Transcript GP_Special_Interest 380KB PPT - Migraine in Primary Care

MIGRAINE IN PRIMARY CARE ADVISORS
Guildford, 24 January 2003, 2-6 pm
General Practitioners with a special
interest in headache (GPSIH)
Introduction and objectives
Dr Andrew Dowson
Kings’ Headache Service, London
Programme
• Dr Andrew Dowson: Introduction and
objectives
• Ms Ann Turner: Plans for the future
organisation of headache services in the UK:
the perspective from Headache UK
• Dr Andrew Dowson: Managing chronic
headaches in the clinic
• Break
• All: Discussion session: Setting up a primary
care headache clinic: a practical guide
• Dr Andrew Dowson: Conclusions
Objectives of today’s meeting
• Review Headache UK’s overall plans for
UK headache services
• Discuss the practicalities of setting up
a primary care headache clinic
• Discuss the optimal way to manage
chronic headaches
Outputs
• Article on how to set up a headache
clinic in primary care
– Multidisciplinary focus
• Document for RCGP
• Article on the management of chronic
headaches
– Algorithms for CDH and cluster headache
• MIPCA newsletter
• Slide set
Headache UK
Organisation of headache
services in the UK
Ann Turner
Chairman Headache UK
January 2003
What is Headache UK?
• An umbrella group representing the 5
national charities currently working in
headache:
• Migraine Action Association
• Migraine Trust
• Migraine in Primary Care Advisers
• British Association for the Study of
Headache
• Organisation of the Understanding of Cluster
Headache
Why do we need it?
• To improve and facilitate
communication
• To avoid duplication of effort and waste
of resources
• To make best use of increasingly
scarce resources
• To lobby government for improvement
in headache services
How did it start?
• HW2000 Preliminary discussions
• June 2001 Exploratory meeting
• October 2001 Group formally formed
and objectives identified
What has it achieved?
• Representations to government and the Department
of Health re. the inclusion of headache in the NSF
• Official launch of HUK at the Houses of Parliament
(June 2002)
• Formation of an All Party Parliamentary Group on
Primary Headache Disorders (October 2002)
• Headache highlighted in House of Commons debate
(January 2003)
• Developed relationships with other agencies for
educational purposes e.g. CPPE and University of
Bath
Introduction
• Development of primary care-led NHS
– PCGs and PCTs
– Headache services to be incorporated
• At present, migraine, cluster headache and
other headaches are under-estimated, underdiagnosed and under-treated in the UK
• Despite this, the personal and economic
burdens of headache are high
• Current NHS spending on the management
of headache disorders is inadequate,
unevenly distributed and not optimally
managed
Current situation
• Overall quality of primary care headache services
unknown
– Ad hoc services performed on demand
• Present services are neither adequate nor cost
effective
–
–
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–
–
–
No national or local targets
Little research, auditing or benchmarking undertaken
Access to headache care is restricted
Few GPs and neurologists are interested in headache
Few nurses and other professionals are employed
Secondary care neurology departments are overstretched,
exacerbated by inappropriate referrals for headache
– The burden of headache remains high
Objectives
• To review the organisation of headache
services in primary care and
recommend changes necessary to
improve headache care
• An initial document was prepared in
2000
• Headache UK will revise the document
and use it to lobby government
agencies and healthcare providers
BASH 2000
Aims
• To expand the role of primary care in the
management of headache disorders
• Improve patients’ access to effective care
• Achieve consensus among professional
organisations
• Implementation of a multidisciplinary approach to
care
• Headache services to be re-organised in a stratified
way
–
–
–
–
Local general practice
Primary care headache centres
Secondary care headache centres
Tertiary care centres
BASH 2000
Local general practice
Local general practice: principles
• Each GP should provide a first-line headache
service
• All GPs should be well educated in headache
diagnosis and management
• All GPs should work according to accepted
guidelines
• Nurses and pharmacists could take over
many roles in headache management with
appropriate training
– Headache diploma (Leeds Metropolitan
University)
Principles of headache management in
primary care
Sinister / Cluster
/ Chronic
Referral to
specialist
Migraine
Consultation
•Specific
consultation
•Treatment
history
•Patient
education,
counselling
and buy-in
Diagnosis
•Screen for
headache type
Assess
severity
•Attack frequency
and pain severity
•Impact on
patient’s life
•Non-headache
symptoms
•Patient factors
Treatment
plan
•Establish goals
•Acute therapy
•Possible
prophylactic
therapy
Follow-up
Assess outcome
of therapy
Consultation
Taking a careful history is essential
– Use of a headache history questionnaire is
recommended
• Patient education
– Advice, leaflets, websites and patient
organisations (Migraine Action Association,
OUCH [cluster headache], Migraine Trust)
• Patient-centred care
– Patients to take charge of their own management
– Effective communication between patient and
physician
MIPCA 2002
Diagnosis
• Careful differential diagnosis required
• IHS diagnostic criteria are comprehensive,
but may be too complex for everyday use in
primary care
• Simple but comprehensive scheme required
for the differential diagnosis of headache
subtypes
• Diagnosis can then be confirmed with
additional questions
MIPCA 2002
Management individualised for each
patient
Assess illness severity
• Attack frequency and duration
• Pain severity
• Impact on daily living
– Impact questionnaires (MIDAS/HIT)
• Non-headache symptoms
• Patient factors
– History, preference and other illnesses
Individualise care to the illness severity and
needs of each patient
MIPCA 2002
Follow-up procedures
• Instigate proactive long-term follow-up
procedures
• Monitor the outcome of therapy
– Headache diaries
– Impact questionnaires (MIDAS/HIT)
• Make appropriate treatment decisions
Individual headaches
• Migraine
– In most cases, management can occur in primary
care
• Cluster headache / CDH
– Initial diagnosis made in primary care
– Initial management probably best conducted in
secondary care (long waiting lists)
– Follow-up and long-term management devolved
into primary care
• Sinister headaches
– Diagnosis and management in secondary care
Implementation of guidelines:
multidisciplinary approach
• Primary care headache team
– GP, practice nurse, ancillary staff and sometimes
pharmacist (core team)
– Community pharmacist
– Community nurses
Associate team
– Optician
members
– Dentist
– Complementary practitioners
– Specialist physician (additional resource)
MIPCA 2002
Primary care
Pharmacist
Practice
nurse
Ancillary
staff
Primary care
physician
Patient
MIPCA 2002
Core team
Roles of GP and nurse
• GP
– Overall diagnosis and management of the patient
• Nurse
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–
–
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Advice and information
Initial triage assessment
Conduct investigations and tests
Review follow-up assessments
Role in prescribing (from 2003)
• Also possible role for pharmacists in the future
Primary care
Community nurse
Optician
Pharmacist
Practice
nurse
Ancillary
staff
Primary care
physician
Dentist
Complementary
practitioner
Patient
MIPCA 2002
Associate team
Core team
Requirements
• Implementation of new diagnostic and
management guidelines
• Training for GPs, nurses and pharmacists
– Role of specific GP educators?
• User-friendly guide for patients
– In association with patient groups
– Information on preparation for consultation and
realistic expectations
Issues
• Government target: 75% of practices
currently conducted in secondary care will
be transferred to primary care within the next
7 years
• Need to change current practices and
patterns of behaviour
– Most GPs do not practice individualised care
– Increased flexibility needed
– Role of the ‘specialist patient’
Primary care headache
centres
Primary care headache centres
• Headache referral centres established within
–
–
–
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Individual GP clinics
PCGs
PCTs
Resource / Interest driven
• Each centre staffed by people with an
interest in headache management:
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–
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Physicians
Specialist nurses
Physical therapists
Psychologists
BASH 2000
Primary care
Community nurse
Optician
Pharmacist
Practice
nurse
Specialist
care
Ancillary
staff
Primary care
physician
Physician with expertise
in headache:
GP; PCT; specialist
Dentist
Complementary
practitioner
Patient
MIPCA 2002
Associate team
Core team
Pathways of care
Secondary and tertiary
care specialists
Sinister, refractory and rare
variant headaches
Headache
management
Consultation
Diagnosis
Primary care
specialist
Migraine; Cluster
headache; Chronic daily
headache
Assess
severity
Treatment
plan
Uncomplicated migraine
and TTH
Primary care
Follow-up
Requirements
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•
•
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Political and health authority buy in
Sufficient funding
Staff training
Interest / will for service
Secondary care headache
centres
Needs
• More specialist care needed for the more
complex patient
• Needy patients should be seen rapidly
• Symbiosis needed between primary and
secondary care
• Audits of the services that headache centres
are offering
• More neurologists with a special interest in
headache
Secondary care headache centres
• Establish formally
– In association with regional neurological centres?
• Services:
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–
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Telephone advice to primary care staff/patients?
Emergency
Referral
Urgent
services
Routine
(Education for primary care centres?)
Requirements
• Political and health authority buy in
• Sufficient funding
– Currently under-resourced
• Staff training
• Interest/will to provide service
Conclusions: overall needs
• Simple to use, rational, evidence-based guidelines
for diagnosis and management in primary care
– New MIPCA guidelines?
• Implicit role of patient support organisations
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–
Migraine Action Association (MAA)
OUCH (cluster headache)
Educational initiatives for the general public
Specialist patient
• Specific schemes of continuing professional
development
• Audit and development of best practice for all levels
of care
Managing chronic headaches in the
clinic
Dr Andrew Dowson
Chronic headaches
• Chronic daily headache (CDH)
– Medication overuse headache (MOH)
• Cluster headache
• Other headaches
– Short, sharp headache
– Headaches associated with old age
Chronic daily headache (CDH)
Headache severity
10
a. Chronic tension-type headache
5
1
2
Months
3
Chronic daily headache (CDH)
Headache severity
10
b. Migraine superimposed over CTTH
5
1
2
Months
3
Chronic daily headache (CDH)
Headache severity
10
c. Chronic migraine
5
1
2
Weeks
3
CDH - presentation
• A history of headaches lasting >4 hours,
occurring on >15 days per month1
• May be associated with overuse of
symptomatic headache medications (MOH)2
– Analgesics, opioids, ergots, triptans
• May be associated with a history of
head/neck injury3
1. Headache Classification Committee. Cephalalgia 1988;8 (Suppl 7):1-92
2. Diener H-C, Katsarava Z. Curr Med Res Opin 2001;17 (Suppl 1):17-21
3. Couch JR, Bearss C. Headache 2001;41:559-64
CDH – screening / diagnosis
• Specific consultation
– Headache history
– Provide relevant information
– Obtain patient’s engagement with care
• Conduct differential diagnosis
– Monitor for sinister headache
• Assess:
– Severity (impact, frequency, duration, pain
severity, patient preferences, co-morbidities)
– Abuse of symptomatic medications?
– Neck stiffness/ restricted movement?
Dowson AJ. Doctor 2003; in press
Exclude sinister
Headache (<1%)
ETTH
(40-60%)
Patient presenting
with headache
Q1. What is the impact of the headache
on the sufferer’s daily life?
low
High
Q2. How many days of headache
does the patient have every month?
Migraine/CDH
 15
> 15
Q3. For patients with chronic daily
headache, on how may days per week
does the patient take analgesic medications?
<2
No medication
overuse
Migraine
(10-12%)
Consider short-lasting
Headaches (<1%)
CDH
(5%)
Q4. For patients with migraine, does the
patient experience reversible sensory
symptoms associated with their attacks?
2
Medication
overuse
Yes
With aura
No
Without aura
Dowson AJ et al. Curr Med Res Opin 2002;18:414-39
CDH – goals of therapy
• Relieve the pattern of daily or neardaily headaches
– Prevent all headaches,
or
– Resume a pattern of original intermittent
primary headaches
• Reduce the impact on the patient’s
daily life
CDH – treatment
• Physical therapy and exercises to the neck
– Patients with neck stiffness
• Withdraw offending headache medications
– Inpatient or outpatient
• Prophylaxis
– Antidepressants
– Anticonvulsants
– Botox?
• Limited acute medication
– e.g. a triptan if the patient has a history of migraine
Dowson AJ. Doctor 2003; in press
Dowson AJ et al. CNS Drugs 2003; in press
CDH – follow-up
• Instigate proactive long-term follow-up
procedures to assess pattern of headaches
and patients’ response to therapy
– Headache diaries
– Impact tools
• If successful, withdraw prophylaxis gradually
and retain acute medications
• If unsuccessful, refer
Dowson AJ. Doctor 2003; in press
Dowson AJ et al. CNS Drugs 2003; in press
CDH management – key features
•
•
•
•
Monitor for sinister headache
Diagnostic assessment
Assess impact on the patient’s daily life
Monitor for medication overuse and
head/neck injury
• Proactive, long-term, patient-centred
approach
• Most patients can be managed by primary
care specialists or GPs
Dowson AJ. Doctor 2003; in press
Prediction of CDH developing from
migraine
• Retrospective, 1-year audit of triptan
usage in nine UK clinical practices
• 360 adults with migraine
• Patient records and a questionnaire
analysed
• Endpoints
– Triptan usage (tablets/yr)
– Predictors of high usage
Williams D et al. Curr Med Res Opin 2002;18:1-9
Triptan usage over 12 months
Low
70
59.8
Patients (%)
60
50
High
40
Moderate
30
15.4
20
8.8
7.4
10
7.4
0
1 to 36
37 to 53
54 to 94
95 to 149
150+
Williams D et al. Curr Med Res Opin 2002;18:1-9
Predictors of high triptan usage and
therefore risk of CDH
• Use of several other non-triptan medications
to treat conditions other than migraine
• Patients’ perception of all headaches as
migraine
• Lack of concern about taking too much
medication
• One triptan dosage reported as sufficient to
treat an attack
Williams D et al. Curr Med Res Opin 2002;18:1-9
Decision tree
Number of other medications taken
over last 12 months
≥5
1-4
Do you have concerns about taking
too much medication?
Would a single dose normally
be sufficient?
Yes
No
Risk of overuse of triptans
Williams D et al. Curr Med Res Opin 2002;18:1-9
Recommendations for GPs
• Audits of triptan usage
• Patients identified as high triptan users:
– Review of diagnosis
– Identification of possible causes of increased
frequency of attacks
– Investigation of suspected non-migraine
headaches
• Review high triptan users every 3-6 months
Williams D et al. Curr Med Res Opin 2002;18:1-9
Discussion
Development of an algorithm for CDH
management
Cluster headache
Headache severity
10
5
1
Weeks
Cluster headache - presentation
• A history of headaches lasting >15-180 min,
occurring up to several times per day
– Abrupt onset and cessation
• Excruciating pain, with red/watering eyes and/or
blocked nose
• Attacks occur in 2-3 month clusters (80-90%) or
chronically (10-20%)
• Male prevalence
• Induced by alcohol
Headache Classification Committee. Cephalalgia 1988;8 (Suppl 7):1-92
Dowson AJ. Migraine: Your Questions Answered; 2003
Cluster headache – screening /
diagnosis
• Specific consultation
– Headache history
– Provide relevant information
– Obtain patient’s engagement with care
• Conduct differential diagnosis
– Monitor for sinister headache
• Assess:
– Severity (impact, frequency, duration, pain
severity, non-headache symptoms, patient
preferences, co-morbidities)
Dowson AJ. Migraine: Your Questions Answered 2003
Exclude sinister
Headache (<1%)
ETTH
(40-60%)
Patient presenting
with headache
Q1. What is the impact of the headache
on the sufferer’s daily life?
low
High
Q2. How many days of headache
does the patient have every month?
Migraine/CDH
 15
> 15
Q3. For patients with chronic daily
headache, on how may days per week
does the patient take analgesic medications?
<2
No medication
overuse
Migraine
(10-12%)
Consider short-lasting
Headaches (<1%)
CDH
(5%)
Q4. For patients with migraine, does the
patient experience reversible sensory
symptoms associated with their attacks?
2
Medication
overuse
Yes
With aura
No
Without aura
Dowson AJ et al. Curr Med Res Opin 2002;18:414-39
Consider short-lasting
Headaches (<1%)
Usually male
Frequency/occurrence
Frequency:
several attacks/day
Occurrence:
Clusters or chronic
Duration
15-180 min
Pain intensity
Excruciating
Non-headache
symptoms
Red/watering eyes
Blocked nose
Cluster headache
Cluster headache – goals of therapy
• Prevent the occurrence of the
headaches
• Effectively and rapidly treat attacks that
occur
• Reduce the impact on the patient’s
daily life
Cluster headache – treatment
• Long-term prophylaxis
– Verapamil (gold standard): High doses
– Lithium
• Short-term prophylaxis
–
–
–
–
Prednisolone
Methysergide
Ergotamine
Gabapentin (future)
• Abortive
– Subcutanous sumatriptan (gold standard)
– Inhaled oxygen
Matharu M, Goadsby PJ. Pract Neurol 2001;1:42-9
Cluster headache – follow-up
• Long-term prophylactic and abortive
therapies needed
• Proactive long-term follow-up
– Headache diaries
• Long-term snapshot
– Impact tools
• If unsuccessful, refer
Dowson AJ. Migraine: Your Questions Answered 2003
Cluster headache management – key
features
•
•
•
•
Monitor for sinister headache
Diagnostic assessment
Assess impact on the patient’s daily life
Proactive, long-term, patient-centred
approach
• Most patients can be managed by
primary care specialists
Discussion
Development of an algorithm for cluster
headache management
Other chronic headaches
•
•
•
•
•
Short, sharp headaches
Sinus headaches
Trigeminal neuralgia
Post-herpetic neuralgia
Temperomandibular dysfunction
Can all be managed using the same
strategies as for migraine, CDH and cluster
headache
Conclusions
• The same strategies can be used to
manage all headache subtypes
– Careful screening
– Differential diagnosis
– Assessment of severity
– Tailoring of treatment to the individual
– Proactive follow-up
– Multidisciplinary care team
General Practitioners with Special
Interests - GPwSI
Dr Jerry Sender
Merrow, Guildford
General Practitioners with Special
Interests-GPwSI
•
•
•
•
•
•
Background
Areas for GPwSI
Threats vs opportunities
General principles
Local experience
Funding
GPwSI
•
•
•
•
•
•
Background
NHS Plan July 2000
Improving access
Reducing waiting times
1,000 GPwSI by 2004
Recognise pre-existing expertise
GPwSI
• Areas for GPwSI
• Non clinical – Education
- Research/Academia
- Appraisal/Mentoring
- Management
GPwSI
• Clinical – ENT
- Dermatology
- Substance misuse
- Rheumatology
- Minor surgery
- Endoscopy / Cystoscopy
- Sports medicine
GPwSI
• Models for GPwSI in clinical practice
• Provides local service for PCT
• Provides local service within 1ry/2ry
care team – usually based in 2ry care
• Provides service within 2ry care team
GPwSI
• Opportunities
• Enhancing patient care
access/communication
• GP career development
• Improved relationship with 2ry care
• Efficiency / Costs
GPwSI
•
•
•
•
•
Threats
Degrade generalism
Reduce capacity for GMS work/access
Sacrifice quality – ease W/L pressures
Risk – increased at expense of patient
and GPwSI
GPwSI
•
•
•
•
•
•
•
•
General principles
Enhance service. Not substitute or duplicate
Local flexibility meeting local needs
Adequate resources
Contract
Training / Support
Define areas of competence / standards
Clinical governance / CME
GPsWI
•
•
•
•
•
•
•
Local experience
Setting up
Negotiate
Identify time
Supervision
Audit
Remuneration
Discussion session:
Setting up a primary care headache
clinic: a practical guide
Overview
•
•
•
•
Strategy: Principles of care
Tactics: Key tasks
Organisational structure
Development of the service
– RCGP framework
Strategy: differences in philosophy
Primary care:
• Emphasis on management
Secondary care
• Emphasis on diagnosis
Strategy: Principles of care - 1
MIPCA / HCPC principles
Screening and diagnosis
• Almost all headaches are
benign/primary and can be managed by
all practising clinicians.
• Use questions / a questionnaire
assessing impact on daily living for
diagnostic screening and to aid
management decisions.
Strategy: Principles of care - 2
Management
•
Share management between the clinician and the
patient.
•
Provide individualised care and encourage
patients to treat themselves.
•
Follow-up patients, preferably with headache
diaries.
•
Assess the success of therapy using specific
outcome measures and monitor the use of acute
and prophylactic medications regularly.
•
Adapt management to changes that occur in the
illness and its presentation over the years.
Strategy: Principles of care - 3
Treatments: Migraine
•
Provide acute medication to all migraine patients
and recommend it is taken as early as possible in
the attack.
•
Provide rescue medication / symptomatic
treatment if the initial therapy fails.
•
Prescribe prophylactic medications to patients
who have four or more migraine attacks per month
or who are resistant to acute medications.
•
Consider concurrent co-morbidities in the choice
of appropriate prophylactic medication.
•
Work with the patient to achieve comfort with the
treatment recommended and that it is practical for
their lifestyle and headache presentation.
Tactics: Key tasks
• Counselling and education for patients
and primary care professionals
• Differential diagnosis
• Tailoring of care to the individual’s
needs
• Proactive follow-up
• Headache team
– Liaison with primary care
– Liaison with specialist physicians
Counselling and education
• Engagement with the patient
– Develop good communication skills
• Information sources
– Books
– Leaflets
– Websites
– Patient organisations
Counselling and education
• Links with professional groups
– IHC
– MIPCA
– Migraine Trust
– BASH
Headache UK
• Links with patient support
organisations
– Migraine Action Association
– OUCH
Headache UK
Differential diagnosis
• Simple diagnostic screen
– MIPCA algorithm
• Confirmatory diagnostic appraisal
– IHC criteria: 92-page document!
– Simpler algorithms needed for specific headache
subtypes
Exclude sinister
Headache (<1%)
ETTH
(40-60%)
Patient presenting
with headache
Q1. What is the impact of the headache
on the sufferer’s daily life?
low
High
Q2. How many days of headache
does the patient have every month?
Migraine/CDH
 15
> 15
Q3. For patients with chronic daily
headache, on how may days per week
does the patient take analgesic medications?
<2
No medication
overuse
Migraine
(10-12%)
Consider short-lasting
Headaches (<1%)
CDH
(5%)
Q4. For patients with migraine, does the
patient experience reversible sensory
symptoms associated with their attacks?
2
Medication
overuse
Yes
With aura
No
Without aura
Dowson AJ et al. Curr Med Res Opin 2002;18:414-39
Migraine diagnosis: IHS criteria
• Five or more lifetime headache attacks lasting 4-72
hours each and symptom-free between attacks
• Two or more of the following headache features:
–
–
–
–
Moderate-severe pain
Unilateral
Throbbing/pulsating
Exacerbated by routine activities
• One or more of the following non-headache features:
– Aura
– Nausea
– Photophobia/phonophobia
• Exclusion of secondary headaches
Headache Classification Committee of the IHS. Cephalalgia 1988;7 (Suppl 7):19-28
Diagnosing sinister headaches
Indicating
not
No
Is the patient very young
or elderly?
Yes
No
Is the headache new onset
(<6 months)?
Yes
No
Is the headache very acute?
Yes
Indicating
possibly
sinister
sinister
No
No
Does the patient have atypical or
non-reproducible symptoms?
Symptoms:
Rash; Non-resolving neurological deficit;
Vomiting, Pain or tenderness, Accident or
head injury; Infection; Hypertension
Yes
Yes
Tailoring of care
• Assessment of illness severity
–
–
–
–
–
–
Impact on the patient’s daily life
Headache frequency
Headache duration
Pain intensity
Any non-headache associated symptoms
Patient factors
• Prescribe therapy appropriate to the
presenting illness severity
– Good evidence-base for therapeutic effect
Assessing illness severity
• Headache history questionnaires
• Headache diaries
• Impact questionnaires
– MIDAS
– HIT
Therapies - migraine
• Acute treatments
– Triptans
– Simple or combination analgesics
• Prophylaxis
– Beta-blockers
– Serotonin antagonists
– Sodium valproate
– Amitriptyline
Therapies - CDH
• Withdrawal of overused medications
• Physical treatments to the neck
• Prophylaxis
– Tricyclic antidepressants (e.g.
amitriptyline)
– Anticonvulsants (e.g. sodium valproate)
– Botox
• Limited use of acute medications
Therapies – cluster headache
• Acute medications
– Subcutaneous sumatriptan
– Oxygen inhalation
• Prophylaxis
– Prednisolone
– Methysergide
– Ergotamine
– Verapamil
– Lithium
Short-term
Long-term
Proactive follow-up
• Regular monitoring of patients
– Headache diaries
– Impact questionnaires
• Review of medication
– Switch if necessary
• Long-term review throughout evolution of
illness
– e.g. for overuse of acute medications by migraine
sufferers and consequent development of CDH
Organisational structure
•
•
•
•
Overall pyramid of care
Primary care headache team
Primary care specialist (GPSIH) team
Pathways of care
Overall pyramid of care
Specialist care
n = 350
Primary care
Specialist
n = 600
Primary care
n = 36,000
Patient
n = 15 approx
interested in
headache
Primary care headache team
Primary care
Community nurse
Optician
Pharmacist
Practice
nurse
Specialist
care
Ancillary
staff
Primary care
physician
Physician with expertise
in headache:
GP; PCT; specialist
Dentist
Complementary
practitioner
Patient
Associate team
Core team
Dowson AJ et al. Curr
Med Res Opin
2002;18:414-39
Primary care specialist (GPSIH) team
Physical
therapist
Patient
Primary care
team
Clinical
psychologist
GPSIH
Specialist nurse
Neurologist
Pathways of care
Pathways of care
Sinister, refractory and rare
variant headaches
Secondary and tertiary
care specialists
Headache
management
Consultation
Diagnosis
Primary care
specialist
Migraine; Cluster
headache; Chronic daily
headache
Assess
severity
Treatment
plan
Uncomplicated migraine
and TTH
Primary care
Follow-up
Patient
Patients not needing to see a
GPSIH
• Patients with episodic tension-type
headaches
• Patients with uncomplicated migraine
Appropriate patients for GPSIH - 1
• Migraine patients unable to be
managed in primary care
– Refractory to treatment with acute and
prophylactic medications
– Specific migraine patient sub-groups
•
•
•
•
•
Side effects
Contraindications
Co-morbidities
At-risk women and children
At-risk of developing CDH
Appropriate patients for GPSIH - 2
• Chronic daily headache (CDH) /
medication overuse headache (MOH)
• Cluster headache
• Short, sharp headaches
• Headaches associated with old age
• Refractory ‘sinus’ headaches
Appropriate patients to refer
• Patients with suspected sinister
headaches
• Patients refractory to repeated
treatments
• Patients with rare headache subtypes
• Patients requiring specific
investigations?
– Should be available to GPSIH
Development of the service: RCGP
framework
RCGP framework*
•
•
•
•
Core activities
Competencies
Facilities available
Governance, accountability, monitoring
and audit
• Training, induction and support
• Local guidelines
* Based on the draft GPSI framework on epilepsy; RCGP 2002
Core activities - 1*
• Clinical leadership in developing
headache services for primary care
• Support and improve care of patients
by GPs and PCHTs
• Lead development of shared care
services
• Develop pathways of care
* Based on the draft GPSI framework on epilepsy; RCGP 2002
Core activities - 2*
• Develop skills and knowledge of
primary care
– Education
• Provide a limited clinical service
– Special groups or conditions
• Provide templates for patient annual
reviews and practice audits
* Based on the draft GPSI framework on epilepsy; RCGP 2002
Core activities - 3*
• Support primary care teams to enhance
care
– Annual drug reviews
– Female patients
– Support practices
– Sources of information on education and
social aspects
• Training to develop skills and
knowledge
* Based on the draft GPSI framework on epilepsy; RCGP 2002
Competencies - 1*
• Accurate diagnosis
• Appropriate referral (two-way)
• Knowledge of pharmaceutical
treatments
• Optimal management with modern
therapies
* Based on the draft GPSI framework on epilepsy; RCGP 2002
Competencies - 2*
•
•
•
•
Understand psychosocial aspects
Understand natural history of headache
Able to provide follow-up
Understand roles of support
organisations
* Based on the draft GPSI framework on epilepsy; RCGP 2002
Facilities*
• Access to specialist support and specialist
investigations
• Access to peer support
• Access to educational material (e.g. courses
and conferences)
• Access to shared care services, including
multidisciplinary team members (e.g.
specialist nurses)
• Access to clinical psychology services
• Membership of MIPCA specialisation group?
* Based on the draft GPSI framework on epilepsy; RCGP 2002
Governance, accountability and
monitoring*
• Accountable to the PCT board
• Clinical responsibility to the GPSIH
• Governance follows that used for the PCT
–
–
–
–
Clinical audit
Communications standards
Event monitoring
Complaint handling
• Quality assessed using RCGP Quality Team
Development (QTD) Programme
* Based on the draft GPSI framework on epilepsy; RCGP 2002
Monitoring / clinical audit*
• Locally convened group to oversee
development, monitoring, governance and
audit
–
–
–
–
–
–
PCO Clinical Governance lead
GPSI
LMC
PCO
Specialist clinical representative
Patient representative
Locally
dependent
* Based on the draft GPSI framework on epilepsy; RCGP 2002
Training- basic*
• At least 2 years’ experience in general
practice
– MRCGP or equivalent
• Relevant experience
– Clinical assistant / equivalent diploma
• Baseline competencies
– Assessment, investigation and treatment of
patients with headache
– Appropriate referral
– Roles of support organisations
– Knowledge of modern treatments
– Psychosocial aspects
* Based on the draft GPSI framework on epilepsy; RCGP 2002
Training- ongoing*
• Annual appraisal
• Portfolio / log book of clinics
• Diploma in headache
National headache organisations (MIPCA /
Headache UK?) should consider developing
a core syllabus for a Diploma in Headache
for GPs (2-3 days’ work)
* Based on the draft GPSI framework on epilepsy; RCGP 2002
Induction and support - 1*
• Appropriate system of mentoring and
continuing professional development
• Induction
–
–
–
–
–
Risk management
Networking
National clinical networks
Clinical governance
Audit and reporting
• Continuing professional development
* Based on the draft GPSI framework on epilepsy; RCGP 2002
Induction and support - 2*
• Continuing professional development
–
–
–
–
–
Multi-professional team meetings
Audit events
Courses
Conferences
Funding needed
• Mentor / peer support
– Local neurologist
– Headache specialist
– GPSIH
* Based on the draft GPSI framework on epilepsy; RCGP 2002
Local guidelines*
•
•
•
•
•
•
Referral to GPSIH
Direct referral to consultant neurologist
Response time
Exclusion criteria
Treatment and monitoring
Care for women
* Based on the draft GPSI framework on epilepsy; RCGP 2002
Summary*
•
•
•
•
•
Core competencies, facilities and training
Defined activities
Support and ongoing training
Governance, monitoring and audit
Adapting to local needs and practices
* Based on the draft GPSI framework on epilepsy; RCGP 2002