Structured headache services as the solution to the ill-health burden of headache: 1. Rationale and Description

DOI: https://doi.org/10.1186/s10194- 021- 01265- z

Abstract-Summary In countries where headache services exist at all, their focus is usually on specialist (tertiary) care.

This is clinically and economically inappropriate: most headache disorders can effectively and more efficiently (and at lower cost) be treated in educationally sup- ported primary care.

High demand for headache care, estimated here in a needs-assessment exercise,

is the biggest of the challenges to reform.

The structured headache services model presented here by experts from all world regions on behalf of the Global Campaign against Headache is the suggested health- care solution to headache.

It develops and refines previous proposals, responding to the challenge of high demand by basing headache services in primary care, with two supporting arguments.

Only primary care can deliver headache services equitably to the large numbers

of people needing it.

The model calls for vertical integration between care levels (primary, secondary and tertiary), and protection of the more advanced levels for the minority of patients who need them.

Introduction Governments, politicians and health-service managers concerned about the cost of headache care for very large numbers of people fail to recognize a fundamentally important aspect of the economics of headache disorders: untreated, they are a huge financial drain.

A wealth of evidence attests the efficacy of treatments for migraine and other

primary headache disorders that can well be provided by non-specialists [479].

In a reasonable expectation, good health care delivering these treatments effi- ciently to those who will benefit from them will substantially reduce the ill-health burden of headache.

Regrettably, throughout the world, the opportunity is missed: health-care sys- tems that ought to provide this care either do not exist or, where they do, fail to reach many who need it [36, 480].

Methods Experts from all world regions, in headache, health service organization or health- technology assessment, were brought together to contribute to these proposals through email correspondence.

They took evidence from the published literature and, using this, built a headache- care model by developing and refining previous proposals for headache service

1.4

Governance

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organisation [13, 50, 90, 118, 131, 142, 178–482] put forward by Lifting The Burden (LTB) [483] and the European Headache Federation (EHF) [484].

They extended the applicability of the model beyond Europe through their own expertise and local knowledge and by drawing from experience and understanding gained by the Global Campaign against Headache during its 16 years of activities worldwide [483].

The Problems In a United Kingdom (UK) study based in primary care 20 years ago, 17% of regis- tered patients aged 16–65 years had consulted a general practitioner (GP) because of headache [485].

Effective treatments exist [479, 486], but the proposal that everyone with head-

ache has need for professional care is not arguable in a resource-limited world. The first is that only those with disabling headache need professional care. In every million people in the world, therefore, there are 80,000 adults (12% of the 660,000 aged 15–64  years) who need care because of migraine-attributed disability.

In the absence of better data, a conservative but reasonable working basis is that headache-care needs in these age groups, in terms of numbers, are, proportionately, half those of adults [178, 482]: another 17,000 (0.5*13.5% of the 250,000 aged 14 or under) in each million of the population.

The Health-Care Solution Nationwide structured and educationally supported headache services embedded and integrated within a country’s health-care system are the means of efficiently, effectively and equitably mitigating the personal and societal burdens of headache to the greatest extent possible with resources available, a proposition put forward by LTB and endorsed by WHO a decade ago [90].

Structured headache services pull elements together from primary, secondary

and specialist (tertiary) care, and, importantly, from pharmacy services.

The model does not require every HCP in primary care to offer headache ser- vices if they can share caseload between themselves according to their skills and interests, an arrangement that may be administratively easy in group practices or health centres.

With these and the educational supports, this level should competently meet the needs of most people needing professional care for headache [178, 487]: most cases of migraine (and almost all of TTH, if needing care) can be diagnosed and managed here by HCPs who should be familiar with recommended acute and preventative drugs [484] and aware of the constraints in managing fertile women (important since these are a high proportion of people with migraine).

Concluding Remarks Many problems beset the current compartmentalized division of headache services between primary, secondary and tertiary care.

The model is amenable to horizontal integration with other care services, and

capable of adaptation to suit local cultures and health-care systems.

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1 Public Health

The need for better—and better resourced—headache services exists in all coun-

tries, differing only quantitatively.

At a time when momentum is again developing for health-service reform divert- ing resources from secondary to primary care [488, 489], there is opportunity for change.

Acknowledgement A machine generated summary based on the work of Steiner, Timothy J.; Jensen, Rigmor; Katsarava, Zaza; Stovner, Lars Jacob; Uluduz, Derya; Adarmouch, Latifa; Al Jumah, Mohammed; Al Khathaami, Ali M.; Ashina, Messoud; Braschinsky, Mark; Broner, Susan; Eliasson, Jon H.; Gil-Gouveia, Raquel; Gómez-Galván, Juan B.; Gudmundsson, Larus S.; Herekar, Akbar A.; Kawatu, Nfwama; Kissani, Najib; Kulkarni, Girish Baburao; Lebedeva, Elena R.; Leonardi, Matilde; Linde, Mattias; Luvsannorov, Otgonbayar; Maiga, Youssoufa; Milanov, Ivan; Mitsikostas, Dimos D.; Musayev, Teymur; Olesen, Jes; Osipova, Vera; Paemeleire, Koen; Peres, Mario F.  P.; Quispe, Guiovanna; Rao, Girish N.; Risal, Ajay; de la Torre, Elena Ruiz; Saylor, Deanna; Togha, Mansoureh; Yu, Sheng-Yuan; Zebenigus, Mehila; Zewde, Yared Zenebe; Zidverc-Trajković, Jasna; Tinelli, Michela, 2021 in The Journal of Headache and Pain.

Editorial. Valuing headache’s solution