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Medical Specialties

and Clinics

Migraine

The DNI Headache Clinic

By: Jane Melling
Clinical Nurse Specialist

The headache clinic in the Dublin Neurological Institute was opened in January 2010 by Dr Martin Ruttledge (Consultant Neurologist) and Ria Bhola (C.N.S. headache). The clinic runs every Wednesday on a weekly basis and continues to grow each year. To date the headache clinic has treated more than 3000 patients.

In 2011 the headache service was audited by the headache team here in the DNI. They clinically analysed 200 patients who were new referrals to the headache clinic between January 2010 and January 2011. The results were presented at E.H.M.T.I.C . (European Headache and Migraine Trust International Congress, in 2011).

Ms Jane MellingOver two thirds of patients were referred to the Headache clinic by primary care physicians with the remaining 30% being referred by other medical specialties. The majority of patients referred were female, 120 were under the age of forty while only 5% of new referrals were over sixty. All but 3 patients were reviewed and examined by a consultant neurologist. Ninety three percent of patients were diagnosed with migraine (70% chronic and 30% episodic). The remainder of the patients who attended were diagnosed with trigeminal autonomic cephalgia, temporal arthritis, trigeminal neuralgia or headaches with a structural cause. Medication overuse headache was present in 52% of our cohort with the majority overusing Paracetamol and Codeine based medications. Almost three quarters of patients attending the clinic who were diagnosed with migraine had never been on prophylactic therapy. 148 patients attending our clinic were started on prophylactic agents-the most commonly prescribed being Amitriptyline, followed by Topiramate and Flunarazine. Migraine was significantly the most common headache type encountered in the clinic. Review of treatment patterns used prior to the initial clinic evaluation suggests that management of migraine in Irish primary care is suboptimal. The fact that so few migraine patients have ever been on a preventative clearly established the need for a specialist headache clinic.

The most common reason for referral to the headache continues to be for migraine management. Migraine is a recurrent headache disorder which manifests in attacks lasting 4-72 hours. Typical characteristics of the headache are unilateral location, pulsating quality, moderate or severe intensity, aggravation by routine physical activity and association with nausea and/or photophobia (light sensitivity) and phonophobia (noise sensitivity). IHS (2011)

Migraine is among the most common disorders of the nervous system. There are approximately 12%-15% of Irish people who suffer with migraine at any given time. This accounts for over 500,000 people i.e. 137 in every 1000 people. 25% of woman will experience migraine during their life time and the World Health Organisation (2012) has ranked it in the top 20 of all conditions in relation to disability worldwide. Chronic migraine is associated with personal & societal burden of pain, disability, damaged quality of life and financial cost. Despite regional variation, migraine is a worldwide problem which affects people of all race, age, income levels and geographical areas. The average migraineur in Ireland misses 1-5 days per year due to migraine attack with a significant cost to the economy (estimated at over 200 million per year). Migraine remains undiagnosed and undertreated in at least 50% of patients with less than 50% of migraine patients consulting a physician (W.H.O.:Lifting the burdon 2011)

At the headache clinic we focus not only on management of symptoms through medication but encourage patients to identify possible triggering factors and implement lifestyle modifications, which may help limit or reduce attacks and ultimately improve quality of life. Common trigger factors include diet, sleep, exercise, hormones and environmental factors. Prior to consultation at the clinic, new patients attending are asked to fill out a migraine diary. The migraine diary is an important tool, which allows the patient to document their headache frequency and severity, to establish a headache pattern and identify possible triggering factors. We continue to utilise the diary at each clinic visit, to track their progress. The migraine diary developed by the migraine association of Ireland is available through the Migraine Association of Ireland/ www.migraine.ie.

The role of the headache nurse is evolving rapidly. Originally the role primarily involved patient support and education. Although this remains the cornerstone of the position, it has also expanded to include patient consultation including headache history taking and assessment. As a headache nurse, I work closely with the medical team and Neurologist to provide high quality care for the patients. To facilitate patients who are working, I run a nurse led evening clinic on the 1st & 3rd Tuesday of the month to ensure continuity of care, monitor patient progress, educate and ensure prescribed medication is tolerated. I provide phone based support and a point of contact for patients who have queries or concerns regarding their treatment plan. Patients who require an appointment to this clinic should contact their GP and ask for a referral letter to the Headache Clinic in the DNI. Letters should be addressed to: Headache clinic, Dublin Neurological Institute, Mater Misericirdoae University Hospital, 57 Eccles Street, Dublin 7.