Ambassador Program Guideline for Management of Primary Headache in Adults, 2 Edition

283 Pages·2017·3.61 MB·English

by  Stefanie Kletke

Ambassador Program
Guideline for Management of
Primary Headache in Adults,
nd
2 Edition
Background Document
Supporting documents and process description

July 2017
Abbreviations
All abbreviations that have been used in this document are listed here unless the abbreviation is well
known, has been used only once, or has been used only in tables or appendices, in which case the
abbreviation is defined in the figure legend or in the notes at the end of the table.
AGREE Appraisal of Guidelines for Research and Evaluation
AHS Alberta Health Services
Alberta CPG Alberta Clinical Practice Guideline for Management of Primary Headache in Adults
CADTH Canadian Agency for Drugs and Technologies in Health
CPG clinical practice guideline
CS case series study
DALY disability-adjusted life-year
EO expert opinion
G guideline
G1 to G11 seed guidelines
GDG Guideline Development Group
GLIA GuideLine Implementability Appraisal
GUC Guideline Update Committee
HTA health technology assessment
IHE Institute of Health Economics
IHS International Headache Society
MA meta-analysis
NA not applicable
NR Nonsystematic/narrative review
NRCS nonrandomized comparative study
NRT non-randomized trial
NSAID non-steroidal anti-inflammatory drug
qSR quasi-systematic review
RCT randomized controlled trial
SC Steering Committee
SR systematic review
TOP Toward Optimized Practice
US FDA United States Food and Drug Administration

Ambassador Program guideline for management of
primary headache in adults, 2nd Edition: Background document i
Table of Contents
Abbreviations ............................................................................................................................... i
SCOPE OF THIS DOCUMENT ................................................................................................. 1
ABOUT THE ALBERTA CPG ................................................................................................... 2
Purpose....................................................................................................................................... 2
Objectives................................................................................................................................... 2
Target Users............................................................................................................................... 2
Multidisciplinary Participation................................................................................................. 3
Guideline and Companion Documents ................................................................................... 3
For clinicians ............................................................................................................................ 3
For patients .............................................................................................................................. 4
Conflict of Interest..................................................................................................................... 4
Funding and Editorial Independence...................................................................................... 4
Legal aspects ............................................................................................................................ 5
Terms of Use.............................................................................................................................. 5
BACKGROUND AND PLANNING ........................................................................................... 6
Overview of the Ambassador Program .................................................................................... 6
Development of the Alberta CPG (1st Edition) ........................................................................ 7
Set-Up and Planning of the Alberta CPG (2nd Edition) Update Process............................... 7
About Headache – Epidemiology and Disease Burden......................................................... 8
References ................................................................................................................................. 10
IDENTIFYING, SELECTING, AND APPRAISING THE SEED GUIDELINES................. 13
Rationale ................................................................................................................................... 13
Identifying Seed Guidelines..................................................................................................... 14
Inclusion criteria..................................................................................................................... 14
Exclusion criteria.................................................................................................................... 15
Literature search strategies ..................................................................................................... 15
Table 1: Search strategy used to identify relevant headache seed guidelines........................................... 15
Table 2: Search strategy used to identify relevant systematic reviews for the IHE Database.................... 18
“Do Not Know” Recommendations, New Interventions, and Medication Table .............. 21
Selecting the Seed Guidelines.................................................................................................. 21
Critically Appraising the Seed Guidelines ............................................................................. 22
Critically Appraising the Systematic Reviews on New Interventions ................................. 23
Ambassador Program guideline for management of
primary headache in adults, 2nd Edition: Background document ii
Extracting Data ....................................................................................................................... 23
References ................................................................................................................................ 25
GUIDELINE DEVELOPMENT PROCESS.............................................................................2 7
General Process ....................................................................................................................... 27
Guidelines reviewed ............................................................................................................... 27
Update protocol ..................................................................................................................... 27
Table 3: Ambassador Program guideline update protocol................................................................ 28
Committees ............................................................................................................................ 29
Formulating recommendations............................................................................................... 29
Figure 1: Process of formulating recommendations and resolving parking lot items................................ 31
Rationale and Process for Developing Recommendations .................................................. 32
Classification of Recommendations ...................................................................................... 34
Table 4: Definitions for recommendation categories ........................................................................ 35
Limitations of the Guideline Development Process ............................................................. 35
References ................................................................................................................................ 36
REVIEWING, EVALUATING, AND ENDORSING THE ALBERTA CPG ........................ 38
Reviewing the Alberta CPG .................................................................................................... 38
Evaluation Strategy ................................................................................................................. 39
Advancing knowledge ............................................................................................................ 39
Capacity-building.................................................................................................................... 39
Informed decision-making ..................................................................................................... 40
Health impacts ....................................................................................................................... 40
Broad economic and social impacts ........................................................................................ 41
References ................................................................................................................................. 41
DISSEMINATING, IMPLEMENTING, AND UPDATING THE ALBERTA CPG .............. 42
Potential Barriers to Guideline Uptake and Implementation .............................................. 42
Key actors .............................................................................................................................. 42
Figure 2: Perceived barriers to providing the best care possible to patients with headache (n=23 family
physicians) ............................................................................................................................ 43
Dissemination and Implementation Plan.............................................................................. 44
Update Process ........................................................................................................................ 45
Table 5: Potential barriers to the use of care pathways, chronic pain and headache management, and
implementing the Alberta CPG recommendations ......................................................................... 46
References ................................................................................................................................ 49
Ambassador Program guideline for management of
primary headache in adults, 2nd Edition: Background document iii
APPLICABILITY OF THE ALBERTA CPG – ECONOMIC/COST IMPLICATIONS ...... 50
General Aspects ....................................................................................................................... 50
Economic Implications Reported in the Seed Guidelines .................................................... 51
Resource Implications of the Alberta CPG ........................................................................... 52
References ................................................................................................................................ 52
APPENDIX A: Participants in the Update Process for the Alberta CPG, 2nd Edition
.......................................................................................................................................................5 4
Table A.1: Guideline Update Committee – Active members .......................................................... 54
Table A.2: Additional subcommittee members ............................................................................. 56
Table A.3: Guideline Update Committee – Resigned member......................................................... 56
Table A.4: Guideline Update Committee – Ex-officio members...................................................... 56
Table A.5: Steering Committee and Research Team members ......................................................... 57
Figure A.1: Multidisciplinary Guideline Update Committee and subcommittee participation from the
Alberta Health Services zones (active members) ............................................................................ 58
APPENDIX B: Alberta CPG Update Process – Roles and Activities .......................... 59
Figure B.1: Relationships among the committees in the guideline update process................................... 59
Figure B.2: Alberta CPG update process and involvement of stakeholders, experts, and committee members
........................................................................................................................................... 62
APPENDIX C: Participants in the Development Process for the Alberta CPG, 1st
Edition .........................................................................................................................................6 3
Table C.1: Guideline Development Group – Active members ......................................................... 63
Table C.2: Guideline Development Group – Resigned member........................................................ 64
Table C.3: Guideline Development Group – Ex-officio members..................................................... 64
Table C.4: Steering Committee and Research Team members.......................................................... 65
Table C.5: Advisory Committee members ................................................................................... 66
Table C.6: Advisory Committee – Ex-officio members .................................................................. 67
APPENDIX D: Excluded Guidelines ....................................................................................6 8
Table D.1: Summary of excluded guidelines ................................................................................ 68
Table D.2: Summary of guidelines excluded after reviewing the AGREE quality appraisal results (Steering
Committee meeting, 25 March 2015)......................................................................................... 71
APPENDIX E: Modifications Made to the AGREE II Tool............................................... 73
APPENDIX F: Systematic Review Quality Assessment Checklist .............................. 74
APPENDIX G: Quality Assessment Results for Systematic Reviews of New
Interventions .............................................................................................................................8 2
Table G.1: Critical appraisal results for systematic reviews of new interventions .................................. 82
APPENDIX H: Included Seed Guidelines ...........................................................................8 6
Table H.1: Summary of included seed guidelines........................................................................... 86
Ambassador Program guideline for management of
primary headache in adults, 2nd Edition: Background document iv
APPENDIX I: Critical Appraisal Results (Modified AGREE II Tool)............................. 92
Table I.1: Standardized domain scores AGREE II (%) – Included seed guidelines ............................ 92
Table I.2: Standardized domain scores AGREE II (%) – Guidelines excluded by the Steering Committee
........................................................................................................................................... 93
Table I.3: Average quality score based on seven designated quality criteria – Included seed guidelines....... 94
Table I.4: Average quality score based on seven designated quality criteria – Excluded seed guidelines ..... 95
APPENDIX J: Inventory of Recommendations from New Seed Guidelines ............. 96
Acute Migraine Pharmacological Interventions ................................................................... 98
Table J.1a: Acute migraine – General principles .......................................................................... 98
Table J.1b: Acute migraine – Pharmacological interventions ......................................................... 101
Table J.1c: Approach to the individual patient/pharmacological acute migraine treatment strategies ...... 116
Table J.1d: Menstrual migraine – Advice and diagnosis .............................................................. 125
Table J.1e: Migraine – Acute treatment in pregnancy and lactation ................................................ 126
Table J.1f: Perimenopausal or menopausal migraine – Hormone and pharmacological therapy ............. 131
Migraine Prophylaxis ............................................................................................................. 151
Table J.2a: Episodic migraine prevention/migraine prophylaxis – General considerations ................... 151
Table J.2b: Episodic migraine prevention/migraine prophylaxis – Pharmacological interventions.......... 155
Table J.2c: Approach to the individual patient/prophylactic drug treatment strategies based on the clinical
setting ................................................................................................................................ 165
Table J.2d: Migraine prophylaxis – Menstrual migraine .............................................................. 170
Table J.2e: Migraine prophylaxis – Pregnancy and lactation ......................................................... 172
Migraine Non-Pharmacological Interventions .................................................................... 188
Table J.3a: Migraine – Non-pharmacological treatment ............................................................... 188
Table J.3b: Migraine – Non-pharmacological prophylaxis............................................................ 191
Tension-Type Headache ....................................................................................................... 194
Table J.4a: Tension-type headache – Pharmacological treatment..................................................... 194
Table J.4b: Tension-type headache – Non-pharmacological treatment.............................................. 196
Table J.4c: Tension-type headache – Pharmacological prophylaxis .................................................. 198
Cluster Headache .................................................................................................................. 204
Table J.5a: Cluster headache – Referral for surgery ..................................................................... 204
Table J.5b: Cluster headache – Pharmacological prophylaxis ........................................................ 205
Table J.5c: Cluster headache in pregnancy and lactation – General statements .................................. 207
Cervicogenic Headache ......................................................................................................... 210
Table J.6: Cervicogenic headache – Non-pharmacological treatment ................................................ 210
Table J.7: Recommendation ratings used by the new seed guidelines................................................. 213
Table J.8: Glossary of terms for interventions included in the inventory tables.................................... 218
Ambassador Program guideline for management of
primary headache in adults, 2nd Edition: Background document v
Appendix K: Summary of Parking Lot Items ..................................................................219
Table K.1: Diagnosis and investigation..................................................................................... 219
Table K.2: Management of migraine headache............................................................................ 221
Table K.3: Management of tension-type headache........................................................................ 232
Table K.4: Management of cluster and cervicogenic headache ......................................................... 236
Table K.5: Other parking lot items.......................................................................................... 238
Table K.6: Expertise of subcommittee participants ...................................................................... 241
APPENDIX L: List of New and Revised Recommendations .......................................246
APPENDIX M: Sample of the Additional Information Provided to the Guideline
Update Committee and Subcommittees ..........................................................................249
APPENDIX N: Sample of Documents Used to Track Committee Deliberations ....259
Table N.1: Sample of working document for the Guideline Update Committee and subcommittees ....... 259
Table N.2: Sample of abridged working document summarizing subcommittee outcomes for the Guideline
Update Committee................................................................................................................ 260
APPENDIX O: List of Recommendations with Evidence Sourced from IHE
Database Systematic Reviews ...........................................................................................261
APPENDIX P: Process Used to Formulate Recommendations .................................264
APPENDIX Q: Recommendation Categories ..................................................................265
APPENDIX R: Feedback on Guideline Documents .......................................................268
Figure R.1: Sample of the online survey sent to Guideline Update Committee and subcommittee members
(August 2016) .................................................................................................................... 268
Table R.1: Suggestions for improving the guideline from Guideline Update Committee and subcommittee
members (n=6) (August 2016) .............................................................................................. 269
Table R.2: Barriers to implementing the Alberta CPG recommendations – summary of responses from
Guideline Update Committee and subcommittee members (n=6) (August 2016) .............................. 271
Table R.3: Suggestions for improving patient information sheets from IHE Lay Advisory Committee
members (n=8) (April 2016)................................................................................................. 272
Table R.4: Feedback on the patient brochure from Calgary Headache Assessment & Management Program
patients (n=2) (January/February 2017)................................................................................. 273
APPENDIX S: Declaration of Competing Interest Form...............................................274
Table S.1: Competing interests declared by GUC members ........................................................... 276
Ambassador Program guideline for management of
primary headache in adults, 2nd Edition: Background document vi
SCOPE OF THIS DOCUMENT
This background document outlines the methods used to update the Alberta Clinical Practice
Guideline for Management of Primary Headache in Adults, which was produced as part of the Alberta
Ambassador Guideline Adaptation Program.

This document should be cited as: Institute of Health Economics (IHE). Ambassador Program guideline
for management of primary headache in adults, 2nd Edition: Background document. Edmonton (AB): Institute of
Health Economics; 2017. Available from: http://www.ihe.ca/research-programs/hta/aagap/headache.
The citation for the background document describing the methods and process used to create the 1st
Edition of this guideline is as follows: Institute of Health Economics (IHE). Ambassador Program
guideline for management of primary headache in adults: Background document. Edmonton (AB): Institute of
Health Economics; 2013. Available from:
http://www.ihe.ca/download/ambassador_headache_final_100_pager.pdf.
Ambassador Program guideline for management of
primary headache in adults, 2nd Edition: Background document
SCOPE OF THIS DOCUMENT 1
ABOUT THE ALBERTA CPG
This section contains the following information about the Alberta Clinical Practice Guideline for
Management of Primary Headache in Adults, 2nd Edition:
 Purpose, objectives, and target users
 Multidisciplinary committees involved in its development
 Type and location of guideline and companion documents available to clinicians and
patients
 Conflict of interest, funding, and editorial independence
 Terms of use
Purpose
The purpose of the 2nd edition of the Alberta Clinical Practice Guideline for Management of Primary
Headache in Adults (herein referred to as the Alberta CPG) is to help Alberta clinicians make evidence-
informed decisions about the care of adult patients (18 years of age or older) with headache. The
guideline was written to provide healthcare professionals in community practice and patients in
Alberta with guidance about the prevention, diagnosis, evaluation, management, and treatment of
headache.
It is expected that providing relevant, up-to-date information to assist primary care practitioners in
the prevention, diagnosis, evaluation, management, and treatment of headache will allow more
patients to be competently managed in the primary care setting and decrease unnecessary referrals to
increasingly overburdened specialists.
Objectives
The primary objectives are to:
• increase the use of evidence-informed approaches to the prevention, assessment, diagnosis,
and treatment of headache for patients in primary care;
• promote appropriate specialist referrals and use of diagnostic tests in patients with headache;
• provide guidance on the parenteral pharmacological treatment of refractory migraine attacks
for use in appropriate settings where parenteral medications can be safely administered; and
• encourage patients to engage in appropriate self-management.
Target Users
The guideline is intended to be used by any healthcare provider (e.g., family physician, physical
therapist, occupational therapist, nurse, nurse practitioner, pharmacist, psychologist, or chiropractor)
in a primary care setting who is responsible for the care of patients with headache.
Ambassador Program guideline for management of
primary headache in adults, 2nd Edition: Background document
ABOUT THE ALBERTA HEADACHE GUIDELINE 2
Multidisciplinary Participation
Two multidisciplinary committees were involved in the development of the Alberta CPG, 2nd
Edition:
• The Steering Committee (SC) guided the collection and collation of research material,
provided operational oversight, and acted as a secretariat to the Guideline Update
Committee (GUC).
• The GUC reviewed the 1st Edition of the Alberta CPG and revised the recommendations,
where necessary, to reflect current research in the management of headache.
A Research Team of health technology assessment (HTA) researchers with methodological expertise
from the Institute of Health Economics (IHE) assisted the SC and the GUC in developing the
Alberta CPG, 2nd Edition. The profile of each committee participant is listed in Appendix A. A flow
diagram of the development process for the Alberta CPG, 2nd Edition, and an outline of the roles and
activities of each of the committees are provided in Appendix B.
Guideline and Companion Documents
The Alberta CPG, 2nd Edition and its companion documents are hosted by Toward Optimized
Practice (TOP), the program responsible for provincial CPGs, on its website
(www.topalbertadoctors.org/cpgs/). The Alberta CPG, 2nd Edition, was posted on the TOP website on
20 December 2016. Additional companion documents are hosted by or linked to on the IHE on the
Ambassador Program website (www.ihe.ca/research-programs/hta/aagap/headache).
For clinicians
1. Guideline
a) Guideline for Primary Care Management of Headache in Adults, 2nd Edition
b) Quick Reference (algorithm, medication table, and key messages), 2nd Edition
2. Practice tools
a) Headache History Guide (in Appendix F: Resources and Tools of Alberta CPG, 2nd Edition)
b) Headache Diary Sheets (long and short form)
c) Headache disability measurement tools:
• Headache Impact Test (HIT-6). Available at:
http://www.headaches.org/2007/11/16/headache-management-tools-hit/
• Migraine Disability Assessment Scale (MIDAS). Available at:
http://www.headaches.org/wp-content/uploads/2015/01/MIDAS.pdf?7a7d37
3. 2017 Canadian Guideline for Opioids for Chronic Non-Cancer Pain. Hamilton (ON): Michael G.
DeGroote National Pain Centre at McMaster University; 2017. Available at:
http://nationalpaincentre.mcmaster.ca/guidelines.html
4. Instructional YouTube videos:
a) Temporomandibular and neck exam. Available at: https://youtu.be/QirMbworS10
b) Neurological exam. Available at: https://www.youtube.com/watch?v=fgwN1P5PDaA
Ambassador Program guideline for management of
primary headache in adults, 2nd Edition: Background document
ABOUT THE ALBERTA HEADACHE GUIDELINE 3