7. Appropriate safety netting eg 999 if weakness,collapse or call GP/111 if paresthesia, visual disturbance associated with headache

1.  Data Gathering, interpretation and diagnosis.

• Explores symptoms and takes a thorough history about the migraine including: onsite, onset, radiation, character of headaches.

• Pattern of headache eg relationship with periods, early mornings, symptoms worse on bending or sneezing

• Frequency, duration, triggers, relieving factors – analgesia used, effect, rest, associated features, e.g. visual disturbances, body weakness, vomiting, sensory or motor deficits, sensitivity to sounds or lights, aura

• Explores if this headache is different to usual migraine i.e. differential diagnoses are excluded such as cluster headache (watery eyes?), tension type headache (stress? distribution of headache? character? sleep), medication overuse headache

• Exclude the headache red flags: SOL, Meningitis, Head Injury, Giant cell arteritis, Stroke.
  Differentials: Eye Strain, Stress, Medication-over use (codeine, NSAIDs, PCM), medication side-effect, neck pain

• Asks about impact of the migraine on work / sociallife, explore how they have coped with their symptoms.

• Elicits family history of migraine.

• Ask about medication use including analgesia and contraception.

• In clinic; asks to examine fundoscopy, BP and neurological examination including gait, temporal arteritis, neck for muscle movements/spasm.

2. Clinical Management and managing medical complexity

1. Explains the diagnosis of recurrent attacks of migraine

2. Addresses patient concerns/agenda before presenting doctor’s clinical agenda.

3. Medication: depending on clinical presentation and history, discuss meds and shared agreement with patient

• Manage Acute: Offers a suitable triptan – e.g. sumatriptan 50-100mg orally +/- paracetamol or an NSAID +/- an antiemetic (metoclopramide 10mg or prochlorperazine 10mg). Discusses starting treatment for migraine prophylaxis – eg a beta blocker – if not better after arrangefollow up within 2–8 weeks (follow-up)

 - Mention side effects of tryptans: Side effects include sensations of tingling, heat, heaviness, pressure or tightness in any part of body, including the chest. To stop and speak to doctor if side effects are too intense

• Treat prophylactically: Propranolol - Initially 80 mg daily (either 40 mg BD or 80 mg modified-release once a day) OR Amitriptyline 25–75 mg at night OR Topiramate - Initially 25 mg at night for 1 week, then increase in steps of 25 mg at weekly intervals

 - For topiramate, explains risks of foetal abnormalities & the need for regular contraception if she becomes sexually active

4. Discuss triggers; If stress is a likely trigger, offers advice on managing stress. Offers lifestyle advice when relevant; hydration, nutrition, reduce caffeine/alcohol, increase exercise/walks.

5. Discusses headache diary with the patient, to be done for 4 to 8 weeks to assess treatment & identify any other triggers.

6. If relevant, discuss contraception and medication over use. Offer sick note if relevant.

8. Follow up within 4 weeks to assess treatment, titrate the dose of medications, review headache diary, offer support.

9. PIL: The Migraine Trust, patient info, British Association for the Study of Headache (BASH), Lifting the Burden.

3. Relating to Others

• Allows patient’s ‘golden minute’ – may elicit stress or impact

• Creates rapport, responds appropriately to ICE.

• Pick up on patient cues and follow through or responds appropriately.

• ddresses patient’sidea, concerns/agenda

• Elicits social history and impact of headaches.

• Empathetic towards the patient’s social situation or impact of headaches.

• Explains medical information empathetically without alarming the patient

• Clear, concise explanations of risks of medication, and when discussing red flag symptoms for safety netting.

• Agrees a shared management plan.

• Empower the patient to try headache diary and try lifestyle changes

Other Considerations

1.  Contraception CHC and Migraines. 

• Complex to manage; if needing to stop CHC, advise on other forms of contraception

• As per FRSH guidelines:

 - absolute contraindication (UKMEC 4) if migraine with aura

 - Relative contraindication (UKMEC 2-3) depending on if initiative or continuing. Discuss with patients, stop if risk outweighs the benefits.

2. Medication Overuse Headches.

• Common in people with migraine and can be avoided by restriction of acute medication to a maximum of 2 days per week.

• Can occur with 15 or more days per month use of simple analgesics (such as aspirin, ibuprofen and paracetamol) or 10 or more days use per month of triptans or combination analgesics.

• Difficult to manage; as patient would not want to stop medications.

• Explain: it can exacerbate pre-existing primary headache disorder, withdrawal is mainstay

• Advise to stop taking all overused acute headache medications for at least 1 month, to stop drugs such as triptans, ergotamines, and simple analgesics abruptly, to keep a headache diary.

• Advise there may be initial worsening of headache and other withdrawal symptoms for 1–2 weeks during and after drug withdrawal, so the timing of withdrawal should be planned according to the person's lifestyle and commitments. Recovery may continue for 2–3 months.

• Review and reassess the underlying headache disorder 4–8 weeks after the start of drug withdrawal, and manage appropriately