Clinical Case Scenarios Slide Set Powerpoint 2183787181
Clinical Case Scenarios Slide Set Powerpoint 2183787181
Clinical Case Scenarios Slide Set Powerpoint 2183787181
• Background
• NICE Pathway
• The cases
• NICE Evidence
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NICE Pathways
website
The learning objectives for these clinical case scenarios are to improve
knowledge on:
• how to manage acute migraine.
• best practice for migraine prophylaxis (including migraine
prophylaxis for women and girls of childbearing potential).
• treating cluster headaches, including the key points about
ordering home and ambulatory oxygen.
• where to find information for patients on acute
migraine, migraine prophylaxis and cluster headaches.
You would explain the diagnosis to Claire and Joseph and reassure
them that a serious underlying cause is unlikely, based on Joseph’s
history and your examination of him, which showed no abnormalities.
Given that Joseph is likely to have recurrent migraines that will need
treatment, you would explain the risk of medication overuse headache.
At the time of publication of these cases (January 2016), only nasal sumatriptan had a UK
marketing authorisation for this indication in people aged 12 to 18 years
You would tell Claire and Joseph that the other option would be
monotherapy with either paracetamol or NSAID and you would ensure
that the dose was optimised.
Claire asks what they should do if the nasal triptan doesn’t work and
whether there are there alternative medications.
b) What tool could you use to help assess the effectiveness of the
nasal triptan?
a) You would explain that Joseph should try the sumatriptan nasal
spray for at least 3 headaches because it isn’t possible to tell
whether it’s working based on just 1 headache. If it still doesn’t work
well enough then they should return to you and you would offer
combination therapy with nasal sumatriptan, and a non steroidal
anti-inflammatory. You explain that it is a case of finding out which
type of treatment works best for Joseph.
b) You could give Joseph a headache diary containing prompts for him
to record the frequency, duration and severity of his headaches as
well as his response to the triptan. You would explain to Joseph and
Claire that keeping the diary will help them to learn more about his
migraines (See next slide).
Headache diaries are more accurate than recall and allow patterns of
events to be more clearly seen. They also play an important role in
acknowledging the impact of headache. Keeping the diary will help the
patient to learn more about their migraines, for example whether they
occur in patterns and whether they are triggered by anything in
particular. The diary will also enable them to record any changes in
how often the migraines happen, how painful they are, how well the
treatments for them are working and any side effects from the
treatments.
You would use this information in the standard review you carry out
after starting or changing treatment.
Claire and Joseph thank you for your help and leave. As you are
reflecting on Joseph's case, you think about other treatment
options that might be suitable for Joseph if the triptan nasal spray
doesn’t work well enough for him.
At the time of publication of these cases (January 2016), only nasal sumatriptan had a UK
marketing authorisation for this indication in people aged 12 to 18 years
You note from Anaka's records that other than the medication
mentioned above she is not taking any other forms of medication.
You want to confirm that she is not a taking combined hormonal
contraceptive for contraception purposes. Why is this?
With Anaka's consent you arrange an appointment for her with the
contraceptive service so she can talk about the options for suitable
contraception if she were to take topiramate.
You would advise Anaka to complete the diary in order to: understand
any patterns or triggers that may cause her symptoms; be more alert to
changes in the regularity or severity of her attacks; and learn the
effectiveness of any new medications she takes. It will also help inform
the standard review process, to assess the treatment’s effectiveness
and the presence of side effects after starting or changing a treatment
plan.
Experts agree that many people can stop prophylaxis after 6 months of
treatment and continue to benefit from the prophylactic treatment.
You would tell Anaka that taking riboflavin (400 mg once a day) may
help to reduce her migraine frequency and intensity. You would tell her
that products containing riboflavin can be purchased from pharmacies
and health food stores.
Anaka tells you that her mum also takes treatment to prevent
migraines, but that she takes amitriptyline.
Anaka says amitriptyline works for her mum and asks why she has not
been offered it.
You would also review and discuss her use of triptan, NSAIDs and anti-
emetics, because of the risks associated with these medications
during pregnancy.
Anaka asks you if there is any reading she can do to learn more about
her condition.
b) You would provide Anaka with information (in a format suitable for
her) about headache disorders, including information about support
groups (see supporting information in notes).
What advice and support can you offer Malcolm about his diagnosis?
You would also talk about the options for management (see case
continued) and reassure him that you recognise these severe
headaches are having a big impact on him.
When you ask Malcolm about how his attacks have been since his
admission to the emergency department, he becomes upset and says
that that they are very painful.
He asks if there is any more that can be done to reduce the pain during
attacks.
You need to make Malcolm aware that the nasal triptan does not have
UK marketing authorisation for this indication (correct at time of
publication of these case scenarios in January 2016).
You highlight that, if he is not receiving adequate relief with the nasal
triptan, you will meet with Malcolm again and talk about subcutaneous
triptan.
As required, you would explain that during an attack he will need to use
a non-rebreathing mask and reservoir bag, and that the oxygen will be
running at a flow rate of at least 12 litres per minute.
You are prescribing Malcolm the nasal triptan. How much should you
prescribe?
You would calculate this according to his history of cluster bouts and
based on the manufacturer’s maximum daily dose.
To order the oxygen you must complete a home oxygen order form
(HOOF). There are sections for ambulatory oxygen and long term or
short burst oxygen.
What medications would you not offer Malcolm for the acute
management of his cluster headache attacks?
Nisha currently has a severe migraine with aura that started 60 minutes
ago.
She took her usual oral triptan and NSAID 50 minutes ago and her
migraine has not responded. Nisha has also vomited 6 times during
this attack; once just after taking the oral medication.
Given that the oral preparations of NSAID and triptan were not effective
for Nisha, you offer her intramuscular metoclopramide or
prochlorperazine.
• the guideline
• Information for the public
• costing statement and template
• baseline assessment tool
• academic detailing aid
• diagnosis poster