Lifting the Burden

 There are key questions: how should headache services be structured, organized and delivered: where, to whom, by whom, how much and with what objectives:

a) in well-resourced areas?
b) in medium-resourced areas (if differently)?
c) in poorly-resourced areas?

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"Reform service models [that are] concentrated on hospital care and focus instead on prevention and the efficient provision of high-quality, affordable, integrated, community-based, people-centred primary and ambulatory care, paying special attention to underserved areas."

World Health Organization (2016)

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There is general agreement that headache services should be based in primary care, in accordance with WHO recommendations [reference 1].
Lifting The Burden has collaborated with the European Headache Federation to develop proposals for a headache service organizational model on three levels, with specialist headache care reserved for the quite small proportion of people (maybe 1%) who need it:

Level 1.
General primary care

• front-line headache services (accessible first contact for most people with headache)
• ambulatory care delivered by primary health-care providers
• managing >90% of people requiring headache care
• referring when necessary, and acting as gatekeeper, to:

Level 2.
Special-interest headache care

• ambulatory care delivered by physicians in primary or secondary care with a special interest in headache
• managing >90% of those referred from level 2
• referring when necessary to:

Level 3.
Headache specialist centres

• advanced multidisciplinary care delivered by headache specialists in hospital-based centres

Click here to view the pdf file Recommendations for headache service organisation and delivery in Europe.
The model is adaptable according to resources and health-service infrastructure.
In poorly-resourced areas, level 1 may not be provided by doctors but by, for example, clinical officers with basic training. There may be little purpose in commitment of resources to exclusion of secondary headaches for which treatments are not available. Inability to treat these need not and should not be a barrier to treating primary headache and medication-overuse headache.

Reference
1. World Health Organization. Atlas of headache disorders and resources in the world 2011. Geneva: WHO 2011.

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