The International Headache Society (IHS) in 1988 agreed on criteria for the diagnosis of headache. The Norwegian State Drug Control Agency in 1994 issued recommendations for the treatment of migraine. The indicators are based on these guidelines.
Six aims have been considered in the formulation of indicators :
1. Correct diagnosis of migraine
A good history is essential. We aim to document that IHS-criteria are fulfilled and that migraine patients are not misdiagnosed. The use of questionnaires based on IHS criteria have proved to be useful in general practice
2. The patient is advised about external triggers of attacks
A number of external factors may trigger attacks, and the knowledge of the patient about these is important.
3. Pharmaceutical treatment is based on a sequential trial of active substances doses and formulation.
The safest, best known and cheapest drugs should be tried first. A paper in the Lancet 1995 showed 900 mg of acetylic acid combined with 10 mg of metoclopramide to be as effective as a tablet of 100 mg sumatriptane.
4. The migraine patient experiences satisfactory control of attacks
60-70% of migraine patients with frequent serious attacks respond to treatment with beta-blocking agents without intrinsic stimulating effect.
5. Treatment takes unwanted side effects into account.
All analgesics may produce headache after some time of regular use. This is preventable or treatable and deserves greater attention from practitioners.
6. Migraine patients are referred to a specialist in the event of diagnostic doubt, suspicion of serious underlying disease or treatment failure.
Optimal use of resources at a high competence level requires active co-operation between primary and secondary lines of care.
Referring to these aims the project has chosen the following indicators
Most general practitioners need decision support to make a correct diagnosis of migraine. This must be organised in the office.
• Are guidelines for the care of migraine patients available in the practice?
• Does the practice have diagnostic questionnaires/computer software ?
• Is educational material for patients available?
These give documentation of diagnosis and treatment of migraine patients.
• In a patient with migraine diagnosis, are IHS criteria fulfilled, or has the diagnosis been made by a neurologist?
• If a patient has a headache diagnosis, has a migraine diagnosis been excluded?
• If sumatriptane has been prescribed, have ergotamine compounds been tried out?
• In a patient with migraine or other diagnosis of headache, have narcotic analgetics or other opiates been prescribed?
• In a migraine patient, has the prescription of ergotamine exceeded 100 mg during the last year?
• In a patient with ergotamine or sumatriptane medication, is there evidence of coronary/other atherosclerotic disease?
• If a patient suffers more than three serious attacks per month, has preventive medication been used?
• What fraction of patient with migraine or other headache has been referred to neurologist? Strictly, this cannot be labelled an indicator, but is nevertheless suited for discussion in peer groups.
These assess the results of treatment and patient satisfaction.
• Among the registered patients, the number sickness certification days with migraine diagnosis.
• Does a patient with migraine have more than three major attacks per month?
• Does a patient with migraine know at least three attack-provoking factors?
• How satisfied is the migraine patient with the drug-induced relief of pain?
• How quickly is themigraine patient enabled to return to ordinary activity following treatment?
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