1) Welcome to an accredited #tweetorial on #migraine, focusing on continuity of care, education, communication & resources for you & your patients. I am Annika Ehrlich, MS, FNP-C, AQH, CNRN (@EhrlichNP). Follow this thread & earn 0.75h CE/#CME credit! @academiccme @UCSFHospitals pic.twitter.com/IPTq0c4uHP
— @migraine_ce (@migraine_ce) October 4, 2021
3) As reviewed in our previous @migraine_ce tweetorials (you can still earn credit! just go to https://t.co/3Rt15X6pUA), #migraine is one of the most common neurologic conditions, affecting over 1 billion people worldwide.
— @migraine_ce (@migraine_ce) October 4, 2021
5) Given that migraine is a genetic neurologic disorder, pts may experience periods of worsened and/or improved symptoms throughout their lifespan. Providing education about migraine, possible progression, and non-pharmacologic management strategies …
— @migraine_ce (@migraine_ce) October 4, 2021
7) Robert, 25M with no sig PMH, presents to your office for eval of #headaches that occur several times/mo & are quite disabling. Headache is located over his left temple but can move location and is “pounding”. He prefers to lie down in a dark room when he gets these headaches.
— @migraine_ce (@migraine_ce) October 4, 2021
9) He does remember getting occasional headaches starting in childhood, but not as severe, & frequency has been ⬆️ing over the past few years. Family history is positive for headaches in his mother. History, Review of Systems and the physical exam, including fundoscopy, are WNL.
— @migraine_ce (@migraine_ce) October 4, 2021
11) … meets ICHD3 criteria for migraine without aura (episodic, as he is getting 2-5 headache attacks/mo).
ICHD3 Criteria for Migraine:
Number of attacks: At least 5
Duration: 4-72 hours (untreated or unsuccessfully treated)— @migraine_ce (@migraine_ce) October 4, 2021
13) @ahsheadache joined the Choosing Wisely initiative of @ABIMFoundation in 2013 to help make recs regarding tests & procedures in headache medicine. 1 rec: “don’t do neuroimaging studies in pts w/stable headaches that meet criteria for migraine”, given low yield in this group.
— @migraine_ce (@migraine_ce) October 4, 2021
15) … & genetic testing at this time does not provide any useful info due to the complex nature of migraine. You focus communication on teaching that migraine is an inherited neurologic disorder, & ask if he would like to review some things that he can do …
— @migraine_ce (@migraine_ce) October 4, 2021
17) It is important to partner with patients and educate that lifestyle factors can be triggers but are not the cause of their underlying migraine disorder.
Some of the most important lifestyle factors to consider when evaluating a patient with migraine include:— @migraine_ce (@migraine_ce) October 4, 2021
19) SLEEP: How much sleep is the patient getting per night? Do they snore, or wake up with headache (consider #OSA)? Do they go to sleep & wake up at the same time? Are they napping during the day? Obstructive sleep apnea & insomnia are associated with migraine.
— @migraine_ce (@migraine_ce) October 4, 2021
21) … or in addition to other pharmacologic treatments.
One study randomized participants to an exercise group (40min 3x/wk) or a med group w/topiramate. Both groups demonstrated reduction in migraine attacks. Cephalalgia 2011;31:1428–1438. pic.twitter.com/pR5t4kTxFT— @migraine_ce (@migraine_ce) October 4, 2021
23) See https://t.co/OqiZGmqMBq as a resource. If a patient asks which diet is best for someone w/migraine, the best answer is EAT: consistency is key with migraine. Keeping well-hydrated and blood sugar levels stable is important.
— @migraine_ce (@migraine_ce) October 4, 2021
25) … particularly interested in identifying triggers, pursuing specific diets, or those having trouble maintaining a healthy diet. See Headache 2020;60:1300–1316. Patients should be counseled on sticking to a healthy diet full of fresh fruit &vegetables, lean proteins & …
— @migraine_ce (@migraine_ce) October 4, 2021
27) Mark your answer and return TOMORROW for more education! @MigraineDisordr @CSWhiteMD @stephanieJnahas @MiaMinenMD @ThomasBerkMD @ahsheadache @diamondheadache @AMastersMD @DrMeganDonnelly @AEPaceMD @ffiorito27 @AmaalStarlingMD @daviddodick @mrobbinsmd @aligha1981 @ASunejaMD
— @migraine_ce (@migraine_ce) October 4, 2021
29) Yesterday's poll? FALSE. While some pts might benefit from eliminating caffeine from their diet altogether, elimination may not be necessary. Keeping caffeine to a minimum (1-2 cups of coffee, for example), limiting to morning hours & keeping daily consumption consistent …
— @migraine_ce (@migraine_ce) October 5, 2021
31) DIARY: Headache diaries are impt tools for both HCP & pt to help identify patterns & show avg # of headache attacks, severity, & acute med use over time. Paper diaries can be helpful & customized, and there are many electronic applications, such as https://t.co/PRywP7iqmT
— @migraine_ce (@migraine_ce) October 5, 2021
a. Biofeedback
b. Cognitive Behavioral Therapy
c. Mindfulness Based Stress Reduction
d. Any of the above— @migraine_ce (@migraine_ce) October 5, 2021
34) Biobehavioral treatment should be tailored to the pt after having a discussion of possible options & pref. Accessibility, affordability, time considerations & pt belief systems should factor into recommendations.
— @migraine_ce (@migraine_ce) October 5, 2021
36) Biofeedback is a method of:
a) meditation to help with stress reduction
b) controlling body reactions through physiologic feedback.
c) changing belief cycles to help reduce pain symptoms.
d) measuring biomarkers to determine best therapeutic treatments.— @migraine_ce (@migraine_ce) October 5, 2021
38) The following websites offer information about Biofeedback and finding certified providers:https://t.co/NP7Jlb2tbFhttps://t.co/1FPAZOMzcw pic.twitter.com/MfKpkiagbL
— @migraine_ce (@migraine_ce) October 5, 2021
40) Suggestions to help pts find a pain psychologist:
Call insurance carrier, ask for “a behavioral medicine provider who specializes in pain treatment.”
Visit state/county Psychological Assoc, “Find a Psychologist” page, enter insurance & select “Pain” or “Chronic Illness”.— @migraine_ce (@migraine_ce) October 5, 2021
42) Mark your answer and return tomorrow for wrap-up and a link to your FREE CE/#CME! @aligha1981 @SimyParikh @DrCDougherty @ClintLauritsen @AMastersMD @maryannmays11 @Neuralgroover @thedizzydoc @Neurotweeps @HindiyehNada @RKrel @RRaoMD @NithiAnandMD @okheadachedr @SocBlackNeuro
— @migraine_ce (@migraine_ce) October 5, 2021
44) The answer to yesterday's quiz is C. A recent double-blinded, randomized clinical trial compared the effectiveness of Mindfulness Based Stress Reduction (MSBR) to standard headache education in a group of 89 participants with migraine. doi: 10.1001/jamainternmed.2020.7090. pic.twitter.com/5W5IZIhkmG
— @migraine_ce (@migraine_ce) October 6, 2021
46) There is strong evidence for smartphone application efficacy as a delivery model of biobehavioral treatments:
— @migraine_ce (@migraine_ce) October 6, 2021
48) A sample of the free apps for relaxation/pain mgt: Calm introduces mindfulness w/5 minute instructions. It offers a guided body scan, relaxation scenes & sounds to support self-guided meditation.
Headspace teaches the basics of meditation and mindfulness in 10 min/day.— @migraine_ce (@migraine_ce) October 6, 2021
50) Here are a few resources:
— https://t.co/JIYDFumkXG
— https://t.co/YmVChOsABc
— https://t.co/vQxFBpy9SB
— https://t.co/GiFmm24nDf
— Pain psychologist Dawn Buse offers resources and guided medications on her website: https://t.co/N86MW7J1pc— @migraine_ce (@migraine_ce) October 6, 2021
52) … & is also primary caregiver for her mother. Her mood has improved w/addition of duloxetine 60 mg QD & she is treating her acute migraine attacks successfully w/a combo of OTC naproxen and rizatriptan 10 mg.
What might you consider reviewing with Michaela at this visit?— @migraine_ce (@migraine_ce) October 6, 2021
54) … back to school full time & uncertainties of possible #COVID19 exposure. She is getting less sleep, and you discover she has ⬆️d caffeine use & is also taking OTC Tylenol w/ a diet coke several days/wk to treat when she feels like a headache might be coming on.
— @migraine_ce (@migraine_ce) October 6, 2021
56) C is best. Exploring barriers to optimum SEEDS success is the appropriate next step. “SEEDS” refers to Sleep, Exercise, Eat, Diary, Stress. Michaela may be a candidate for an additional preventive med to help control her migraine attacks, or Botox …
— @migraine_ce (@migraine_ce) October 6, 2021
58) What might be the best strategy for communicating about lifestyle factors that could be contributing to Michaela’s migraine symptoms?
a. Active listening
b. Use open-ended questions
c. Use Ask-Tell-Ask approach
d. Any of the above— @migraine_ce (@migraine_ce) October 6, 2021
60) … can all be effective for assessment and therapeutic relationship with patients.
doi: 10.1007/s11916-008-0040-3.— @migraine_ce (@migraine_ce) October 6, 2021
62) One would be offering a summary of the evidence to support CBT in reducing freq/severity of migraine. You then ask Michaela if this would be of interest & if she has any questions. After some discussion, you agree to refer to a pain psychologist who offers telehealth visits.
— @migraine_ce (@migraine_ce) October 6, 2021
64) You then review recs regarding caffeine, hydration, & sleep, & provide additional resources that might be helpful, with respect to her busy life & expressing understanding of her responsibilities. You ask her what might be feasible for her right now & tell her that …
— @migraine_ce (@migraine_ce) October 6, 2021
66) You ask if she understood this information and if she has any questions regarding your recommendations. She agrees to work on reducing caffeine use slowly, and to work on approaches with pain psychology. She would like to wait on adding medication measures at this time …
— @migraine_ce (@migraine_ce) October 6, 2021
68) That's it! You made it! And FOLLOW US here to KEEP earning CE/#CME on #migraine management. For your FREE 0.75h credit NOW, go to https://t.co/cgq45nYVZI and grab your certificate. I'm @EhrlichNP and program chair @headacheMD are proud you trust US for your continuing ed! pic.twitter.com/talVwYQzmU
— @migraine_ce (@migraine_ce) October 6, 2021
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