Input needed on proposals for the organisation of headache services in Europe

27 August 2008
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Given that 17% of the adult population suffer from disabling migraine or other headache, it is estimated that, in Europe, around 120,000 people in every million would benefit from good headache care. The overwhelming majority of these patients, around 90%, can be treated in the primary care environment, with the remaining 10% requiring more specialist levels of management.

Currently, there are no formal standards for headache service provision, yet, without these, good headache management is unlikely to reach all who need it. Standards would ensure that those who need care, and more specialist management, are provided for at appropriate levels within health care systems.

Defining what the service requirements should be for the medical care of headache is a task the European Headache Federation (EHF) and Lifting The Burden have outlined in a proposal to be published in the European Journal of Internal Medicine.

Making the conservative but realistic assumption that only 50% of those who might benefit from medical care actually seek it, and calculating the minimum contact times needed within primary care, EHF and LTB have estimated the number of medical full-time equivalents required for a headache service in a European country.

Outlining minimum standards of service that can be adapted nationally according to the local health service structure, organisation and delivery, EHF and LTB propose three levels of headache service (see Table). Although these levels exist already in some countries, the authors point out: "Many patients do not progress from level one who would benefit from doing so". Clear guidance on referral upwards is a part of the proposals.

The authors also acknowledge that such a shift in organisation would prompt increased demand for headache services and have training implications. However, this increase in demand would simply be an uncovering of existing patient needs. A greater emphasis on headache diagnosis and management within medical schools' undergraduate curricula would provide newly qualified doctors with a better understanding of a burdensome set of disorders that many of them will encounter with great frequency.

Comments on the proposals are welcome and information on where to send correspondence will be provided in a future issue of LTB News, once they are published.

TABLE: Headache services organized on three levels

Resource requirement Population covered Role
Level 1: Headache primary care primary care
1 full-time physician for 35,000 population		 Meet the needs of 90% of people consulting with headache
  • Accessible first contact for most people with headache
  • Provide front-line headache services and act as gatekeepers to level 2
  • Competently diagnose and manage most migraine and tension-type headache and recognise other common primary and secondary headache disorders: cluster headache, medication-overuse headache, chronic post-traumatic headache, headaches attributed to subarachnoid haemorrhage, giant cell arteritis, low cerebrospinal fluid pressure or increased intracranial pressure or hydrocephalus caused by neoplasm, classical trigeminal neuralgia and persistent idiopathic facial pain
Level 2: Headache clinics 1 full-time equivalent physician for a maximum population of 200,000 Provide care to 10% of patients seen at level 1 and referred to level 2
  • Run by trained physicians in primary or secondary care, referring when needed to level 3
  • Have access to other services such as neurology, psychology, physiotherapy
  • Competently diagnose and manage more difficult cases of primary headache and some secondary headache disorders
Level 3: Academic headache centres 1 full-time equivalent physician for a maximum population of 2 million Provide advanced care to 10% of patients seen at level 2 and referred to level 3
  • Specialist secondary care, hospital-based
  • Offer full-time inpatient facilities (minimum 2 beds/million population) and work in multi-disciplinary teams with access to equipment and specialists in other disciplines for diagnosis and management of the underlying causes of all secondary headache disorders