Our recent BASH GPwER meeting in London was an inspirational day of learning and networking. Dr Sam Johnson shares the highlights.
Face to Face meetings with colleagues are inspiring
Being completely captivated last time we met, when hearing about the work that Dr Phil Holland and his team has been doing in the Wolfson SPARC lab, and having a teaser of the role of holistic medicine in migraine management, I was thoroughly looking forward to this session, which promised to expand on this. Furthermore, following one of the previous meetings about setting up an Integrated Training Post for Headache within the GP training programme, we were joined by one such ITP trainee - Dr Ben Hueso- who had recently started on the programme. It is great to see that this project has led to our first member through this scheme. [Editor's note: See Dr Rachel Kilner's earlier blog about this scheme]
Neuromodulation - a novel approach
We began the day with a talk from the team behind Nerivio - a neuromodulation device that is licensed for both acute and preventative treatment of migraine. Although not currently available on the NHS, this may be something that we can offer our patients in the not-too-distant future as an alternative to medical therapy.
Exploring the use of GLP-1 receptor agonists
A truly fascinating talk from Dr Olivia Grech explained her work surrounding mechanisms and new treatments for headache in raised intracranial pressure. There is a clear need for novel approaches to treating Idiopathic Intracranial Hypertension, as there is insufficient evidence to recommend any drug as a treatment for this condition. Weight loss is currently one of the only evidence based treatments for the condition. Enter GLP1 receptor agonists. Her work has shown that, seemingly independent of its role in weight loss, and likely through its role in regulating CSF resorption, exenatide can be used to treat IIH. Although this drug is no longer available in the UK, it may be that other GLP1 receptor agonists have potential for treating this challenging condition.
Healing and Science - working holistically
I’m not sure how to even begin to summarise the following “Clash of the Titans” talk. Titled: “Bridging the science of medicine and art of healing", we first heard from Dr David Kernick, challenging the traditional scientific paradigm and models that we use to make sense of the world, and reframing this within migraine, more specifically focusing more on “allostasis” rather than “homeostasis” - and how recurrent predictive error of the brain can lead to increased “allostatic load”. As migraine becomes more chronic, it invariably becomes harder to treat, and it might be that such patients benefit more from an holistic approach.
We explored concepts such as “interoceptive” and “exteroceptive” healing, which led nicely on to Dr Holland’s talk - expanding on the anatomical and physiological substrates of interoception and exteroception. Whilst still having a good dose of in-depth “science stuff” (such as orexin being a key integrator of interoceptor signals), Dr Holland also showed how this might fit into the holistic approach, for example why mindfulness can help to improve interoception, minimising predictive error, and ultimately reducing allostatic load.
New projects are being developed
Two of our members shared updates on projects they have been involved in developing. Firstly, Dr David Watson shared the Grampian and Migraine Trust project on partnering with pharmacy teams to improve migraine management. [Editor's note: see earlier blog from Dr David Watson and Rob Music about this project]It seems that this was an untapped resource and there was a lot of uptake in the Grampian area from pharmacists to improve their knowledge. A useful learning point for me was, when writing to the GP asking them to titrate medications, why not ask the pharmacotherapy team to supervise this?
We then heard from Dr Rebecca Walker about the National Migraine Centre Registry project. It was really interesting to hear about the rationale for developing such a registry, and the benefits that such a registry might bring, particularly in terms of research potential and prioritising patient care.
Feedback from the recent MTIS symposium
Dr Kay Kennis presented highlights from the recent Migraine Trust International Symposium. [Editior's note: see earlier blog from Dr Kennis] My personal highlights of her talk were
1. As CGRP peaks at 11pm, there is some evidence for taking medication such as Rimegepant in the evening
2. The SPACE EM study is the first large study of CGRP mAbs in children and shows some evidence of benefit of Fremanezumab as a preventer
3. GLP1 receptor agonists such as liraglutide show a reduction of migraine days per month in obese patients
4. Rimegepant has good safety data for cardiovascular disease
5. GON blocks - mixed reviews for chronic migraine however clear evidence of benefit in cluster headache.
The impact of medication may affect relationships
Dr Goska Trubshaw gave a fascinating talk on sexual dysfunction with neurological drugs. This is something I don’t usually talk enough about with patients, but she provided a really useful table on the specific type of sexual dysfunction with some of the more commonly prescribed neurological drugs.
More about AI in medicine -a useful tool shared
Finally, Dr Marcus Lewis provided a brief but useful update on AI in medicine, specifically in the form of a website OpenEvidence.com, a free to use AI search engine, which uses the entire PubMed database as a source. He talked us through how best to use this, and top tips as ever were to provide context in order to get the most useful answer out of the AI.
Our next BASH GPwER meeting is planned for Friday March 21st. Please email info@bash.org.uk for more information about this meeting.
Dr Sam Johnson
GPwER in Headache
Winchester
