The video version of this podcast can be found here:
This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE.
My name is Fernando Florido and I am a General Practitioner in the United Kingdom. In this episode I will go through new and updated guidelines published in May 2024 by the National Institute for Health and Care Excellence (NICE), focusing on those that are relevant to Primary Care only.
I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.
There is a podcast version of this and other videos that you can access here:
Primary Care guidelines podcast:
· Redcircle: https://redcircle.com/shows/primary-care-guidelines
· Spotify: https://open.spotify.com/show/5BmqS0Ol16oQ7Kr1WYzupK
· Apple podcasts: https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148
There is a YouTube version of this and other videos that you can access here:
The Practical GP YouTube Channel:
https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk
The YouTube video on the management of headaches can be found here:
· https://youtu.be/6AZttMzfFr0?si=yxPcoC4legE8zS_p
The Full NICE News bulletin for May 2024 can be found here:
The links to the guidance covered can be found here:
Atogepant for preventing migraine - Technology appraisal guidance [TA973] can be found here:
· https://www.nice.org.uk/guidance/ta973
Headaches in over 12s: diagnosis and management - Clinical guideline [CG150] can be found here:
· https://www.nice.org.uk/guidance/cg150
The educational poster on the diagnosis of diagnosis of tension-type headache, migraine and cluster headache can be found here:
· https://www.nice.org.uk/guidance/cg150/resources/diagnosis-poster-pdf-188219341
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Transcript
If you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description.
Hello and welcome, I am Fernando, a GP in the UK. Today, we are looking at the NICE updates published in May 2024, focusing on what is relevant in Primary Care only.
And again, in May we have had very little new guidance relevant to primary care, in fact, there was only one guideline containing relevant information for us, the published technology appraisal on atogepant for migraine prophylaxis. You may remember that we covered this to some degree last month, when we reviewed the final draft NICE guidance on the subject. To make up for the shortage of Primary Care updates, we will also go through the clinical signs and symptoms that differentiate between tension-type headache, migraine and cluster headache. We will do so by reviewing the NICE guideline on headaches. If you are interested in the full headache guideline, covering headaches other than migraine, please see the corresponding video on this channel. The link is in the episode description.
Right, we have a migraine heavy episode, so let’s jump into it.
And let’s start with an overview. Although we are covering atogepant, the guidance on Rimegepant is very similar. Both Rimegepant and atogepant, are a new class of drugs, also known as gepants, that have been developed specifically for the treatment of migraines. They are a calcitonin gene-related peptide (or CGRP) receptor antagonist which works by blocking this CGRP receptor. And although the mechanism of action is not fully understood, we know that CGRP is a protein found in the sensory nerves of the head and neck and causes blood vessels to dilate, which can lead to inflammation and migraine pain.
Unlike triptans, gepants do not cause vasoconstriction so they do not have the same cardiovascular contraindications and cautions as triptans.
Gepants can be used as an acute treatment of migraine and also as prophylaxis, but only if there have been at least 4 migraine days per month and where at least 3 previous preventive treatments have failed. Rimegepant is only recommended as prophylaxis of episodic migraines, whereas NICE has recommended atogepant as prophylaxis for both chronic and episodic migraines.
What’s the difference between episodic and chronic migraine?
The definition of episodic migraine is when there are fewer than 15 headache days each month. On the other hand, chronic migraine is when for more than 3 months there are at least 15 headache days a month, with at least 8 of those having features of migraine.
And here it is a good time to look at the clinical features of migraine compared to other types of headaches such as tension-type headache and cluster headache.
NICE has produced a poster that classifies the signs and symptoms for all three types of headaches. Let’s have a look at it:
The first thing to look at are the features of the headache in terms of:
· Location
· Quality
· Intensity and
· Duration
So, the location of the pain is:
· Bilateral in tension type headache,
· Unilateral or bilateral in migraine and
· Unilateral, generally around the eye, above the eye and along the side of the head/face in cluster headache.
The quality of the pain is:
· Pressing or tightening and non-pulsating in tension headache,
· Pulsating in migraine although it can be described as throbbing or banging in young people and
· It can be variable in cluster headache, as it can be sharp, boring, burning, throbbing or tightening.
As for the intensity of the pain, it can be:
· Mild or moderate in tension-type headache
· Moderate or severe in migraine and
· Severe or very severe in cluster headache.
And for the duration, we will say that it generallylasts:
· From 30 minutes to continuous in tension-type headache,
· 4 to 72 hours in migraine in adults although it can be shorter in young people, from 1 to 72 hours and
· From 15 minutes to 3 hours in cluster headaches, so usually a shorter headache but much more intense.
Other factors that can help us differentiate between them are the effects that the headaches have on daily activities and whether there are other associated symptoms.
When considering the effects of daily living, we will say that:
· Tension-type headache is not usually aggravated by routine activities,
· Migraines are aggravated by, or causes avoidance of, routine activities and
· Cluster headache causes restlessness or agitation.
And when considering other symptoms, we must be aware that:
· Tension headaches don’t normally have any
· Migraine can be associated to light and sound sensitivity or nausea and vomiting.
· If there is migraine with aura, we need to remember that typical aura symptoms can occur with or without headache and include:
o Visual symptoms such as flickering lights, spots or lines and partial loss of vision
o Sensory symptoms such as numbness and pins and needles and
o Speech disturbance.
o But in order to diagnose migraine with aura the symptoms must be fully reversible, develop over at least 5 minutes and last generally between 5 minutes and 1 hour.
Finally, in cluster headache, we will find, usually on the same side as the headache, associated symptoms such as:
· A red or watery eye
· Nasal congestion or a runny nose
· A swollen eyelid
· Forehead and facial sweating and
· A constricted pupil or drooping eyelid
This is the summary poster that NICE has produced in the headache guideline. The link to it is in the episode description. Now that we have had a look at the clinical features, let’s go back to the management.
Currently, the most effective prophylactic options for people with chronic migraines who have already tried 3 prophylactic treatments are drugs that need to be injected, such as for example:
· Erenumab and galcanezumab and
· botox
So, oral treatments such as atogepant or Rimegepant offer more choice for patients.
When should we stop atogepant? We should stop it after 12 weeks if the frequency of migraines does not reduce by:
· at least 50% in episodic migraine (that is, fewer than 15 headache days per month)
· at least 30% in chronic migraine (that is, 15 or more headache days per month, with at least 8 of those having features of migraine).
Clinical trial evidence shows that atogepant reduces monthly migraine days more than placebo, but there is no clinical trial evidence directly comparing it with other preventive medicines. The results from indirect comparisons are uncertain and it is unclear whether atogepant is better or worse than the other treatments. However, it has lower costs than injectables, so it is recommended for preventing episodic and chronic migraine after 3 or more preventive medicines have been tried.
So now, with that in mind, let’s quickly look at the preventative treatment pathway that NICE has produced.
First, for prophylaxis treatment to be considered, the patient needs to have 4 or more migraine days per month.
In that case, we will give 1st, 2nd and 3rd line prophylaxis with propranolol, amitriptyline and topiramate.
If there is inadequate response, then we move to 4th line treatment.
For episodic migraine we can give Rimegepant.
For both episodic and chronic migraines, we have a number of injectable medications and atogepant as the only oral medication.
Finally, if it is chronic migraine, then the recommended treatment will be with botox.
Rimegepant is an oral lyophilisate that should be placed on the tongue or under the tongue and it will disintegrate in the mouth and can therefore be taken without liquid. However, atogepant is a tablet to be taken orally.
We have come to the end of this episode. Remember that this is not medical advice and it is only my summary and my interpretation of the guidelines. You must always use your clinical judgement.
Thank you for listening and goodbye.
