To prescribe only treatments that have objective evidence of favourable efficacy and tolerability. To utilise prospective follow-up procedures to monitor the success of treatment. To organise a team approach to headache management in primary care.

Dowson AJ, Bradford S, Lipscombe S, Rees T, Sender J, Watson D, Wells C. · King's College Hospital, London, UK. · Int J Clin Pract. · Pubmed #15646412 No free full text.

Abstract: Chronic daily headache (CDH), which is often linked to a history of migraine, tension-type headache and the abuse of headache medications, and cluster headache are the best known of the chronic headaches. These headaches may not be well recognised or well treated in primary care. This article outlines the development of management algorithms for these headache subtypes, designed for use by the primary care physician with an interest in headache. Principles of care for chronic headaches include implementation of screening procedures, differential diagnosis, tailoring of management to the individual's needs, proactive follow-up and a team approach to care. These principles can be customised to the headache subtype by the selection of appropriate therapies. The optimal treatments for CDH include physical therapy to the neck if there is any stiffness there, withdrawal of abused medications and treatment of any subsequent withdrawal symptoms and headache prophylaxis, together with the provision of acute medications as rescue therapy. Optimal treatments for cluster headache include short- and long-term prophylaxis to prevent the headaches developing and acute medications for use as rescue. If treatment is ineffective, alternative medications can be provided at follow-up, with the possibility of referral for refractory patients.

Dowson A, Mullen MJ, Peatfield R, Muir K, Khan AA, Wells C, Lipscombe SL, Rees T, De Giovanni JV, Morrison WL, Hildick-Smith D, Elrington G, Hillis WS, Malik IS, Rickards A. · The King's Headache Service, King's College Hospital, Denmark Hill, London SE5 9RS, UK. · Circulation. · Pubmed #18316488 links to  free full text

Abstract: BACKGROUND: Patent foramen ovale (PFO) is prevalent in patients with migraine with aura. Observational studies show that PFO closure resulted in migraine cessation or improvement in approximately 80% of such patients. We investigated the effects of PFO closure for migraine in a randomized, double-blind, sham-controlled trial. METHODS AND RESULTS: Patients who suffered from migraine with aura, experienced frequent migraine attacks, had previously failed > or = 2 classes of prophylactic treatments, and had moderate or large right-to-left shunts consistent with the presence of a PFO were randomized to transcatheter PFO closure with the STARFlex implant or to a sham procedure. Patients were followed up for 6 months. The primary efficacy end point was cessation of migraine headache 91 to 180 days after the procedure. In total, 163 of 432 patients (38%) had right-to-left shunts consistent with a moderate or large PFO. One hundred forty-seven patients were randomized. No significant difference was observed in the primary end point of migraine headache cessation between implant and sham groups (3 of 74 versus 3 of 73, respectively; P=0.51). Secondary end points also were not achieved. On exploratory analysis, excluding 2 outliers, the implant group demonstrated a greater reduction in total migraine headache days (P=0.027). As expected, the implant arm experienced more procedural serious adverse events. All events were transient. CONCLUSIONS: This trial confirmed the high prevalence of right-to-left shunts in patients with migraine with aura. Although no significant effect was found for primary or secondary end points, the exploratory analysis supports further investigation. The robust design of this study has served as the model for larger trials that are currently underway in the United States and Europe.

Williams D, Cahill T, Dowson A, Fearon H, Lipscombe S, O'Sullivan E, Rees T, Strang C, Valori A, Watson D. · The Willows Surgery, Barry, South Glamorgan, Wales, UK. · Curr Med Res Opin. · Pubmed #11999139 No free full text.

Abstract: A retrospective audit was carried out to investigate triptan usage over a period of one year among 360 adult patients with migraine in nine GP practices in the UK and the Republic of Ireland. Data from patient records were analysed, in conjunction with replies to a questionnaire about patients' perceptions of their migraine and its treatment. The majority of patients included in the audit were women (83%), and most patients (81%) were aged between 35 and 64 years. Most patients in the audit population (60%) were in the lowest band of triptan usage (1-36 tablets prescribed over 12 months); 7% had moderate usage (37-53 tablets). A minority of patients appeared to be taking triptans in higher quantities: about 15% of patients had been prescribed 54-94 triptan tablets over a year, 9% had received prescriptions for 95-149 tablets and 7% had received prescriptions for 150 or more tablets. These results indicated that some migraine patients were using triptans at higher than expected rates, and suggested that some patients might have been using their prescribed triptans inappropriately to treat a headache that they incorrectly perceived as migraine (e.g. chronic daily headache). Analyses were carried out to identify predictors of high usage. Predictors identified included the use of several other (non-triptan) medications to treat conditions other than migraine, one triptan dose being reported as sufficient to treat an attack, patient's perception of all headaches as migraine and lack of concern about taking too much medication. Patients identified as using triptans at a higher than expected rate can be called in for review of migraine diagnosis, identification of possible causes of any increased frequency of attacks, and investigation of suspected non-migrainous headaches, such as chronic daily headache and medication-induced headaches. For GPs, such actions would help achieve and maintain a high standard of care for their migraine patients, thus helping to contribute towards meeting the demands of the clinical governance agenda. Audit of triptan usage may also offer financial benefits for the practice, since helping patients to avoid the inappropriate use of triptans could lead to reductions in the overall costs of triptan prescribing within the practice. The high usage predictors could be developed into a checklist of potential indicators for GPs to identify patients who may become high users if prescribed triptans and who might require closer monitoring. We recommend that patients identified as having a potential for high usage should be routinely reviewed, every 3-6 months, to ensure that they are using triptans appropriately to treat migraine. Although triptans are generally safe and well tolerated, unnecessary use of any medication should be avoided.

Watson D, Lipscombe S, Rees T. · No affiliation provided · Br J Gen Pract. · Pubmed #12830572 links to  free full text

This publication has no abstract.