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FM32 Family Medicine
Common Presenting Problems
Toronto Notes 2019
Acupuncture for Migraine Prophylaxis
History
• fever
■ peak temperature, thermometer, route, duration ■ time of day
■ response to antipyretics
• systemicsymptoms
■ weight loss, fatigue, rash, arthralgia, night sweats
• symptomsofpossiblesource
■ UTI/pyelonephritis: dysuria, foul-smelling urine, incontinence, frequency, hematuria, flank pain ■ pneumonia: cough, pleuritic chest pain
■ URTI: cough, coryza, ear pain
■ meningitis: headache, confusion, stiff neck, rash
■ osteomyelitis: bone pain
■ skin: purulent discharge
■ PID: discharge, dyspareunia, lower abdominal pain
■ gastroenteritis: abdominal pain, diarrhea, blood per rectum, vomit
■ medications
■ PE/DVT: swollen legs, pain in calf, SOB, pleuritic chest pain
■ history of cancer/family history of cancer
• infectiouscontacts
■ travel history, camping, day care, contact with TB, foodborne, animals
Possible Investigations
• CBCanddifferential,bloodculture,urineculture,urinalysis • stoolO&P,Gramstain,culture
• CXR, Mantoux skin test, sputum culture
• LP
Management
• increasefluidintake
• general:spongebath,lightclothing • acetaminophen/ibuprofen as needed • treatunderlyingcause
Headache
Primary Headaches
• seeNeurology,N44
Secondary Headaches
• causedbyunderlyingorganicdisease
• account for <10% of all headaches, may be life-threatening
Etiology
• drug: drug withdrawal, medication overuse, drug side effect, and carbon monoxide
• infectious: meningitis, encephalitis, abscess
• vascular: aneurysm, stroke, subarachnoid hemorrhage, hypertension, and temporal arteritis
• endocrine:thyroiddisease,pheochromocytoma
• neoplastic: tumour
• trauma:TMJinjury,c-spineinjury,headinjury,subduralhematoma,andsubarachnoidhemorrhage • other:seriousophthalmologicalandotolaryngologicalcauses
Investigations
• indicated only when red flags are present and may include:
■ CBC for suspected systemic or intracranial infection
■ ESR for suspected temporal arteritis
■ neuroimaging (CT or MRI) to rule out intracranial pathology ■ CSF analysis for suspected intracranial hemorrhage, infection
Management
• basedonunderlyingdisorder
• analgesics may provide symptomatic relief
Cochrane DB Syst Rev 2016:6:CD001218
Purpose: To investigate whether acupuncture is more effective than no prophylactic treatment, routine
care only or sham acupuncture, and whether it is as effective as prophylactic pharmacological treatment, in terms of reducing headache frequency in adults with episodic migraine.
Methods: Meta-analysis of RCTs with a minimum of an 8 wk duration, comparing acupuncture intervention with a no-acupuncture control (no prophylaxis, routine care, sham, or pharmacological prophylaxis).
Results: 22 trials with 4,985 participants were included. Acupuncture was associated with moderate headache frequency reduction compared to no acupuncture (standardized mean difference (SMD) -0.56, 95% CI -0.65 to -0.48), and a reduction of >50% in headache frequency for 41% and 17% of participants receiving acupuncture and no acupuncture, respectively (pooled risk ratio (RR) 2.40, 2.08 to 2.76; number needed to treat (NNT) 4, 3 to 6). Acupuncture showed a small but statistically significant reduction over sham both post-treatment (SMD -0.18, -0.28 to -0.08) and post-follow-up (SMD -0.19, -0.30 to -0.09), with 50%+ headache frequency reduction being achieved in 50% versus 41% of those receiving acupuncture and sham, respectively (pooled RR 1.23, 1.11 to 1.36; NNT 11, 7 to 20); these numbers were 53% and 42%, respectively, post-follow-up (pooled RR 1.25, 1.13 to 1.39; NNT
10, 6 to 18). Number of participants dropping out and reporting adverse effects did not differ significantly between acupuncture and sham groups. Compared to pharmacological prophylaxis, a significant reduction in migraine frequency was noted with drugs (SMD -0.25, -0.39 to -0.10), but the significance was not maintained at follow-up. After 6 months, headache frequency was halved in 59% of patients receiving acupuncture and 54% receiving prophylactic drugs (pooled RR 1.11, 0.97 to 1.26). Those receiving acupuncture were less likely to drop out due to adverse effects or to report adverse events than those receiving drugs.
Conclusion: Adding acupuncture to symptomatic treatment of attacks reduces frequency of headaches. Acupuncture is more effective than sham, and is similarly effective to pharmacological interventions for migraine prophylaxis.
Migraine Screen
POUND
Pulsatile quality
Over 4-72 h
Unilateral
Nausea and vomiting
Disabling intensity
if ≥4 present then a diagnosis is likely (+LR = 24)
Headache Red Flags
SNOOP
Systemic symptoms of illness
• fever
• anticoagulation • pregnancy
• cancer
Neurologic signs/symptoms • impairedmentalstatus • neckstiffness
• seizures
• focalneurologicaldeficits Onset
• suddenandsevere
• newheadacheafterage50 Other associated conditions
• followingheadtrauma
• awakenspatientfromsleep
• jawclaudication
• scalptenderness
• worsewithexercise,sexualactivityor
Valsalva
Prior headache history
• differentpattern
• rapidlyprogressinginseverity/frequency