migraines and other headaches at work dr anna andreou · 2020-04-28 · migraines and other...
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Dr Anna Andreou
The Headache Centre
Guy’s & St Thomas's NHS Foundation Trust &
Wolfson Centre, King’s College London
Migraines and Other Headaches at Work
Headache CentreGeorge Cruikshank
(1792–1878)
• Headache: Pain in the region of the head and neck
• Where is the pain felt: Meninges and extracranial structures
What is a Headache?
Occipital
• It affects nearly everyone occasionally
• One of the most frequent causes of consultation in both general practise and neurological clinics
• Represents an immerse socioeconomic burden
• The NHS expenditure on all headache disorders is estimated at £250 million per year
• The financial burden of all headache disorders on the UK economy is conservatively estimated at £5-7 billion annually (costs of healthcare, lost productivity through both absenteeism and presenteeism, and disability)
IHS code
Classification
Primary headaches
1. Migraine
2. Tension-type headache
3. Trigeminal autonomic cephalalgias
4. Other primary headache disorders
Secondary headaches
5. Headache attributed to trauma or injury to the head and/or neck
6. Headache attributed to cranial or cervical vascular disorder
7. Headache attributed to non-vascular intracranial disorder
8. Headache attributed to a substance or its withdrawal
9. Headache attributed to infection
10. Headache attributed to disorder of homoeostasis
11.Headache or facial pain attributed to disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or cervical structures
12. Headache attributed to psychiatric disorder
Painful cranial neuropathies, other facial pains and other headaches
13. Painful lesions of the cranial nerves and other facial pain
14. Other headache disorders
International Classification of Headache DisordersInternational Headache Society, 3rd Edition , 2018
Tension Type Headache (TTH)
Tension Type Headache (TTH)
• Very common (~60-80%; Women : Men 3:1)
• Pain characteristics: ➢ Bilateral tightness/pressure➢ Mild to moderate➢ Not aggravated by movement➢ Duration: 30 min to several days➢ With or without pericranial tenderness
• No nausea, photophobia and phonophobia
• 3% of the population has chronic TTH ( ≥ 15 days, 6 months)
Tension Type Headache At Workplace
• Usually not disabling, but may be discomfort
• May temporarily affect concertation levels
• Chronic TTH can result in substantial disability and work absence
• If disabling, advise your employees to consult a doctor
• Can be treated with over-the counter analgesics*
Be mindful of Medication Overuse Headache (MOH):Frequent use of painkillers can induce a headache that mimics TTH or migraine (stopping painkillers is an effective treatment of MOH)
Trigeminal Autonomic Cephalalgias
3.1 Cluster headache• 3.1.1 Episodic cluster headache• 3.1.2 Chronic cluster headache
3.2 Paroxysmal hemicrania• 3.2.1 Episodic paroxysmal hemicrania• 3.2.2 Chronic paroxysmal hemicrania
3.3 Short-lasting unilateral neuralgiform headache attacks• 3.3.1 Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing
(SUNCT)• 3.3.1.1 Episodic SUNCT• 3.3.1.2 Chronic SUNCT
• 3.3.2 Short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms (SUNA)• 3.3.2.1 Episodic SUNA• 3.3.2.2 Chronic SUNA
3.4 Hemicrania continua• 3.4.1 Hemicrania continua, remitting subtype• 3.4.2 Hemicrania continua, unremitting subtype
3.5 Probable trigeminal autonomic cephalalgia
Trigeminal Autonomic Cephalalgias
SUNCTParoxysmal
Hemicrania*Cluster Headache
4 15 30 180
• Duration (min)
• Frequency (attacks/day)
Cluster
Headache
Paroxysmal
Hemicrania*
SUNCT/SUNA/HemicraniaContinua*
0.5 - 8 > 5 3 - 200
Trigeminal Autonomic Cephalalgias
* 100% response to Indomethacin
Cluster Headache (CH)
• 0.2-1% prevalence (As prevalent as Multiple Sclerosis!)
• Previously called “Suicidal Headache”
• Women : Men 1:4.3 [up to 1:2.5]- Diagnosis for cluster headaches can be difficult
• Periodic cluster bouts (usually 4-8 weeks), followed by a Remission period
• 1-8 attacks a day, typically occurring at night and at the same time of the day
• 30% of patients develop Chronic Cluster Headache
Cluster Headache (CH)
• Pain characteristics: The pain of a cluster headache is regarded as one of the worst a person can experience and has been described by female sufferers as worse than childbirth - Previously called “Suicidal Headache”
➢ Excruciating orbital/supraorbital/temporal pain ➢ Unilateral, stabbing-like➢ Duration: 15 min to 3h
• At least one ipsilateral autonomic feature (conjunctival lacrimation, nasal congestion and/or rhinorrhea, eyelid edema, forehead and facial sweating)
• Restlessness, such as rocking or pacing
Cluster Headache Treatment
• Acute Treatments: OxygenSumatriptan injectionSumatriptan and zolmitriptan nasal spraysVagus nerve stimulation
• Preventive TreatmentsVerapamilMethysergideLithiumCorticostereoidsTopiramate
Vagus nerve stimulationGreater occipital nerve blockSphenopalatine ganglion block
Cluster Headache At The WorkplaceAdvice for employers and colleagues: Dealing with a Cluster Headache Attack
• Allow a private room for the patient during an attack (patients experience restlessness, some sufferers cry out or bang their heads in response to the pain)
• Ensure they are safe
• Allow safe storage of specific Cluster Headache treatments: a. Oxygen bottles (high flow oxygen is an effective treatment of Cluster Headache
attacks)b. Sumatriptan injections
• Help your employees to avoid triggers:a. Avoid exposing sufferers to stuffy, warm environmentsb. Drinking alcohol during a cluster period may increase the risk of an attack
Advice for employers and colleagues:
• Understand their severity- Train managers to listen and support staff
• Understand that treatments can cause disabling side effects
• Full-time work may become impossible during a Cluster bout and employers will need to be understanding and flexible:
a. Remain in contact with the employee during a bout of cluster headaches
b. Offer flexible solutions in working hours, days and environment
c. Advice your employee to get a specialist consultation with a headache expert (urgent cluster headache clinic at the Headache Centre, Guy’s and St Thomas’ NHS Trust)
d. Advice your employee to seek out the support of people who understand the condition- Charity: Organisation for the Understanding of Cluster Headaches (OUCH)
Cluster Headache At The Workplace
Migraine
Epidemiology of Migraine
1 lifetime prevalence2 one-year prevalence3 not available period for
prevalence
Five Most Prevalent Conditions of the World
Dental caries (adults) 35%
Tension-type Headache 21%
Migraine 15%
Fungal Skin Disease 13%
Other Skin and Subcutaneous Disease 12%
THE GLOBAL BURDEN
OF DISEASE
2010
Migraine – Common & Disabling Disorder
• Migraine is more prevalent than diabetes, epilepsy and asthma combined
• Research suggests that over 190,000 migraine attacks occur every day in the UK
• More than 75% of migraineurs experience at least one attack each month, and more than 50% experience severe impairment during attacks
“Then a pain pierced his head like he’d neverfelt before, it was as though his scar was on fire –half blinded, he staggered backwards . . . The pain in Harry’s head was so bad he fell to his knees”. Rowling JK 2007. Harry Potter and the Philosopher's Stone
Epidemiology of Migraine in Children
• Migraine occurs in 3-10% of children < age of 12
• 18% of 13-14 years old
• Sex ratio 1:1
* Be mindful of employees with children suffering from migraine
Age Specific Prevalence of Migraine
Migraine - The Disorder
Disorder• Repeated attacks
< 15 days/month: Episodic≥ 15 days/month: Chronic
• Family historyMultigenetic predisposition
• Anxiety and depression are common comorbidities in people with migraine
• Triggers (biology)
Stress-relaxation
Hormonal (women)
Sleep: missing/excess
Missing meals
Weather changes
Chemical (alcohol/GTN/CGRP)
Sensory: light, smells
Medication overuse (painkillers)
Attacks
• Premonitory Symptoms
• Head Pain• Unilateral• Throbbing• Movement worsen
•Aura• 20-30% of migraine patients • Transient neurological symptoms
with a typical behaviour• Aura without headache is not
uncommon
• Sensory sensitivity• Sensitivity to light, noise and smells
• Nausea/vomiting
Migraine - The Attacks
Migraine – More Than a Pain Disorder
Adapted from Blau JN. Lancet 1992; 339: 1202–7
A clinical syndrome characterised by headache with specific features and associated symptoms
StructuralFunctional
BehaviouralEnvironmental
Migraine – A Cycling Disorder with Evolutive Characteristics
Episodic migraine Chronic migraine
• Chronic Migraine affects 2% of the UK population
• Headache occurring on ≥ 15 or more days/month for more than three months
Migraine – a Multisymptom Complex of the Brain
MIGRAINE
photophobia
phonophobia
poor concentration
HEADACHE
nausea/vomiting
aura
fatigue
allodynia
osmophobia
speech difficulties
vertigo
yawning
Migraine – Common & Disabling Disorder
Migraine 52.1%
Alzheimer & Other Dementias (15.8%)
Parkinson (1.4%)
Epilepsy (20.1%)
Multiple Sclerosis (1.2%)
Tension Type Headache (4.1%)
Other Neurological Disorders (5%)
Years Lost due to Disability – Neurological Disorders (WHO)
• Migraine is the leading cause of disability among all neurological disorders (and 7th
among all diseases)
• The estimated proportion of time spent with migraine during an average person’s life is 5.3%
• Migraine/chronic headache is the 2nd most frequently identified cause of short-term absence (47%) for non-manual employees
• It is estimated that the UK population loses 25 million days from work or school each year because of migraine
• Absenteeism from migraine estimated cost in the UK is £2.25 billion per year
• Migraine is estimated to cost the NHS £150 million per year, mostly from the costs of prescription drugs and GP visits
• The financial burden of migraine on the UK economy is conservatively estimated at £3.42 billion per year
Migraine – Socioeconomic Burden
• First-line:• Topiramate; * women; contraception
• Propranolol
• Second-line (per NICE Recommendations):• Acupuncture • Riboflabin
• Other preventives:• Amitriptyline, Great Occipital Nerve Block,
Pizotifen, Venlafaxine, Candesartan, Magnesium citrate, Co-Q10, Valproate, single Transcranial Magnetic Stimulation, Vagus Nerve Stimulation
• BOTOX for chronic migraine
• CGRP system monoclonal antibodies
Migraine Treatments
• Triptans *(sumatriptan (also injectable), zolmitriptan, naratriptan, rizatriptan, almotriptan, eletriptan and frovatriptan)
• Paracetamol *
• Aspirin *
• NSAIDS *
• Transcranial magnetic stimulation
* Medication overuse headache
Acute Treatments Preventive Treatments
Advice for employers and colleagues:
• Understand migraine’s severity- Migraine is NOT just a headache, it is a disabling neurological condition
• Understand that treatments can cause disabling side effects
• Train managers to listen and support staff
• Offer flexible solutions in working hours, days and environment
• Advice your employee to get a specialist consultation with a headache expert (there are effective treatments at specialised Headache Centres)
• Advice your employee to seek out the support of people who understand the condition: Charity: Migraine Trust
Migraine At The Workplace
Migraine At The WorkplaceAdvice for employees suffering with migraine:
• Help your employees to recognise and avoid migraine triggers, and have a balanced schedule
Good posture, avoiding neck discomfort, eye strain, and adjustable screen brightness
Avoid stress/ advice on coping with stress
Reduce caffeine intake:Caffeine overuse or withdrawal may trigger a migraine-like attack
Maintaining the same sleep patterns every day- maintain circadian patterns
Maintaining the same eating schedule/pattern every day- maintain circadian patterns
Avoid alcohol- common trigger
Exercise regularly- while exercise can exacerbate head pain during an attack, in the long term studies suggest it cn reduce frequency of attacks
A bright environment or fluorescent light can trigger a migraine or exacerbate migraine headache
Avoid smells that can trigger a migraine attack in individuals
Migraine At The Workplace
Advice for employers and colleagues: Create a migraine friendly workplace
Good posture, avoiding neck discomfort, eye strain, and adjustable screen brightness
Reduce stress/ offer advice on coping with stress
Avoid use of fluorescent light- can trigger a migraine or exacerbate migraine headache
Reduce exposure to smells that can trigger a migraine attack in individuals
Discuss with employees their needs and the disabling nature of their condition. Help them remove the stigma of the “invisible pain”
Reduce exposure to noise that can exacerbate migraine headache
Migraine At The Workplace
Advice for employers and colleagues: Create a “migraine escape room”
• Dark (consider green walls- green light was found not to exacerbate the headache neuronal pathway)
• Quiet
• Patients can sleep (effective migraine treatment)
• Patients can safely take their treatment (which may include injectables)
Disabling Headaches At The Workplace –Take Home Message
• There is no cure for headaches but there are effective treatments
• Empower employees to seek treatment and improve their wellbeing
• Reduce stigma associated with disabling headaches in the workplace
• Provide support for those impacted by disabling headaches in the workplace
Useful Tools for Headache at the Workplace
https://www.migrainetrust.org/wp-content/uploads/2019/06/The-Migraine-Trust-Help-at-work.pdf
https://ihs-gpac.org/workplace-initiative/
The Migraine Trust- Help at work
The International Headache Society- Global Patient Advocacy Coalition- Workplace Initiative
European Migraine and Headache Alliance
https://fitforwork.org/blog/cluster-headaches-debilitating-painful-and-little-known/
Fit For Work- Cluster Headaches
https://www.emhalliance.org/
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