THE ECONOMIC, social and personal burden of headache in the community is substantial. Migraine alone has been found to affect 7.6 per cent of males and 18.3 per cent of females in England. Measures of health-related quality of life in migraine sufferers are similar to patients with other chronic conditions such as arthritis and diabetes, and worse than those with asthma. Other studies have shown that one in three migraine sufferers believe that their problem controls their life and the impact extends to family and friends.
The majority of headache sufferers are reluctant to seek help and when they do the condition is often poorly managed by the GP. Despite the fact that 80 per cent of GP headache consultations are migraine, a large UK primary care database study of new onset headache found that 70 per cent of consultations did not receive a diagnosis at presentation, and of those, only 5 per cent received a diagnosis in the following year.
Headache is often stigmatised and the majority of migraineurs have never consulted their GP despite high levels of disability. Of those who do consult, most only have a single consultation, and for many, pharmacists and opticians are alternative options for advice. The reasons for poor consultation rates are not known but may include a belief that nothing can be done and poor previous experience with headache consultations.
Management of headache services
Up to 30 per cent of neurology referrals are for headache but only a small number of neurologists have a special interest in the area and many referrals are inappropriate for a secondary care setting. There is no difference in impact between neurology headache referrals and patients managed in primary care, but referred patients consult more frequently and have higher levels of headache-related anxiety. Apart from reassurance that no serious pathology is present, inevitably with an inappropriate brain scan (secondary care imaging rates have been shown to be as high as 60 per cent), in many cases the needs of headache sufferers remain unmet.
The British Association for the Study of Headache (BASH) has proposed that intermediate care headache clinics staffed by general practitioners with a special interest (GPwSI) should support GP colleagues who would continue to provide first-line headache care. This development is in line with NHS policy where the hope is that intermediate care will provide more effective and efficient service delivery in local settings. The suitability of this model for headache care has also been recently endorsed by the Royal College of Physicians and the Association of British Neurologists. Local stakeholders can define pathways of care depending on local circumstances and expertise.
Role of the GPwSI in headache
In general, a GPwSI is a practitioner with additional training and experience in a specific clinical area who takes referrals for the assessment/treatment of patients that may otherwise have been referred directly to a secondary care consultant. In the case of headache the GP has had further training in the causes and consequences of headache and is qualified to assess, diagnose and treat with medication or other means and refer for other services. They are also required to maintain and update their skills in headache management.
The specific activities of headache GPwSIs depend much on the local service configuration. They work in a variety of settings from specialist headache clinics in primary care health centres to hospital-based clinics staffed with both neurologists and specially trained headache nurses.
Apart from treating patients the job also includes raising awareness of primary and community practitioners’ roles in the prevention, identification and care of headache. It may also involve teaching trainee GPs, qualified GPs and other staff.
Training and accreditation
Career opportunities for GPs with a special interest in headache are very much determined by local frameworks but a guideline for competences in the provision of services is published by the RCGP and Royal Pharmaceutical Society. This states that training can be acquired in different ways but would be expected to include both practical and theoretical elements. These could include:
• Experience (current or previous) of working in relevant departments
• Self-directed learning with evidence of the completion of individual tasks
• Attendance at recognised meetings/lectures/ tutorials on specific relevant topics
• As a trainee or other post under the supervision of a specialist or consultant in headache in the secondary care service
• As part of a vocational training programme
• As a clinical placement agreed locally
• As part of a recognised university course
• Successfully completing a postgraduate course in headache management
• Evidence of working under direct supervision with a specialist clinician in relevant clinical areas.
BASH has also published frameworks for appraisal and training, accreditation and re-accreditation together with management pathways that can be adapted for local circumstances. These can be found on www.exeterheadacheclinic.org.uk together with other material to support the commissioning of headache services.
A young GP who would like to develop skills towards becoming a GPwSI in headache is advised to contact a local headache clinic (see the BASH website below for a locator map) and ask about training opportunities and the possibility of sitting in on a clinic. You can also join BASH.
Dr David Kernick is a GP with a special interest in headache at the Exeter Headache Clinic at the St Thomas Health Centre
Some useful sites
• www.exeterheadacheclinic.org.uk - Contains support for commissioners, patient information and advice sheets which can be downloaded.
• www.migrainetrust.org- Migraine Trust
• www.migraine.org.uk - Migraine Action Association
Q&A Dr David Kernick, GP with special interest in headache
How did you become a GP with a special interest in headache?
I drifted into an interest in headache on the back of a research grant. I have to admit that at the time headache was rather “heart sink” to me. The PCT had some money left over at the end of the financial year, I helped one or two of their executives who had a problem with migraine and things seem to evolve from there. These days service development is far more planned! What opportunities are there for the development of GPwSI headache services? Invariably headache contains biopsychosocial elements and the GP is well placed to manage this condition. In general, neurologists are not interested in headache and patients referred to secondary care can receive inappropriate investigation and their needs are often not met. Headache is the most common neurological presentation and commissioners will be looking at ways to reduce these referrals. GPs with a special interest can offer better services at reduced costs and also provide educational input for their colleagues who often find headache difficult to manage.
What do you most enjoy about the role?
Although most of what we see is migraine, every case is very different. In many cases you can turn around the lives of people when their problem is having a significant impact upon them and their families. Having 45 minutes to spend with a patient is a real luxury and it makes you realise how much more we could sort out with our own patient’s problems if we had more than the pressurised 10 minutes.
What do you find most challenging about the job?
Overlooking a serious secondary pathology is always a cause for concern. Sooner or later a coincidental brain tumour will present. All one can do is to follow established guidelines and have a documented conversation with the patient about the pros and cons of imaging. Our imaging rates are very low and in most cases a scan is unnecessary.
Do you need a background in neurology to develop an interest in this area?
Although a basic knowledge of neurology is important, particularly for excluding secondary pathologies, this is no more than a competent GP would be expected to know. In 95 per cent of headache presentations, the underlying pathophysiology is not known and the focus is on clinical pattern recognition and not the nuances of neuroanatomy. Clinical experience is probably the most important attribute.