In the first of two articles, C Glover, S Greensmith, A Ranftler, G Donkin, L Jamieson, P Charlesworth, A Turner, and A J Dowson describe how a protocol for pharmacists and primary care practitioners (including optometrists) was designed
In the first of two articles, C Glover, S Greensmith, A Ranftler, G Donkin, L Jamieson, P Charlesworth, A Turner, and A J Dowson describe how a protocol for pharmacists and primary care practitioners (including optometrists) was designed
Headache is a large public health problem, with many sufferers never consulting a GP, remaining undiagnosed and relying on sometimes unproven over-the-counter (OTC) treatments.
Many headache sufferers consult a pharmacist or other primary care provider (such as an optometrist) for care and evidence-based guidelines for the optometrist are published in this two-part series.
Primary care providers are likely to have an enhanced role in headache management in the future, following the switch of many drugs from prescription only (POM) to pharmacy (P) status, and through the introduction of supplementary prescribing for POM drugs.
The main challenges for implementing a headache service are the provision of appropriate training and management algorithms, payment for these enhanced services and auditing of their success.
The Nature of Headaches
Headache is an almost ubiquitous condition, with estimates of 93 per cent of the population experiencing one or more headaches in their lifetimes, and 11 per cent of men and 22 per cent of women having a headache at any point in time.1
The most frequently reported headaches are the benign primary headaches; episodic tension-type headache (TTH), episodic migraine and chronic daily headache (CDH).
CDH comprises daily or near-daily headaches that last for more than four hours on average and are often linked to medication overuse. They usually arise from a primary, episodic headache disorder (migraine or TTH).2 Other headache subtypes are relatively uncommon, affecting <1 per cent of the population.
TTH is estimated to affect 63 per cent of men and 86 per cent of women,1 and is typically a mild-to-moderate bilateral headache associated with fatigue, but with little outward effects on the patient's everyday function.2,3
Migraine affects about 8 per cent of men and 18 per cent of women,4 is typically a moderate-to-severe, unilateral headache associated with nausea, photophobia and numerous co-morbidities (particularly psychiatric illnesses), and is markedly disabling to the patient in terms of reduced ability to perform their daily activities.5,6
CDH affects about 5 per cent of the population,7 and is associated with severe headaches of migraine or TTH-type and chronic fatigue, emotional problems and other co-morbidities.8 It also has a marked impact on patients' ability to function normally.9 About half of CDH sufferers overuse symptomatic headache medications (frequently simple analgesics) on a daily or near-daily basis, and withdrawal symptoms are frequently reported when these medications are withdrawn.10
For such a common condition, it might be expected that effective healthcare services are available to treat the majority of sufferers.
Unfortunately, this is not so, and headache remains under-recognised, under-diagnosed and under-treated in primary care.4,6 In particular, half or more of migraine sufferers do not consult a physician, remain undiagnosed and rely on OTC medications.6 This means that many of them must pass through the doors of community pharmacies for treatment.
There is clearly a need for best practice guidance for primary care providers such as optometrists on how to manage patients with headache.
Recently, evidence-based guidelines for the management of migraine in primary care have been developed in the UK,11 US12 and Canada,13 and for chronic headaches in the UK.14 From the UK guidelines, recommendations have been published to help nurses15 and patients themselves16 manage migraine.
This article describes the development of headache guidelines for pharmacists and primary care providers in the UK.
Methodology
The UK headache guidelines initiative11,14-16 was co-ordinated by the Migraine in Primary Care Advisors (MIPCA: www.mipca.org.uk), a UK-based charity dedicated to the improvement of headache services in primary care.
Pharmacy headache guidelines were developed at a MIPCA meeting of pharmacist, GP and nurse members, in association with the Migraine Action Association (the UK patient support group: www.migraine.org.uk). Drafting of the guidelines involved extensive input from community pharmacists, pharmacy advisers, an optometrist, GPs and nurses.
Research included literature searches accessed via MedLine, monitoring of relevant presentations at international headache and neurology congresses and outputs sourced from the DoH and the Royal Pharmaceutical Society.
Summary of MIPCA guidelines
Principles of care
The MIPCA guidelines for migraine and chronic headache are based on seven principles of care that are generic in scope:
Screening
Patient education and commitment
Differential diagnosis
Assessment of illness severity
Tailoring management to the needs of the individual patient
Pro-active long-term follow up
A team approach to care.
These principles can be used for all headache subtypes, with customisation of the medications prescribed. Figure 1 summarises the principles for the management of migraine.
Screening
Taking a headache history is used to obtain all the information needed during the initial screening procedures. The questions elicit:
The frequency, duration, severity, quality and location of the headache and associated symptoms
The patient's functional impairment during the headache
Medications used and their effectiveness and side effects.
For migraine, the physician looks out for a pattern of episodic, disabling headaches, while for chronic headaches, the pattern is frequent, disabling headaches, with or without a daily or near-daily consumption of headache medications.
Patient education
Part of the screening process is the provision of information to the patient, in the form of oral advice, leaflets, website addresses and details of patient support organisations. Equally important is to elicit their commitment to the care process, explaining and implementing a long-term approach to care, so that the patient can take charge of their own management. This requires effective communication between the patient and the healthcare professional.
Differential diagnosis
UK guidelines for migraine11 and chronic headaches14 propose the use of a simple screening questionnaire for the initial diagnosis of headache subtypes (Figure 2).
The questions are based on diagnostic criteria defined by the International Headache Society (IHS).2 If necessary, further questions can be used to confirm the diagnosis. In using this questionnaire, sinister headaches should always be excluded before asking any of the questions, and another questionnaire can be used to elicit sinister headaches (Figure 3).17
The common headache subtypes are relatively simple to diagnose using this scheme. A high-impact headache (question 1) is indicative of migraine or CDH, whereas a low-impact headache indicates episodic TTH.
Impact can be assessed by simple questioning or by using one of the available impact questionnaires: the migraine disability assessment (MIDAS) questionnaire18 or the headache impact test (HIT).19 Episodic (on <15 days per month), high-impact headaches are indicative of migraine.
However, if the patient has more than 15 days of headache every month, with an average duration of four hours or more, a diagnosis of CDH is indicated (Question 2). For patients with CDH, medication overuse headache (MOH) is indicated if the patient takes symptomatic medications (eg analgesics, ergots or triptans) on two or more days per week (Question 3).
Less than two days of medication use per week indicates that the headache is not due to medication overuse.
Tailoring management to the patient's individual needs
Assessing the severity of the patient's headache is an appropriate way to enable the selection of treatments. To achieve this, the physician assesses headache impact, frequency and duration, pain severity, non-pain symptoms, patient preferences and co-morbidities.
For patients with suspected CDH, additional questions can be asked on the potential abuse of symptomatic medications and the presence of neck stiffness and/or restricted neck movement. If these assessments indicate mild-to-moderate illness severity, conservative management may be appropriate.
However, a moderate-to-severe assessment indicates the need for immediate and comprehensive care. The patient's preferences and co-morbidities are also important in this process. In addition, it is important to have goals for the headache management plan, to have guidelines set up for the success or failure of interventions. These goals cover the relief or prevention of headaches, and the ability to return to normal activities.
Treatments should be provided that are appropriate to the patient's needs, using, wherever possible, therapies that have demonstrated objective evidence of favourable efficacy and safety in randomised, controlled clinical studies.12 Many of these medications are standard OTC medicines and in theory could be supplied by an optometrist.
However, unless the optometrist is familiar with all the contra-indications and interactions, it is recommended that medication should be supplied by the pharmacist. Rescue medications are also widely available and are required for treatment failures or when symptoms break through. The choice of treatments needs to be customised to the specific headache subtype. Simple analgesics are usually effective as acute treatments for episodic TTH, eg paracetamol, aspirin and NSAIDs.
For migraine, analgesic-based therapies may be appropriate as acute treatment for patients with mild-to-moderate intensity attacks, while triptans are usually needed for those with moderate-to-severe attacks.
Faster-acting non-oral nasal spray and subcutaneous injection triptan formulations may be required for patients with particularly severe or unpredictable attacks, and for those with associated nausea and vomiting.
Prophylactic treatment may be required for patients with frequent attacks (= 4 per month), or where acute medications are ineffective or precluded by safety concerns.20 The usual prophylactic medication prescribed is a beta-blocker (most often propranolol). A neuromodulator or an antidepressant may also be effective, although these drugs are not licensed for migraine in the UK.
Behavioural (eg biofeedback, relaxation, stress-reduction and trigger avoidance) and complementary therapies (eg feverfew, magnesium, vitamin B2, butterbur and acupuncture) are also useful as adjunctive prophylaxis for migraine. Unfortunately, the evidence base for CDH treatments is suboptimal and specific therapies cannot be recommended. The strategy for managing CDH is multi-phasic, involving neck exercises for those with a history of head injury or neck stiffness, the withdrawal of any overused medications, introduction of headache prophylaxis and limited acute medications to deal with breakthrough attacks.
Long-term follow up
Proactive, long-term follow up is a key strategy in the management of all headaches. Procedures are implemented to assess the patient's pattern of headaches and their response to therapy.
Headache diaries and impact questionnaires are invaluable in this regard. Alternative therapies are provided for patients who have failed on initial treatments. For this process to be successful, long-term commitment from both the patient and the healthcare provider are required.
The team approach to care
One of the primary aims of MIPCA's new guidelines is to encourage the management of headache in primary care. To make this work, a team approach is recommended, with the primary care physician concentrating on accurate diagnosis and prescription of appropriate treatments.
The practice nurse forms the first point of contact for the patient and conducts routine assessment procedures. Other healthcare professionals (eg pharmacists, opticians and dentists) may identify patients in the general population and direct them into the team (Figure 4). This scheme is now used as the model for the National Service Framework for Long-term Conditions.21
The next article will look at specific management guidelines and protocols of which all optometrists should be aware.
References
1 Rasmussen BK, Jensen R, Schroll M, Olesen J. Epidemiology of headache in a general population: a prevalence study. J Clin Epidemiol, 1991;44:1147-57.
2 Headache Classification Committee of the International Headache Society. The international classification of headache disorders; 2nd Edition. Cephalalgia, 2004;24(Suppl 1):1-160.
3 Rasmussen BK. Migraine and tension-type headache in a general population: psychosocial factors. Int J Epidemiol, 1992;21:1138-43.
4 Steiner TJ, Scher AI, Stewart WF, Kolodner K, Liberman J, Lipton RB. The prevalence and disability burden of adult migraine in England and their relationships to age, gender and ethnicity. Cephalalgia, 2003;23:519-27.
5 Breslau N, Rasmussen BK. The impact of migraine: Epidemiology, risk factors, and co-morbidities. Neurology, 2001;56 (Suppl 1):4-12.
6 Lipton RB, Goadsby PJ, Sawyer JPC, Blakeborough P, Stewart WF. Migraine: diagnosis and assessment of disability. Rev Contemp Pharmacother, 2000;11:63-73.
7 Castillo J, Muoz P, Guitera V, Pascual J. Epidemiology of chronic daily headache in the general population. Headache, 1999;39:190-6.
8 Tepper SJ, Rapoport AM, Sheftell FD, Bigal ME. Chronic daily headache - an update. Headache Care, 2004;1:233-45.
9 Bigal ME, Rapoport AM, Lipton RB, Tepper SJ, Sheftell FD. Assessment of migraine disability using the migraine disability assessment (MIDAS) questionnaire: a comparison of chronic migraine with episodic migraine. Headache, 2003;43:336-42.
10 Zwart J-A, Dyb G, Hagen K, Svebak S, Holmen J. Analgesic use: A predictor of chronic pain and medication overuse headache: The Head-HUNT Study. Neurology, 2003;61:160-4.
11 Dowson AJ, Lipscombe S, Sender J, Rees T, Watson D. New guidelines for the management of migraine in primary care. Curr Med Res Opin, 2002;18:414-39.
12 Silberstein SD, for the US Headache Consortium. Practice parameter: evidence-based guidelines for migraine headache (an evidence-based review). Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology, 2000; 55:754-62.
13 Pryse-Phillips WEM, Dodick DW, Edmeads JG, Gawel MJ, Nelson RF, Purdy RA et al. Guidelines for the diagnosis and management of migraine in clinical practice. Can Med Assoc J, 1997;156:1273-87.
14 Dowson AJ, Bradford S, Lipscombe S, Rees T, Sender J, Watson D et al. Managing chronic headaches in the clinic. Int J Clin Pract, 2004;58:1142-51.
15 MacBean H, Leech J, Dungay J, Dowson AJ. New guidelines for the management of migraine by nurses. Practice Nursing, 2004;15:346-50.
16 Turner A, Lipscombe S, Laughey WF, Rees T, Few A, Dowson AJ. New guidelines and questionnaires to help patients manage their migraine. Headache Care, 2005;2: in press.
17 Dowson AJ, Sender J, Lipscombe S, Cady RK, Tepper SJ, Smith R et al. Establishing principles of migraine management in primary care. Int J Clin Pract, 2003;57:492-507.
18. Stewart WF, Lipton RB, Dowson AJ, Sawyer J. Development and testing of the Migraine Disability Assessment (MIDAS) Questionnaire to assess headache-related disability. Neurology, 2001;56 (Suppl 1):S20-28.
19 Kosinski M, Bayliss MS, Bjorner JB, Ware JE Jr, Garber WH, Batenhorst A et al. A six-item short-form survey for measuring headache impact: the HIT-6. Qual Life Res, 2003;12:963-74.
20 Tepper SJ, D'Amico D, Baos V, Blakeborough P, Dowson AJ. Guidelines for prescribing prophylactic medications for migraine: a survey among headache specialist physicians in different countries. Headache Care, 2004;1:267-72.
21 Department of Health. The National Service Framework for Long-term Conditions. www.dh.gov.uk/longtermnsf, 2005.
* C Glover is a consultant for Glovers Healthcare; S Greensmith is community pharmacy facilitator, Guildford & Waverley PCT; A Ranftler is community pharmacist, Cheshire; G Donkin is lead prescribing support pharmacist, Surrey Heath and Woking PCT; P Charlesworth is an optometrist, College of Optometrists councillor and director of Replay Learning; A Turner is director of the Migraine Action Association; AJ Dowson is director of King's Headache Service, King's College Hospital, London
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Headache is a large public health problem, with many sufferers never consulting a GP, remaining undiagnosed and relying on sometimes unproven over-the-counter (OTC) treatments.
Many headache sufferers consult a pharmacist or other primary care provider (such as an optometrist) for care and evidence-based guidelines for the optometrist are published in this two-part series.
Primary care providers are likely to have an enhanced role in headache management in the future, following the switch of many drugs from prescription only (POM) to pharmacy (P) status, and through the introduction of supplementary prescribing for POM drugs.
The main challenges for implementing a headache service are the provision of appropriate training and management algorithms, payment for these enhanced services and auditing of their success.
The Nature of Headaches
Headache is an almost ubiquitous condition, with estimates of 93 per cent of the population experiencing one or more headaches in their lifetimes, and 11 per cent of men and 22 per cent of women having a headache at any point in time.1
The most frequently reported headaches are the benign primary headaches; episodic tension-type headache (TTH), episodic migraine and chronic daily headache (CDH).
CDH comprises daily or near-daily headaches that last for more than four hours on average and are often linked to medication overuse. They usually arise from a primary, episodic headache disorder (migraine or TTH).2 Other headache subtypes are relatively uncommon, affecting <1 per cent of the population.
TTH is estimated to affect 63 per cent of men and 86 per cent of women,1 and is typically a mild-to-moderate bilateral headache associated with fatigue, but with little outward effects on the patient's everyday function.2,3
Migraine affects about 8 per cent of men and 18 per cent of women,4 is typically a moderate-to-severe, unilateral headache associated with nausea, photophobia and numerous co-morbidities (particularly psychiatric illnesses), and is markedly disabling to the patient in terms of reduced ability to perform their daily activities.5,6
CDH affects about 5 per cent of the population,7 and is associated with severe headaches of migraine or TTH-type and chronic fatigue, emotional problems and other co-morbidities.8 It also has a marked impact on patients' ability to function normally.9 About half of CDH sufferers overuse symptomatic headache medications (frequently simple analgesics) on a daily or near-daily basis, and withdrawal symptoms are frequently reported when these medications are withdrawn.10
For such a common condition, it might be expected that effective healthcare services are available to treat the majority of sufferers.
Unfortunately, this is not so, and headache remains under-recognised, under-diagnosed and under-treated in primary care.4,6 In particular, half or more of migraine sufferers do not consult a physician, remain undiagnosed and rely on OTC medications.6 This means that many of them must pass through the doors of community pharmacies for treatment.
There is clearly a need for best practice guidance for primary care providers such as optometrists on how to manage patients with headache.
Recently, evidence-based guidelines for the management of migraine in primary care have been developed in the UK,11 US12 and Canada,13 and for chronic headaches in the UK.14 From the UK guidelines, recommendations have been published to help nurses15 and patients themselves16 manage migraine.
This article describes the development of headache guidelines for pharmacists and primary care providers in the UK.
Methodology
The UK headache guidelines initiative11,14-16 was co-ordinated by the Migraine in Primary Care Advisors (MIPCA: www.mipca.org.uk), a UK-based charity dedicated to the improvement of headache services in primary care.
Pharmacy headache guidelines were developed at a MIPCA meeting of pharmacist, GP and nurse members, in association with the Migraine Action Association (the UK patient support group: www.migraine.org.uk). Drafting of the guidelines involved extensive input from community pharmacists, pharmacy advisers, an optometrist, GPs and nurses.
Research included literature searches accessed via MedLine, monitoring of relevant presentations at international headache and neurology congresses and outputs sourced from the DoH and the Royal Pharmaceutical Society.
Summary of MIPCA guidelines
Principles of care
The MIPCA guidelines for migraine and chronic headache are based on seven principles of care that are generic in scope:
Screening
Patient education and commitment
Differential diagnosis
Assessment of illness severity
Tailoring management to the needs of the individual patient
Pro-active long-term follow up
A team approach to care.
These principles can be used for all headache subtypes, with customisation of the medications prescribed. Figure 1 summarises the principles for the management of migraine.
Screening
Taking a headache history is used to obtain all the information needed during the initial screening procedures. The questions elicit:
The frequency, duration, severity, quality and location of the headache and associated symptoms
The patient's functional impairment during the headache
Medications used and their effectiveness and side effects.
For migraine, the physician looks out for a pattern of episodic, disabling headaches, while for chronic headaches, the pattern is frequent, disabling headaches, with or without a daily or near-daily consumption of headache medications.
Patient education
Part of the screening process is the provision of information to the patient, in the form of oral advice, leaflets, website addresses and details of patient support organisations. Equally important is to elicit their commitment to the care process, explaining and implementing a long-term approach to care, so that the patient can take charge of their own management. This requires effective communication between the patient and the healthcare professional.
Differential diagnosis
UK guidelines for migraine11 and chronic headaches14 propose the use of a simple screening questionnaire for the initial diagnosis of headache subtypes (Figure 2).
The questions are based on diagnostic criteria defined by the International Headache Society (IHS).2 If necessary, further questions can be used to confirm the diagnosis. In using this questionnaire, sinister headaches should always be excluded before asking any of the questions, and another questionnaire can be used to elicit sinister headaches (Figure 3).17
The common headache subtypes are relatively simple to diagnose using this scheme. A high-impact headache (question 1) is indicative of migraine or CDH, whereas a low-impact headache indicates episodic TTH.
Impact can be assessed by simple questioning or by using one of the available impact questionnaires: the migraine disability assessment (MIDAS) questionnaire18 or the headache impact test (HIT).19 Episodic (on <15 days per month), high-impact headaches are indicative of migraine.
However, if the patient has more than 15 days of headache every month, with an average duration of four hours or more, a diagnosis of CDH is indicated (Question 2). For patients with CDH, medication overuse headache (MOH) is indicated if the patient takes symptomatic medications (eg analgesics, ergots or triptans) on two or more days per week (Question 3).
Less than two days of medication use per week indicates that the headache is not due to medication overuse.
Tailoring management to the patient's individual needs
Assessing the severity of the patient's headache is an appropriate way to enable the selection of treatments. To achieve this, the physician assesses headache impact, frequency and duration, pain severity, non-pain symptoms, patient preferences and co-morbidities.
For patients with suspected CDH, additional questions can be asked on the potential abuse of symptomatic medications and the presence of neck stiffness and/or restricted neck movement. If these assessments indicate mild-to-moderate illness severity, conservative management may be appropriate.
However, a moderate-to-severe assessment indicates the need for immediate and comprehensive care. The patient's preferences and co-morbidities are also important in this process. In addition, it is important to have goals for the headache management plan, to have guidelines set up for the success or failure of interventions. These goals cover the relief or prevention of headaches, and the ability to return to normal activities.
Treatments should be provided that are appropriate to the patient's needs, using, wherever possible, therapies that have demonstrated objective evidence of favourable efficacy and safety in randomised, controlled clinical studies.12 Many of these medications are standard OTC medicines and in theory could be supplied by an optometrist.
However, unless the optometrist is familiar with all the contra-indications and interactions, it is recommended that medication should be supplied by the pharmacist. Rescue medications are also widely available and are required for treatment failures or when symptoms break through. The choice of treatments needs to be customised to the specific headache subtype. Simple analgesics are usually effective as acute treatments for episodic TTH, eg paracetamol, aspirin and NSAIDs.
For migraine, analgesic-based therapies may be appropriate as acute treatment for patients with mild-to-moderate intensity attacks, while triptans are usually needed for those with moderate-to-severe attacks.
Faster-acting non-oral nasal spray and subcutaneous injection triptan formulations may be required for patients with particularly severe or unpredictable attacks, and for those with associated nausea and vomiting.
Prophylactic treatment may be required for patients with frequent attacks (= 4 per month), or where acute medications are ineffective or precluded by safety concerns.20 The usual prophylactic medication prescribed is a beta-blocker (most often propranolol). A neuromodulator or an antidepressant may also be effective, although these drugs are not licensed for migraine in the UK.
Behavioural (eg biofeedback, relaxation, stress-reduction and trigger avoidance) and complementary therapies (eg feverfew, magnesium, vitamin B2, butterbur and acupuncture) are also useful as adjunctive prophylaxis for migraine. Unfortunately, the evidence base for CDH treatments is suboptimal and specific therapies cannot be recommended. The strategy for managing CDH is multi-phasic, involving neck exercises for those with a history of head injury or neck stiffness, the withdrawal of any overused medications, introduction of headache prophylaxis and limited acute medications to deal with breakthrough attacks.
Long-term follow up
Proactive, long-term follow up is a key strategy in the management of all headaches. Procedures are implemented to assess the patient's pattern of headaches and their response to therapy.
Headache diaries and impact questionnaires are invaluable in this regard. Alternative therapies are provided for patients who have failed on initial treatments. For this process to be successful, long-term commitment from both the patient and the healthcare provider are required.
The team approach to care
One of the primary aims of MIPCA's new guidelines is to encourage the management of headache in primary care. To make this work, a team approach is recommended, with the primary care physician concentrating on accurate diagnosis and prescription of appropriate treatments.
The practice nurse forms the first point of contact for the patient and conducts routine assessment procedures. Other healthcare professionals (eg pharmacists, opticians and dentists) may identify patients in the general population and direct them into the team (Figure 4). This scheme is now used as the model for the National Service Framework for Long-term Conditions.21
The next article will look at specific management guidelines and protocols of which all optometrists should be aware.
References
1 Rasmussen BK, Jensen R, Schroll M, Olesen J. Epidemiology of headache in a general population: a prevalence study. J Clin Epidemiol, 1991;44:1147-57.
2 Headache Classification Committee of the International Headache Society. The international classification of headache disorders; 2nd Edition. Cephalalgia, 2004;24(Suppl 1):1-160.
3 Rasmussen BK. Migraine and tension-type headache in a general population: psychosocial factors. Int J Epidemiol, 1992;21:1138-43.
4 Steiner TJ, Scher AI, Stewart WF, Kolodner K, Liberman J, Lipton RB. The prevalence and disability burden of adult migraine in England and their relationships to age, gender and ethnicity. Cephalalgia, 2003;23:519-27.
5 Breslau N, Rasmussen BK. The impact of migraine: Epidemiology, risk factors, and co-morbidities. Neurology, 2001;56 (Suppl 1):4-12.
6 Lipton RB, Goadsby PJ, Sawyer JPC, Blakeborough P, Stewart WF. Migraine: diagnosis and assessment of disability. Rev Contemp Pharmacother, 2000;11:63-73.
7 Castillo J, Muoz P, Guitera V, Pascual J. Epidemiology of chronic daily headache in the general population. Headache, 1999;39:190-6.
8 Tepper SJ, Rapoport AM, Sheftell FD, Bigal ME. Chronic daily headache - an update. Headache Care, 2004;1:233-45.
9 Bigal ME, Rapoport AM, Lipton RB, Tepper SJ, Sheftell FD. Assessment of migraine disability using the migraine disability assessment (MIDAS) questionnaire: a comparison of chronic migraine with episodic migraine. Headache, 2003;43:336-42.
10 Zwart J-A, Dyb G, Hagen K, Svebak S, Holmen J. Analgesic use: A predictor of chronic pain and medication overuse headache: The Head-HUNT Study. Neurology, 2003;61:160-4.
11 Dowson AJ, Lipscombe S, Sender J, Rees T, Watson D. New guidelines for the management of migraine in primary care. Curr Med Res Opin, 2002;18:414-39.
12 Silberstein SD, for the US Headache Consortium. Practice parameter: evidence-based guidelines for migraine headache (an evidence-based review). Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology, 2000; 55:754-62.
13 Pryse-Phillips WEM, Dodick DW, Edmeads JG, Gawel MJ, Nelson RF, Purdy RA et al. Guidelines for the diagnosis and management of migraine in clinical practice. Can Med Assoc J, 1997;156:1273-87.
14 Dowson AJ, Bradford S, Lipscombe S, Rees T, Sender J, Watson D et al. Managing chronic headaches in the clinic. Int J Clin Pract, 2004;58:1142-51.
15 MacBean H, Leech J, Dungay J, Dowson AJ. New guidelines for the management of migraine by nurses. Practice Nursing, 2004;15:346-50.
16 Turner A, Lipscombe S, Laughey WF, Rees T, Few A, Dowson AJ. New guidelines and questionnaires to help patients manage their migraine. Headache Care, 2005;2: in press.
17 Dowson AJ, Sender J, Lipscombe S, Cady RK, Tepper SJ, Smith R et al. Establishing principles of migraine management in primary care. Int J Clin Pract, 2003;57:492-507.
18. Stewart WF, Lipton RB, Dowson AJ, Sawyer J. Development and testing of the Migraine Disability Assessment (MIDAS) Questionnaire to assess headache-related disability. Neurology, 2001;56 (Suppl 1):S20-28.
19 Kosinski M, Bayliss MS, Bjorner JB, Ware JE Jr, Garber WH, Batenhorst A et al. A six-item short-form survey for measuring headache impact: the HIT-6. Qual Life Res, 2003;12:963-74.
20 Tepper SJ, D'Amico D, Baos V, Blakeborough P, Dowson AJ. Guidelines for prescribing prophylactic medications for migraine: a survey among headache specialist physicians in different countries. Headache Care, 2004;1:267-72.
21 Department of Health. The National Service Framework for Long-term Conditions. www.dh.gov.uk/longtermnsf, 2005.
* C Glover is a consultant for Glovers Healthcare; S Greensmith is community pharmacy facilitator, Guildford & Waverley PCT; A Ranftler is community pharmacist, Cheshire; G Donkin is lead prescribing support pharmacist, Surrey Heath and Woking PCT; P Charlesworth is an optometrist, College of Optometrists councillor and director of Replay Learning; A Turner is director of the Migraine Action Association; AJ Dowson is director of King's Headache Service, King's College Hospital, London