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FREDERICK G. FREITAG, D.O. ASSOCIATE DIRECTOR DIAMOND HEADACHE CLINIC

FREDERICK G. FREITAG, D.O. ASSOCIATE DIRECTOR DIAMOND HEADACHE CLINIC ASSOCIATE CLINICAL PROFESSOR OF FAMILY MEDICINE FINCH UNIVERSITY OF HEALTH SCIENCES/CHICAGO MEDICAL SCHOOL CLINICAL ASSOCIATE MIDWESTERN UNIVERSITY CHICAGO COLLEGE OF OSTEOPATHIC MEDICINE.

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FREDERICK G. FREITAG, D.O. ASSOCIATE DIRECTOR DIAMOND HEADACHE CLINIC

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  1. FREDERICK G. FREITAG, D.O. ASSOCIATE DIRECTOR DIAMOND HEADACHE CLINIC ASSOCIATE CLINICAL PROFESSOR OF FAMILY MEDICINE FINCH UNIVERSITY OF HEALTH SCIENCES/CHICAGO MEDICAL SCHOOL CLINICAL ASSOCIATE MIDWESTERN UNIVERSITY CHICAGO COLLEGE OF OSTEOPATHIC MEDICINE

  2. THE NAME GAME: HEADACHE GUIDELINES FOR PRIMARY CARE

  3. WHY DO WE NEED GUIDELINES? PROVIDE GUIDANCE REGARDING TREATMENT OPTIONS REFERENCE SOURCE SUPPORT THE CLINICAL DECISION WE USE TO PATIENTS, THE PUBLIC, INSURANCE INDUSTRY, MEDICOLEGAL ISSUES

  4. WHAT HAS BEEN THE NATURAL HISTORY OF GUIDELINES? NHF-1st edition 1996, 3rdedition 2001 Canadian-1998 Consortium-2000 Primary Care Network-2001

  5. WHAT HAS BEEN THE NATURAL HISTORY OF GUIDELINES? CONSORTIUM-Evidence-Based On Literature With Consensus On Issues Where No Evidence Available NHF- Consensus Based On Evidence In Literature + Consortium Guidelines CANADIAN-Consensus Based On Evidence In Literature PRIMARY CARE NETWORK-Consensus Based On On Evidence In Literature +Above Guidelines

  6. TOPICS NHF CAN US PCN DX + - - + TESTING + - + + NON-PHARM + + + + MIGRAINE + + + + TENSION + - - +/- CLUSTER + - - - OTHER REFERRAL - - <16 Pregnant

  7. HEADACHE DIAGNOSIS IHS- Common starting point for all Additional Guidance Regarding Key Points In History- Canadian: Expansion on IHS Criteria, More Key Question+“Red Flags” PCN:Key Questions, HA Impact, “Comfort Signs” NHF: Questions for History, “Red Flags”

  8. HEADACHE DIAGNOSIS Diagnostic testing: EEG: Both The AAN In The Consortium And Canadian Agree: No Value In Migraine Not Addressed By NHF or PCN

  9. HEADACHE DIAGNOSIS Diagnostic testing: MRI/CT MRI Preferential: PCN, NHF For Posterior Fossa and Exertional Headache, Consortium if White Matter Lesion or Venous Anomalies CT Preferential: NHF-Subarachnoid Hemorrhage Either: NHF, PCN, Canadian, Consortium In General Agreement If: Abnormal Exam, Accelerating Headaches, Etc.,

  10. HEADACHE DIAGNOSIS Diagnostic testing: LP Only Canadian and NHF Both Agree: If + Neuro Exam And Certain Diagnoses Are Suspect (eq Infection, Hemorrhage, Pressure Changes) Diagnostic Testing: Blood Studies Only NHF: Disease Specific Suspicion Indications. Only NHF addresses Thermography and TCD Both Appraised As Not With Value.

  11. Migraine treatment All the Guidelines provide General Caveats Regarding Management of Migraine Both on the Acute and The Preventative Basis Phrase specifics vary but In General These are Similar and none Our Contradictory to the Other Most Extensive Discussion In Consortium

  12. Acute Migraine Treatment NHF: Guidelines on Frequency of Use Limited Specific Guidance in 3rd Ed. From Evidence and Consensus Canadian: Treatment Stratified based headache severity additional guidance on Scientific Evidence N.B. only Sumatriptan available at time of writing Consortium: Guidance on Frequency of Use Guidance based on Level of Evidence Limited other specific guidance based on Consensus PCN: Guidance based on Migraine Phase Limited Other Specific Guidance

  13. Acute Migraine Treatment General Agreement on Medication Choices General Agreement on Frequency of Use between Consortium and NHF. Minimally addressed in PCN and Canadian General Agreement on Place of Triptans Most Variability May Be Due to Stratification Issues + More Recent Data

  14. Acute Migraine Treatment General Agreement on OTC’s with Most significant Difference Over: Aspirin+Acetaminophen+Caffeine Methodological Issues (Evidence Over Consensus and Vice Versa) Differences among Consensus Panels OTC vs. Rx NSAIDs No Clear Differentiation Between OTC strength NSAIDs and RX Strength NSAIDs

  15. Migraine Preventative Medication NHF-Consensus, Additional guidance from Consortium Grading, Non-Rx agents in 3rd edition Canadian: Consensus with Evidence Grading, Canadian only drugs included, Lacks more recent agents, Some practical pointers in text Consortium: Evidence Based, non Rx agents, Comparative Info available PCN: Consensus that agrees with Consortium, Very limited discussion of Prevention, Duration of Trial: Consortium>NHF=?Canadian(several months)>PCN

  16. Migraine Preventative Medication General Agreement Between Guidelines at First Tier Therapy Consortium Provides Most Extensive Recommendations Beyond First Tier, 3rd Ed. Of NHF Similar All Provide Discussion of Non-Rx agents Only Consortium in Consensus caveats provides extensive advice on “ Which agent in Whom” When To Use Based On Multiple Factors Headache Frequency Only At Level Of Rebound

  17. Non Pharmacological Treatment Education: Triggers/Counter Measures: NHF, Canadian, PCN all similar but with variable item specific emphasis Biofeedback: Consortium, PCN, Canadian, NHF agree Cognitive Behavioral: Canadian, Consortium, PCN agree Psychotherapy: NHF and Canadian agree if Psychiatric Illness

  18. Non Pharmacological Treatment Nerve Blocks: limited discussion only in Canadian and NHF Manual Therapies: NHF, Canadian and Consortium agree that lack of evidence to recommend use. PCN + with caveat. Acupuncture: Consortium, NHF and PCN limited + advice. TENS: Canadian and Consortium limited + advice, NHF not well studied

  19. Non Pharmacological Treatment Caffeine- None address Limits! Multiple other therapies addressed in one or the other of Guidelines None get “Rave Reviews”

  20. Other Headache Situations Only NHF Addresses Tension Type Headache and Cluster Headache Treatment Issues To Any Extent Limited Discussion in PCN Limited discussion in PCN on Chronic Migraine+ Assorted “Synonyms” Limited Discussion on Special Populations in PCN and Consortium Limited Discussion on Referral or Specialty Care in NHF and PCN

  21. Summary Despite Evolutionary Differences All The Available Guidelines Are in General Agreement Differences in Style of Management Advice None Provide A Clear Treatment Algorithm-Acute, Preventative, Non Pharmacologic, Referral Only NHF addresses Treatments for Tension Type Headache and Cluster Headache

  22. Where Do We Go From Here? How Do We Make Them Work? Continue Dissemination Educational Programs Built Around Them Assessment Methods To Determine If they Improve Care Reduce costs ( medical and lost time) Prevent Intractability

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