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## Complete Summary

#### GUIDELINE TITLE

Treatment of primary headache: patient education. Standards of care for
headache diagnosis and treatment.

#### BIBLIOGRAPHIC SOURCE(S)

Ruoff G, Urban G. Treatment of primary headache: patient education. In:
Standards of care for headache diagnosis and treatment. Chicago (IL):
National Headache Foundation; 2004. p. 22-6. \[1 reference\]

#### GUIDELINE STATUS

This is the current release of the guideline.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Primary headaches including:

-   Migraine (with or without aura)

-   Tension-type headache (TTH)

-   Cluster headache

-   Chronic daily headache (CDH)

-   Chronic tension-type headache (CTTH)

-   New daily persistent headache

-   Hemicrania continua

#### GUIDELINE CATEGORY

Counseling

#### CLINICAL SPECIALTY

Family Practice\
Internal Medicine\
Neurology

#### INTENDED USERS

Health Care Providers\
Patients\
Physicians

#### GUIDELINE OBJECTIVE(S)

-   To improve the medical treatment of headache

-   To optimize patient education, which includes promoting healthy
    behaviors and providing both patients and their families with a
    thorough understanding of the condition, the treatment options, and
    the consequences of the options chosen

#### TARGET POPULATION

Patients with primary headache disorders

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Patient Education**

1.  Assessment of patient needs

2.  Discussion of diagnosis

    -   Discussion of risk factors

    -   Discussion of headache triggers

3.  Discussion of treatment options

4.  Practice optimization

    -   Appointing a coordinator for all patient education activities

    -   Choosing the right educational tools (i.e., educational
        handouts)

    -   Making the office patient-education-friendly

    -   Maximize time by using timesaving teaching tips

#### MAJOR OUTCOMES CONSIDERED

Not stated

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

Not stated

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Expert Consensus

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not applicable

#### METHODS USED TO ANALYZE THE EVIDENCE

Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

The guidelines presented in this monograph represent the consensus of an
advisory panel of practitioners chosen by the National Headache
Foundation (NHF) for their expertise. In addition to incorporating the
US Headache Consortium\'s recommendations, their conclusions reflect
clinical experience and the most recent medical literature.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Not stated

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Not applicable

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**Patient Education**

**Assess Patient Needs**

An important first step in optimizing patient education is to adequately
assess each patient\'s needs. Take into account patients\' level of
knowledge about their headaches. Also, be aware of their attitudes,
beliefs, and cultural background and how these elements might affect the
treatment process. Be sensitive to environmental and social factors,
which can also play a role in determining patients\' receptivity to
treatment.

**Discuss Diagnosis**

Primary headaches are far more common than secondary headaches. However,
patients often fear a serious underlying cause of their headaches,
making it critical to reassure your patients and yourself as to the
diagnosis. At times, testing is necessary to establish a diagnosis or
rule out underlying disease. If you order tests, be sure to explain them
thoroughly, as well as the rationale for ordering them (i.e., ruling out
secondary headache causes).

Once the history and physical exam are complete, it is important to
share your diagnosis with the patient. Again, patients may have
initiated the consultations on the basis of numerous preexisting notions
of what is causing their headaches. Take the time to explain their
headache type. Once patients understand that their headaches are not
caused by a more serious secondary condition, they often wish to learn
as much about their headaches as possible.

For most patients, it may be helpful to discuss specific risk factors or
headache triggers that may precipitate or exacerbate headache symptoms
(see table below). In addition to helping patients understand the
factors that put their nervous system at risk for migraine, this
discussion provides an opportunity to modify or change some of these
risk factors and avoid future headaches.

**Table: Factors that May Influence Onset or Severity of Migraine
Symptoms**

+---------------------------------+------------------------------------+
| **Physical**                    | **Dietary**                        |
+=================================+====================================+
| -   Menses, ovulation, or       | -   Sour cream                     |
|     pregnancy                   |                                    |
|                                 | -   Ripened cheeses (cheddar,      |
| -   Birth control/hormone       |     Stilton, Brie, Camembert)      |
|     replacement (progesterone)  |                                    |
|     therapy                     | -   Sausage, bologna, salami,      |
|                                 |     pepperoni, summer sausage, hot |
| -   Illness                     |     dogs                           |
|                                 |                                    |
| -   Intense or strenuous        | -   Pizza                          |
|     activity/exercise           |                                    |
|                                 | -   Chicken liver, pate            |
| -   Sleeping too much/too       |                                    |
|     little/jet lag              | -   Herring (pickled or dried)     |
|                                 |                                    |
| -   Fasting/missing meals       | -   Any pickled, fermented, or     |
|                                 |     marinated food                 |
| -   Bright or flickering lights |                                    |
|                                 | -   Monosodium glutamate (MSG)     |
| -   Excessive or repetitive     |     (soy sauce, meat tenderizers,  |
|     noises                      |     seasoned salt)                 |
|                                 |                                    |
| -   Odors/fragrances/tobacco    | -   Freshly baked yeast products,  |
|     smoke                       |     sourdough bread                |
|                                 |                                    |
| -   Weather/seasonal changes    | -   Chocolate                      |
|                                 |                                    |
| -   High altitudes              | -   Nuts or nut butters            |
|                                 |                                    |
| -   Medications                 | -   Broad beans, lima beans, fava  |
|                                 |     beans, snow peas               |
| -   Stress/stress letdown       |                                    |
|                                 | -   Onions                         |
|                                 |                                    |
|                                 | -   Figs, raisins, papayas,        |
|                                 |     avocados, red plums            |
|                                 |                                    |
|                                 | -   Citrus foods                   |
|                                 |                                    |
|                                 | -   Bananas                        |
|                                 |                                    |
|                                 | -   Caffeinated beverages (tea,    |
|                                 |     coffee, cola, etc.)            |
|                                 |                                    |
|                                 | -   Alcoholic beverages (wine,     |
|                                 |     beer, whiskey, etc.)           |
|                                 |                                    |
|                                 | -                                  |
|                                 | Aspartame/phenylalanine-containing |
|                                 |     foods or beverages             |
+---------------------------------+------------------------------------+

**Discuss Treatments**

Once patients have a better understanding of their headache type, it is
important to include them in the treatment decision process. In many
cases, it is beneficial to explain that even though there is no \"cure\"
for headache, with proper treatment headaches can be effectively
managed. Be sure to spend adequate time discussing all the possible
treatment options and any potential side effects. Be specific when
explaining proper medication use, including correct dosing, when to
treat, the frequency of medication usage, and how and when to use rescue
medications if appropriate. Educate patients about nonpharmacologic
treatments, including behavior modification, a healthy diet, and
exercise. Set realistic treatment expectations, and encourage patients
to take responsibility for their treatment. Allow for a question and
answer period before ending the visit.

With appropriate education, providers and patients can establish a
partnership that will improve compliance and greatly increase the
likelihood of a successful treatment outcome. Early investment in
education pays big dividends over years of headache management.

**Optimize Your Practice**

Appointing a coordinator for all patient education activities is an
important step toward tailoring patient education for your practice.
Depending on the practice, allied health professionals or even
nonmedical office staff should play an important role on the patient
education team. Proper training may be necessary to ensure that the
staff is adequately prepared to handle patients effectively.

*Choose the Right Tools*

Educational handouts, such as brochures or fact sheets, can be quite
helpful (refer to table 2.2 of the original guideline document).
Creating your own educational materials, while giving you complete
control over content, can be both time-consuming and costly.
Pharmaceutical manufacturers can often supply your practice with
educational resources, although you should be sure that the content is
clinically sound and not overly promotional. Clinicians can also refer
patients to headache-focused patient organizations such as the National
Headache Foundation ([www.headaches.org](http://www.headaches.org/),
888-643-5552) and the American Council for Headache Education
([www.achenet.org](http://www.achenet.org/), 856-423-0258).

*Make Your Office Patient-Education-Friendly*

Once you have chosen your educational materials, make sure they are
accessible to your patients. Potential locations include the office
entryway, reception area, bathrooms, and exam rooms. In some cases, it
may be ideal to create a \"Patient Library\" in a spare room or closet,
to store all patient education materials. Also, consider making your
educational charts patient-friendly by using checklists or diagrams.

[Maximize Your Time]{.underline}

Finding the time to properly educate your patients may be a challenge.
The table below provides some quick tips to help you maximize your time
and effectively communicate all the information your patient needs.

+-----------------------------------------------------------------------+
| **Timesaving Teaching Tips**                                          |
+=======================================================================+
| -   Keep focused on the goals of patient and family education         |
|                                                                       |
| -   Partner with the patient to establish learning objectives         |
|                                                                       |
| -   Assess knowledge and ability before you teach                     |
|                                                                       |
| -   Never \"assume\"                                                  |
|                                                                       |
| -   Focus on teaching behaviors and skills                            |
|                                                                       |
| -   Actively involve the patient                                      |
|                                                                       |
| -   Take advantage of teachable moments                               |
|                                                                       |
| -   Individualize your teaching                                       |
|                                                                       |
| -   Help the learner believe                                          |
|                                                                       |
| -   Evaluate learning                                                 |
|                                                                       |
| -   Share your teaching with the rest of the healthcare team          |
+-----------------------------------------------------------------------+

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of evidence supporting the recommendations is not specifically
stated.

In addition to incorporating the US Headache Consortium\'s
recommendations, the conclusions reflect clinical experience and the
most recent medical literature.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

With appropriate education, providers and patients can establish a
partnership that will improve compliance and greatly increase the
likelihood of a successful treatment option.

#### POTENTIAL HARMS

Not stated

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

Drug therapy is constantly evolving as new research, clinical trials,
case reports, and opinions are published. Many of the drugs recommended
in these guidelines are not approved by the US Food and Drug
Administration (FDA) for treatment of headache, nor are they necessarily
the same as those therapies recommended by the manufacturer for labeled
indications. Their use in headache, however, may be supported by the
scientific literature and by the authors\' clinical experiences. While
efforts have been made to ensure accuracy, the authors and publisher do
not assume responsibility for the consistent updating of available
information for these guidelines, nor for any errors or omissions, nor
for any consequences thereof. The onus is on the practitioner to
evaluate recommendations in light of the clinical condition of the
patient and recent medical literature. The authors advise the
practitioner to consult other sources, especially the manufacturers\'
warnings and precautions, before prescribing any drug with which they
are unfamiliar. Practitioners are also advised that while these
guidelines will address the needs of many patients, there will be
circumstances calling for exceptions to these recommendations.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Chart Documentation/Checklists/Forms\
Foreign Language Translations\
Patient Resources\
Slide Presentation

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better\
Living with Illness\
Staying Healthy

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Ruoff G, Urban G. Treatment of primary headache: patient education. In:
Standards of care for headache diagnosis and treatment. Chicago (IL):
National Headache Foundation; 2004. p. 22-6. \[1 reference\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2004

#### GUIDELINE DEVELOPER(S)

National Headache Foundation - Private Nonprofit Organization

#### SOURCE(S) OF FUNDING

National Headache Foundation

#### GUIDELINE COMMITTEE

Not stated

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Authors*: Gary Ruoff, MD, and George Urban, MD

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

Electronic copies: None available

Print copies: Available from the National Headache Foundation, 820 N.
Orleans, Suite 218, Chicago, IL 60610; Phone: (888) NHF-5552; Web
address: [www.headaches.org](http://www.headaches.org/)

#### AVAILABILITY OF COMPANION DOCUMENTS

The following are available:

-   Headache screening questionnaire. Chicago (IL): National Headache
    Foundation. 2 p. Electronic copies available in Print Documentation
    Format (PDF) from the [National Headache Foundation Web
    site](http://www.headaches.org/professional/educationindex.html).

-   The complete headache chart. Chicago (IL): National Headache
    Foundation (NHF); 2 p. Electronic copies available in Portable
    Document Format (PDF) from the [National Headache Foundation Web
    site](http://www.headaches.org/consumer/presskit/hachart.pdf)

-   National Headache Foundation fact sheet. Chicago (IL): National
    Headache Foundation (NHF); 2004 Oct. 2 p. Electronic copies
    available in Portable Document Format (PDF) from the [National
    Headache Foundation Web
    site](http://www.headaches.org/consumer/presskit/factsheet.pdf).

Print copies: Available from the National Headache Foundation, 820 N.
Orleans, Suite 218, Chicago, IL 60610; Phone: (888) NHF-5552; Web
address: [www.headaches.org](http://www.headaches.org/)

#### PATIENT RESOURCES

The National Headache Foundation (NHF) has created a variety of
educational resources for patients, including informative brochures, a
patient diary for migraines, Power Point presentations, and patient
guides; many of these resources are available in both Spanish and
English. Some of these items are available as print copies for purchase
through the [NHF online
store](http://www.headaches.org/consumer/storeindex.jsp). Electronic
versions of other resources are available through the consumer education
section of the [NHF Web
site](http://www.headaches.org/consumer/educationindex.html).

Print copies: Available from the National Headache Foundation, 820 N.
Orleans, Suite 218, Chicago, IL 60610; Phone: (888) NHF-5552; Web
address: [www.headaches.org](http://www.headaches.org/).

Please note: This patient information is intended to provide health
professionals with information to share with their patients to help them
better understand their health and their diagnosed disorders. By
providing access to this patient information, it is not the intention of
NGC to provide specific medical advice for particular patients. Rather
we urge patients and their representatives to review this material and
then to consult with a licensed health professional for evaluation of
treatment options suitable for them as well as for diagnosis and answers
to their personal medical questions. This patient information has been
derived and prepared from a guideline for health care professionals
included on NGC by the authors or publishers of that original guideline.
The patient information is not reviewed by NGC to establish whether or
not it accurately reflects the original guideline\'s content.

#### NGC STATUS

This NGC summary was completed by ECRI on April 8, 2005. The information
was verified by the guideline developer on April 26, 2005.

#### COPYRIGHT STATEMENT

These guidelines are for reference purposes only and are not to be mass
produced. This information is copyrighted by the National Headache
Foundation, 2005.

### DISCLAIMER

#### NGC DISCLAIMER

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<http://www.guideline.gov/about/inclusion.aspx> .

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008