migraine in primary care advisors guildford, 24 january 2003, 2-6 pm general practitioners with a...

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 TurnerChairman 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, under-diagnosed 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– 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)

Diagnosis Assess severity

Treatment plan

•Screen for headache type

•Attack frequency and pain severity•Impact on patient’s life •Non-headache symptoms•Patient factors

•Establish goals•Acute therapy•Possible prophylactic therapy

Consultation

•Specific consultation•Treatment history•Patient education, counselling and buy-in

Follow-up

Assess outcome of therapy

Principles of headache management in primary care

Referral to specialist

Sinister / Cluster / Chronic

Migraine

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

physicianMIPCA 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– Optician – Dentist – Complementary practitioners– Specialist physician (additional resource)

Associate team members

MIPCA 2002

Pharmacist

Patient

Primary care physician

Practice nurse

Ancillarystaff

Primary care

Core teamMIPCA 2002

Roles of GP and nurse

• GP– Overall diagnosis and management of the patient

• Nurse– 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

Pharmacist

Community nurse

Optician

Dentist

Complementary practitioner

Patient


Practice nurse

Ancillarystaff

Primary care

Associate team Core teamMIPCA 2002

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– Individual GP clinics– PCGs– PCTs– Resource / Interest driven

• Each centre staffed by people with an interest in headache management:– Physicians– Specialist nurses– Physical therapists– Psychologists

BASH 2000

Pharmacist

Community nurse

Optician

Dentist


Patient


Practice nurse

Physician with expertise in headache:

GP; PCT; specialist

Ancillarystaff

Primary care Specialist care

Associate team Core team

MIPCA 2002

Diagnosis

Assess severity

Treatment plan

Consultation

Follow-up

Headache management

Primary care

Primary care specialist

Secondary and tertiary care specialists

Pathways of care

Uncomplicated migraine and TTH

Migraine; Cluster headache; Chronic daily headache

Sinister, refractory and rare variant headaches

Requirements

• 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

Referral services

Secondary care headache centres

• Establish formally– In association with regional neurological centres?

• Services:– Telephone advice to primary care staff/patients?– Emergency– Urgent– 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– 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)H

ead

ach

e se

veri

ty

Months

5

10 a. Chronic tension-type headache

1 2 3


ead

ach

e se

veri

ty

Months

5

10 b. Migraine superimposed over CTTH

1 2 3


ead

ach

e se

veri

ty

Weeks

5

10 c. Chronic migraine

1 2 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

Patient presenting with headache

Migraine/CDH

low

High

Q1. What is the impact of the headache on the sufferer’s daily life? ETTH

(40-60%)Q2. How many days of headache

does the patient have every month?

> 15 15

CDH(5%)

Q3. For patients with chronic daily headache, on how may days per week does the patient take analgesic medications?

<2 2

No medication overuse

Medication overuse

Migraine (10-12%)

Q4. For patients with migraine, does the patient experience reversible sensory symptoms associated with their attacks?

With aura Without aura

Yes No

Exclude sinister Headache (<1%)

Consider short-lasting Headaches (<1%)

Dowson AJ et al. Curr Med Res Opin 2002;18:414-39

CDH – goals of therapy

• Relieve the pattern of daily or near-daily 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 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 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


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

0

10

20

30

40

50

60

70

1 to 36 37 to 53 54 to 94 95 to 149 150+

Pat

ien

ts (

%)

59.8

7.4

15.4

8.87.4


Low

Moderate

High

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


Decision tree

Number of other medications taken over last 12 months

Do you have concerns about taking too much medication?

Would a single dose normally be sufficient?

Risk of overuse of triptans

1-4 ≥5

No Yes


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


Discussion

Development of an algorithm for CDH management

Cluster headacheH

ead

ach

e se

veri

ty

Weeks

5

10

1

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


Migraine/CDH

low

High




> 15 15

CDH(5%)


<2 2


Medication overuse

Migraine (10-12%)



Yes No





Excruciating

Frequency: several attacks/day

Occurrence:Clusters or chronic

15-180 min

Red/watering eyesBlocked nose

Cluster headache

Frequency/occurrence

Duration

Pain intensity

Non-headache symptoms

Usually male

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 careaccess/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 principlesScreening 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.


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.


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

• Links with patient support organisations– Migraine Action Association– OUCH

Headache UK

Headache UK

Differential diagnosis

• Simple diagnostic screen– MIPCA algorithm

• Confirmatory diagnostic appraisal– IHC criteria: 92-page document!– Simpler algorithms needed for specific headache

subtypes


Migraine/CDH

low

High




> 15 15

CDH(5%)


<2 2


Medication overuse

Migraine (10-12%)



Yes No




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 headachesHeadache Classification Committee of the IHS. Cephalalgia 1988;7 (Suppl 7):19-28

Diagnosing sinister headaches

Is the headache new onset (<6 months)?

Is the patient very young or elderly?

Does the patient have atypical or non-reproducible symptoms?

Indicating

not

sinister

Indicating

possibly

sinister

Is the headache very acute?

Symptoms: Rash; Non-resolving neurological deficit; Vomiting, Pain or tenderness, Accident or

head injury; Infection; Hypertension

No

No

No

No

No

Yes

Yes

Yes

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

Primary caren = 36,000

Primary care Specialist

n = 600

Specialist caren = 350

Patient

Overall pyramid of care

n = 15 approx interested in

headache

Primary care headache team

Pharmacist

Community nurse

Optician

Dentist


Patient


Practice nurse

Physician with expertise in headache:

GP; PCT; specialist

Ancillarystaff

Primary care Specialist care

Associate team Core team


Primary care specialist (GPSIH) team

GPSIH

Specialist nurse

Clinical psychologist

NeurologistPrimary care

teamPatient

Physical therapist

Pathways of care

Diagnosis

Assess severity

Treatment plan

Consultation

Follow-up

Headache management

Primary care

Primary care specialist

Secondary and tertiary care specialists

Pathways of care

Uncomplicated migraine and TTH

Migraine; Cluster headache; Chronic daily headache

Sinister, refractory and rare variant headaches

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



• 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



• 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


Competencies - 1*

• Accurate diagnosis

• Appropriate referral (two-way)

• Knowledge of pharmaceutical treatments

• Optimal management with modern therapies


Competencies - 2*

• Understand psychosocial aspects

• Understand natural history of headache

• Able to provide follow-up

• Understand roles of support organisations


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?


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


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

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


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)


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


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


Local guidelines*

• Referral to GPSIH• Direct referral to consultant neurologist• Response time• Exclusion criteria• Treatment and monitoring• Care for women


Summary*

• Core competencies, facilities and training• Defined activities• Support and ongoing training• Governance, monitoring and audit• Adapting to local needs and practices


migraine in primary care advisors guildford, 24 january 2003, 2-6 pm general practitioners with a...

Documents

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uk headache services

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headache gpsih slide

primary headache disorders

pcts headache services

primary care headache

study of headache organisation