Review ArticlePractice

Guideline for primary care management of headache in adults

Werner J. Becker, Ted Findlay, Carmen Moga, N. Ann Scott, Christa Harstall and Paul Taenzer
Canadian Family Physician August 2015, 61 (8) 670-679;

Abstract

Objective To increase the use of evidence-informed approaches to diagnosis, investigation, and treatment of headache for patients in primary care.

Quality of evidence A comprehensive search was conducted for relevant guidelines and systematic reviews published between January 2000 and May 2011. The guidelines were critically appraised using the AGREE (Appraisal of Guidelines for Research and Evaluation) tool, and the 6 highest-quality guidelines were used as seed guidelines for the guideline adaptation process.

Main message A multidisciplinary guideline development group of primary care providers and other specialists crafted 91 specific recommendations using a consensus process. The recommendations cover diagnosis, investigation, and management of migraine, tension-type, medication-overuse, and cluster headache.

Conclusion A clinical practice guideline for the Canadian health care context was created using a guideline adaptation process to assist multidisciplinary primary care practitioners in providing evidence-informed care for patients with headache.

Headache is one of the most common reasons patients seek help from family physicians. The estimated lifetime prevalence of headache is 66%: 14% to 16% for migraine, 46% to 78% for tension-type headache, and 0.1% to 0.3% for cluster headache.1–3 In Canada, at least 2.6 million adult women and nearly 1 million men experience migraine.4 About 90% of migraine sufferers report moderate to severe pain, with 75% reporting impaired function and 33% requiring bed rest during an attack.5 The economic effects of headache are also substantial. It is estimated that headache accounts for 20% of work absences.6

Vast quantities of over-the-counter medications are taken for headache disorders, and treatment is often suboptimal.1,7 Although most migraine sufferers use acute treatment to relieve their headaches, a substantial number of people who might benefit from prophylactic therapy do not receive it—more than 1 in 4 migraineurs are candidates for preventive therapy.5,8

Better information and education for patients and health professionals is essential to improving management of headache in primary care, which should lead to prompt diagnosis and more effective treatment.9 To help address this, a consortium of organizations and clinicians from Alberta developed the Guideline for Primary Care Management of Headache in Adults.10

Scope

The Alberta guideline is intended to assist any primary care practitioner responsible for the assessment and management of headaches in adults. The guideline’s main focus is primary headache disorders (eg, migraine, tension-type, and cluster headache) and medication-overuse headache. Some advice is also provided for the diagnosis and investigation of secondary headache disorders and the management of cervicogenic headache and temporomandibular joint disorder. The guideline will be helpful to a range of primary health care professionals, including family physicians, physical therapists, occupational therapists, nurses, nurse practitioners, pharmacists, psychologists, and chiropractors.

Development

Leadership

The lead organizations involved in developing the guideline were Toward Optimized Practice (TOP), which develops and disseminates primary care guidelines in Alberta, and the Institute of Health Economics (IHE). Three multidisciplinary committees were formed to coordinate guideline production.

  • The Steering Committee provided operational oversight.

  • The Guideline Development Group (GDG) formulated the recommendations and comprised 9 family physicians, 2 neurologists, an osteopathic physician, a chiropractor, 2 physical therapists, an occupational therapist, a nurse, a pharmacist, 2 psychologists, and a health technology assessment specialist.

  • The Advisory Committee advised the Steering Committee on strategic matters and included representatives from the Alberta College of Family Physicians, the Alberta College of Physicians and Surgeons, Alberta Health Services, Alberta Health, the Pain Society of Alberta, and a chronic pain patient advocacy group, as well as experts in guideline development and dissemination.

A research team of health technology assessment researchers with methodologic expertise from the IHE assisted the Steering Committee and GDG.11

Literature review

The Alberta guideline was developed using a guideline adaptation process, which takes advantage of existing high-quality guidelines and allows guideline developers to modify the recommendations from these seed guidelines to meet the needs of the local health care setting.12 Guideline adaptation is a popular alternative to de novo guideline development owing to the need to reduce duplication and constrain costs in the creation of evidence-informed guidelines.13–15

The research team collaborated with experienced medical librarians to systematically search for existing clinical practice guidelines (CPGs) published between January 2000 and May 2011. The search identified 64 guidelines, 18 of which were deemed relevant after application of specific selection criteria developed by the research team and content experts from the GDG.11 The quality of the guidelines was appraised independently by 2 reviewers (C.M. and N.A.S.) using the AGREE (Appraisal of Guidelines for Research and Evaluation) instrument,16,17 which was modified to reduce the subjectivity of the item scoring and to enable the differentiation of good- from poor-quality guidelines.18 Although an updated AGREE tool was published in May 2009,19,20 the research team elected to use the original instrument in order to maintain consistency with previous guidelines produced by TOP and the IHE. Of the 18 potentially eligible guidelines, 6 were scored as good quality and were chosen as seed guidelines.

Two reviewers (C.M. and N.A.S.) extracted the following information into standardized evidence tables: the source of the guideline, the recommendations, the number and types of studies used to create the recommendations (eg, 5 randomized controlled trials), and the strength of the recommendations. A total of 187 recommendations were tabulated. Discordant recommendations were highlighted in the tables.

Practice recommendations

The GDG reviewed the 6 seed guidelines, their companion documents, and the evidence tables during 13 half-day meetings: 1 face-to-face meeting and 12 Web conferences using WebEx (Cisco Systems Inc), which allowed all GDG members to view documents simultaneously and to register their preferences using an online voting system. The 2 GDG cochairs (W.J.B. and P.T.) led all sessions and conducted roundtable discussions for every recommendation to ensure that each GDG member had a voice in the process.

In some cases, the GDG requested additional evidence to resolve uncertainties or disagreements regarding interpretation of the evidence from the seed guidelines or when new interventions were considered that had not been included in the seed guidelines. These “parking lot” requests triggered examination of individual research studies cited by the seed guidelines, as well as additional systematic reviews on headache disorders identified by a supplementary search for literature published between January 2000 and October 2010.11 The parking lot items were referred for further analysis to ad hoc GDG subcommittees that included one or both cochairs, one IHE researcher, and at least one volunteer from the GDG with expertise in the relevant area. Consensus-based decisions made by the subcommittees were then presented to the GDG for final approval. Occasionally new recommendations were generated from parking lot item discussions. A special GDG subcommittee, which included a neuroradiologist, was created for the diagnostic imaging recommendations. The 23-month guideline development process resulted in 91 draft recommendations.

Each recommendation in the Alberta guideline came from 1 or more seed guidelines, was based on evidence from systematic reviews or quasi-systematic reviews, or was created by the GDG members, based on their collective professional opinion and an analysis of relevant evidence. The original wording of the recommendations was retained whenever possible, and designations were used (eg, SR for systematic review, CS for case series) to maintain a link to the evidence cited by the seed guidelines. The principles outlined in the GuideLine Implementability Appraisal tool, which is designed for appraising the implementability of CPGs, were used as a guide when crafting the recommendations.21,22 Standardized definitions for the types of recommendations made in the Alberta CPG were constructed from the evidence-rating scales used by the seed guidelines. The recommendations were categorized as do when the evidence supported the intervention, do not do when the evidence suggested the intervention was ineffective or harmful, or do not know when the evidence was equivocal, conflicting, or insufficient.

A series of companion documents were created, adapted, or adopted to support the implementation of the guideline. These included a quick reference algorithm, a summary document, patient education sheets, and practice tools (a medication table, a headache history form, a patient diary, and a video demonstrating physical examination of the neck).10

The draft guideline was reviewed by the Advisory Committee, a focus group of primary care physicians, and attendees at 2 Alberta physician conferences. The patient information sheets were reviewed by focus groups of patients and laypeople. The feedback was incorporated into the final documents, which were approved by the GDG in February 2012.

Main message

The seed guidelines are listed in Table 1.23–31 The Alberta guideline’s 91 recommendations are organized into 6 sections. The full guideline and accompanying documents are available from the TOP website.10 The quick reference algorithm* information is provided in Figure 1 and Tables 2⇓ to 4.10 Some general practice points are summarized in Box 1.

Figure 1.
Figure 1.

Quick reference algorithm from the Guideline for Primary Care Management of Headache in Adults

CBT—cognitive behavioural therapy, LOC—level of consciousness, NSAID—nonsteroidal anti-inflammatory drug.

Adapted from Toward Optimized Practice.10

View this table:
Table 1.

Seed guidelines used to create the Guideline for Primary Care Management of Headache in Adults

View this table:
Table 2.

Migraine medications: A) Acute migraine medications. B) Prophylactic migraine medications.

View this table:
Table 3.

Medications for tension-type headache

View this table:
Table 4.

Medications for cluster headache: Consider early specialist referral.

Box 1.

General practice points for managing primary headache in adults

The following are general practice points for the management of primary headache in adults:

  • Rule out secondary headache when diagnosing a primary headache disorder

  • Neuroimaging is not indicated in patients with recurrent headache with the clinical features of migraine, normal neurologic examination findings, and no red flags

  • Neuroimaging, sinus or cervical spine x-ray scans, and electroencephalograms are not recommended for the routine assessment of patients with headache: history and physical and neurologic examination findings are usually sufficient to make a diagnosis of migraine or tension-type headache

  • Migraine is by far the most common headache type in patients seeking help for headache from physicians

  • Migraine is historically underdiagnosed and undertreated; many patients with migraine are not diagnosed with migraine when they consult a physician

  • Migraine should be considered in patients with recurrent moderate or severe headaches and normal neurologic examination findings

  • Patients consulting for bilateral headaches that interfere with their activities are likely to have migraine rather than tension-type headache and might require migraine-specific medication

  • Consider a diagnosis of migraine in patients with a previous diagnosis of recurring “sinus” headache

  • Medication overuse is considered to be present when patients with migraine or tension-type headache use combination analgesics, opioids, or triptans on ≥ 10 d/mo or acetaminophen or NSAIDs on ≥ 15 d/mo

  • Comprehensive migraine therapy includes management of lifestyle factors and triggers, acute and prophylactic medications, and migraine self-management strategies

  • A substantial number of people who might benefit from prophylactic therapy do not receive it

  • NSAID—nonsteroidal anti-inflammatory drug.

    • Section 1: headache diagnosis and investigation

    Box 2 presents important elements of the history for patients presenting with first-time headache or a change in headache pattern. Box 3 presents an approach to the physical examination specifically for primary care providers.29 Box 4 presents red flags and other potential indicators of secondary headache.29 Table 5 presents a simplified strategy for diagnosing primary headache disorders.32,33

    View this table:
    Table 5.

    Diagnosing primary headache syndromes

    Box 2.

    Important elements of the headache history in patients presenting with headache for the first time or those with a change in headache pattern

    Explore the following important elements of the headache history:

    • Headache onset (thunderclap, head or neck trauma), previous attacks (progression of symptoms), duration of attacks (< 3 hours, > 4 hours, continuous), days per month with headache

    • Pain location (unilateral, bilateral, associated neck pain, etc)

    • Headache-associated symptoms (nausea, vomiting, photophobia, conjunctival injection, rhinorrhea, etc)

    • Relationship of headache attacks to precipitating factors (stress, posture, cough, exertion, straining, neck movement, jaw pain, etc)

    • Headache severity and effect on work and family activities

    • Acute and preventive medications tried, response, and side effects

    • Presence of coexistent conditions that might influence treatment choice (insomnia, depression, anxiety, hypertension, asthma, and history of heart disease or stroke)

  • Based on expert opinion of the Guideline Development Group.

    • Box 3.

    Approach to the physical examination of a patient presenting with headache for the first time or with a change in headache pattern

    The physical examination should incorporate the following elements:

    • Screening neurologic examination

      • -general assessment of mental status

      • -cranial nerve examination

        • —fundoscopy, pupils, eye movements, visual fields, evaluation of facial movements for asymmetry and weakness

      • -assessment for unilateral limb weakness, reflex asymmetry, and coordination in the arms

      • -assessment of gait, including heel-toe walking (tandem gait)

    • Neck examination

      • -posture, range of motion, and palpation for muscle tender points

    • Blood pressure measurement

    • If indicated by other neurologic symptoms or signs on screening examination, a focused neurologic examination (eg, lower cranial nerve examination in a patient with dysarthria, or plantar responses in a patient with reflex asymmetry)

    • If indicated by associated jaw complaints, an examination for temporomandibular disorders

      • -assessment of jaw opening

      • -palpation of muscles of mastication for tender points

  • Based on the Scottish Intercollegiate Guidelines Network guideline29 and expert opinion of the Guideline Development Group.

    • Box 4.

    Red flags and other potential indicators of secondary headache: Appropriate referral or investigation should be considered.

    Red flags: emergent (address immediately)

    • Thunderclap onset

    • Fever and meningismus

    • Papilledema with focal signs or reduced level of consciousness

    • Acute glaucoma


    Red flags: urgent (address within hours to days)

    • Temporal arteritis

    • Papilledema without focal signs or reduced level of consciousness

    • Relevant systemic illness

    • Elderly patient: new headache with cognitive change


    Other possible indicators of secondary headache (less urgent)

    • Unexplained focal signs

    • Atypical headaches (not consistent with migraine or tension-type headache)

    • Unusual headache precipitants

    • Unusual aura symptoms

    • Onset after age 50 y

    • Aggravation by neck movement; abnormal neck examination findings (consider cervicogenic headache)

    • Jaw symptoms; abnormal jaw examination findings (consider temporomandibular joint disorder)

  • Based on the Scottish Intercollegiate Guidelines Network guideline29 and expert opinion of the Guideline Development Group.

    • Section 2: migraine

    A comprehensive approach to migraine management is summarized in Box 5. Section 2 of the guideline contains recommendations for lifestyle management, acute treatment, prophylaxis, menstrual migraine, and migraine treatment during pregnancy. The full guideline provides a detailed medication table for migraine that includes available formulations, usual doses, relative and absolute contraindications, and adverse events. Boxes 6 and 7 show the indications and considerations for prescribing prophylactic drugs for migraine.28,29 Recommended medications are outlined in Table 2.10

    Box 5.

    Comprehensive migraine management

    Consider the following when managing patients with migraine:

    • Pay attention to lifestyle and specific migraine triggers in order to reduce the frequency of attacks. Lifestyle factors to avoid include the following:

      • -irregular or skipped meals

      • -irregular or too little sleep

      • -a stressful lifestyle

      • -excessive caffeine consumption

      • -lack of exercise

      • -obesity

    • Use acute pharmacologic therapy for individual attacks

    • Use prophylactic pharmacologic therapy, when indicated, to reduce attack frequency

    • Use nonpharmacologic therapies

    • Evaluate and treat coexistent medical and psychiatric disorders

    • Encourage patients to participate actively in their treatment and to employ self-management principles:

      • -self-monitoring to identify factors influencing migraine

      • -managing migraine triggers effectively

      • -pacing activity to avoid triggering or exacerbating migraine

      • -maintaining a lifestyle that does not worsen migraine

      • -practising relaxation techniques

      • -maintaining good sleep hygiene

      • -developing stress management skills

      • -using cognitive restructuring to avoid catastrophic or negative thinking

      • -improving communication skills to talk effectively about pain with family and others

      • -using acute and prophylactic medication appropriately

  • Based on expert opinion of the Guideline Development Group.

    • Box 6.

    Pharmacologic prophylaxis for migraine

    Prophylactic medication is indicated in the following circumstances:

    • Recurrent migraine attacks are causing considerable disability despite optimal acute drug therapy

    • Frequency of acute medication use is approaching levels that place the patient at risk of medication-overuse headache

      • -acute medications are used on ≥ 10 d/mo for triptans, ergots, opioids, and combination analgesics

      • -acute medications are used on ≥ 15 d/mo for acetaminophen and NSAIDs

    • Recurrent attacks with prolonged aura are occurring (hemiplegic migraine, basilar-type migraine, etc)

    • Contraindications to acute migraine medications are making symptomatic treatment of migraine attacks difficult

  • NSAID—nonsteroidal anti-inflammatory drug.

  • Based on expert opinion of the Guideline Development Group.

    • Box 7.

    Pharmacologic prophylaxis for migraine

    Consider the following when prescribing prophylactic medication:

    • Educate patients on the need to take the medication daily and according to the prescribed frequency and dosage

    • Ensure that patients have realistic expectations as to what the likely benefits of pharmacologic prophylaxis will be:

      • -Headache attacks will likely not be abolished completely

      • -A reduction in headache frequency of 50% is usually considered worthwhile and successful

      • -It might take 4–8 wk for substantial benefit to occur

      • -If the prophylactic drug provides substantial benefit in the first 2 mo of therapy, this benefit might increase further over several additional months of therapy

    • Evaluate the effectiveness of therapy using patient diaries that record headache frequency, drug use, and disability levels

    • For most prophylactic drugs, initiate therapy with a low dose and increase the dosage gradually to minimize side effects

    • Increase the dose until the drug proves effective, until doselimiting side effects occur, or until a target dose is reached

    • Provide an adequate drug trial. Unless side effects mandate discontinuation, continue the prophylactic drug for at least 6–8 wk after dose titration is completed

    • Because migraine attack tendency fluctuates over time, consider gradual discontinuation of the drug for many patients after 6 to 12 mo of successful prophylactic therapy, but preventive medications can be continued for much longer in patients who have experienced substantial migraine-related disability

  • Based on Géraud et al28 and the Scottish Intercollegiate Guidelines Network guidelines.29

    • Section 3: tension-type headache

    This section contains recommendations on lifestyle, acute and prophylactic drug therapy, and management of tension-type headache during pregnancy. Recommended medications are outlined in Table 3.10

    Section 4: medication-overuse headache

    Migraine sufferers are particularly prone to developing medication-overuse headache. Recommendations for diagnosis and management of medication-overuse headache are shown in Boxes 8 and 9.29

    Box 8.

    Diagnosis of medication-overuse headache

    Consider the following in the diagnosis of medication-overuse headache:

    • Consider a diagnosis of medication overuse headache in patients with headache on ≥ 15 d/mo and assess patients for possible medication overuse (use of triptans, ergots, combination analgesics, or opioid-containing medications on ≥ 10 d/mo, or use of acetaminophen or NSAIDs on ≥ 15 d/mo)

    • When medication-overuse headache is suspected, the patient should also be evaluated for the presence of the following:

      • -psychiatric comorbidities (depression and anxiety); these might need to be considered in planning an overall treatment strategy

      • -psychological and physical drug dependence

      • -use of inappropriate coping strategies. Rather than relying on medication as a main coping strategy, patients with suspected medication overuse might benefit from training in and development of more adaptive self-management strategies (eg, identification and management of controllable headache triggers, relaxation exercises, effective stress management skills, and activity pacing)

    • Headache diaries that record acute medication intake are important in the prevention and treatment of medication-overuse headache

  • NSAID—nonsteroidal anti-inflammatory drug.

  • Based on the Scottish Intercollegiate Guidelines Network guideline29 and expert opinion of the Guideline Development Group.

    • Box 9.

    Management of medication-overuse headache

    Treatment plans for patients with medication-overuse headache should include the following:

    • Patient education. Patients need to understand that

      • -acute medication overuse can increase headache frequency

      • -when medication overuse is stopped, headache might worsen temporarily and other withdrawal symptoms might occur

      • -many patients will experience a long-term reduction in headache frequency after medication overuse is stopped

      • -prophylactic medications might become more effective

    • A strategy for cessation of medication overuse

      • -abrupt withdrawal should be advised for patients with suspected medication-overuse headache caused by simple analgesics (acetaminophen, NSAIDs) or triptans; however, gradual withdrawal is also an option

      • -gradual withdrawal should be advised for patients with suspected medication-overuse headache caused by opioids and opioid-containing analgesics

    • Provision of a prophylactic medication while medication overuse is stopped. While many prophylactic agents are used (tricyclics, β-blockers, etc), drugs with the best evidence for efficacy in chronic migraine with medication overuse are

      • -onabotulinumtoxinA, 155 units to 195 units injected at intervals of 3 mo by clinicians experienced in its use for headache

      • -topiramate with slow titration to a target dose of 100 mg/d

    • A strategy for the treatment of remaining severe headache attacks with limitations on frequency of use (eg, a triptan for patients with analgesic overuse, dihydroergotamine for patients with triptan overuse, etc)

    • Patient follow-up and support

  • NSAID—nonsteroidal anti-inflammatory drug.

  • Based on the Scottish Intercollegiate Guidelines Network guideline29 and expert opinion of the Guideline Development Group.

    • Section 5: cluster headache

    Cluster headache is managed with a number of pharmacologic therapies. These can be initiated and monitored in primary care, but early specialist referral is recommended because this headache type is uncommon, disabling, and challenging to manage. Recommended medications are outlined in Table 4.10

    Section 6: other headache disorders

    This section of the guideline focuses on hemicrania continua, cervicogenic headache, and headache secondary to temporomandibular joint disorders. Treatment of these conditions will likely involve referral to an appropriately trained therapist or specialist.

    Implementation and update plans

    The guideline has been disseminated through presentations and workshops at provincial, regional, and national conferences. It is also listed in the CMA Infobase,34 where it was among the 10 most downloaded guidelines for nearly 6 months. It also appears on the Michael G. DeGroote National Pain Centre website35 and is listed by the US National Guideline Clearing House.36 A pilot project is under way at the University of Calgary in Alberta to present the headache guideline using interactive webinars.

    The evidence base for the Alberta CPG will be assessed annually and will be updated when new evidence is found that changes the recommendations.

    Limitations

    The guideline adaptation process precluded an in-depth analysis of the validity or a formal assessment of the strength and quality of the underlying empirical evidence, which made categorizing the strength and type of recommendations problematic. To counter this problem, standardized definitions were constructed for the types of recommendations made in the Alberta CPG (eg, what constituted a do or do not do recommendation) from the overlapping evidence-rating scales used by the seed guidelines, and designations were used (eg, SR for systematic review) to maintain a link to the evidence type referenced by the seed guidelines in support of their recommendations.10,11

    The lack of high-quality scientific evidence for headache investigations, diagnosis, red flags, and specialist referral meant that many recommendations in these areas relied on the opinions of the GDG or the experts who developed the seed guidelines. However, these issues were overcome by using credible seed guidelines, scrupulously listing the evidence type and source for all recommendations, and clearly documenting the subjective contextualization process.

    Adaptation processes are limited by the time lag between the publication of primary studies and their incorporation into guidelines, which means that recently published evidence was not necessarily incorporated into the Alberta CPG and that not all of the treatment options available were covered by the seed guidelines. To help offset this, the research team updated searches regularly throughout the Alberta guideline adaptation process.

    There was debate among the GDG members about incorporating newly emerging headache treatments that were not identified in the seed guidelines. A conservative approach was adopted whereby a recommendation for an emerging intervention was created only if it had been assessed in a systematic review.

    None of the seed guidelines included formal economic evaluations or cost analyses, nor did they discuss the economic implications of their recommendations. Owing to time and resource constraints, a formal cost analysis or economic evaluation of the effect of the Alberta CPG was not conducted. However, any statements on economic aspects made by the seed guidelines were noted in the accompanying background document.11

    Conclusion

    The format and brevity of the Guideline for Primary Care Management of Headache in Adults reflects its intent—to provide Canadian primary care providers across multiple disciplines with a comprehensive suite of resources for assessing and managing headaches in adults. A guideline summary and algorithm, as well as practice tools and patient information sheets, are provided to support comprehensive headache management that emphasizes patient engagement and self-management, as well as evidence-informed interventions.

    Acknowledgments

    We thank the members of the Ambassador Program Guideline Development Group, the Advisory Committee, and the Steering Committee for their commitment and hard work. We also thank all of the organizations that provided support during the guideline development process, particularly Toward Optimized Practice for guidance in the final stages of the guideline process and for hosting the completed guideline online. Special thanks to Dr James N. Scott (radiology) and Dr Robert Ashforth (radiology) for their invaluable contributions to the diagnostic imaging components of the guideline. We also thank Ms Wendy McIndoo for administrative assistance and Ms Liz Dennett and Ms Dagmara Chojecki for information services support. Funding for this initiative was provided by Alberta Health. The views expressed herein do not necessarily represent the official policy of Alberta Health.

    Notes

    EDITOR’S KEY POINTS

    • Headache is a common reason why patients seek help from family physicians, and treatment is often suboptimal. This article outlines the development and key recommendations of the clinical practice guideline created by a multidisciplinary guideline development group to assist Canadian primary care practitioners with providing evidence-informed care for patients with headache.

    • Migraine, which is historically underdiagnosed, is by far the most common headache type in patients seeking help for headache. Neuroimaging, sinus or cervical spine x-ray scans, and electroencephalograms are not recommended for the routine assessment of patients with headache: history and physical and neurologic examination findings are usually sufficient to make a diagnosis. Comprehensive migraine therapy includes management of lifestyle factors and triggers, acute and prophylactic medications, and migraine self-management strategies. Treatment of tension-type, cluster, and medication-overuse headache is also outlined.

    Footnotes

    • This article is eligible for Mainpro-M1 credits. To earn credits, go to www.cfp.ca and click on the Mainpro link.

    • This article has been peer reviewed.

    • La traduction en français de cet article se trouve à www.cfp.ca dans la table des matières du numéro d’août 2015 à la page e353.

    • ↵* The original quick reference algorithm is available in an easy-to-print format at www.cfp.ca. Go to the full text of the article online and click on CFPlus in the menu at the top right-hand side of the page.

    • Contributors

      All authors contributed to the literature review and interpretation, and to preparing the manuscript for submission.

    • Competing interests

      Dr Becker served on medical advisory boards for AGA Medical, Allergan, Merck, and Pfizer; received speaker’s honoraria from Allergan, Merck, Pfizer, Serono, and Teva; and received research support as part of multicenter clinical trials (served as local principal investigator) from AGA Medical, Allergan, Medtronic, and Merck. However, these interests had no influence on the design, data analysis, formulation, or content of the guideline. None of the other authors has any conflict of interest to declare.

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