What happens to new-onset headache in children that present to primary care? A case-cohort study using electronic primary care records.

The aim was to describe the consulting behaviour and clinical outcomes of children presenting with headache in primary care. This was a historical cohort study using data from the UK General Practitioner Research Database. Cases were children aged 5-17 years who presented to primary care with primary headache (migraine, tension-type headache, cluster headache) or undifferentiated headache (no further descriptor). Controls were age, sex and practice matched. Their records were examined for consultations, referrals, relevant treatments and specific diseases in the subsequent year. Children with headache (n = 48 575) were identified and matched to controls. At presentation, 9321 (19.2%) of headaches were labelled primary, 549 (1.1%) secondary and 38 705 (79.7%) received no formal diagnosis. Of the latter group, 2084 (5.4%) received a primary headache diagnosis in the subsequent year. Following a diagnosis of migraine, 258 (3.5%) had received a triptan and 1598 (21%) were using propranolol or pizotifen. Total consultations were higher in cases than in controls in the year before the headache: cases ages 5-8 years, mean (s.d.) 5.0 (4.0) consultations; controls 4.0 (3.5) consultations. In 1 year controls had 43 430 consultations, of which 256 (0.6%) were for headache, of whom 64 (25%) were referred to secondary care. Headache was a risk factor for benign and malignant tumours, cerebrovascular disease, primary disorders of raised intracranial pressure and depression. This risk was reduced if a diagnosis of a primary headache disorder could be made. Although there is an increased likelihood of a serious pathology with headache presentations, the risk is small particularly if a diagnosis of a primary headache is made. General practitioners are likely to be underdiagnosing migraine. This study can inform management guidelines for new presentations of headache in primary care, particularly when a secondary pathology is suspected.

Measuring the impact of headache in children: a critical review of the literature.

Headache is the most frequent neurological symptom and commonest manifestation of pain in childhood. Measuring the impact of headache in terms of health status, functioning and quality of life can inform the prioritization of competing resource claims, screen for unmet need, improve communication between patient and physician and monitor response to treatment. We undertook a critical review of the literature measuring the impact of headache in children and identified 33 papers that contained relevant information. Findings reflected a wide range of settings, age groups, methodologies and outcome measures. Considerable methodological limitations affected all studies, including inadequate description of study design, methodology and data analysis. Nevertheless, although we found the existing literature to be of inconsistent quality, the impact of headache in children and adolescents is substantial. Rigorous studies are required to quantify this burden using measures that are valid and reliable and whose development has been informed by both theoretical and practical perspectives.

What happens to new-onset headache presented to primary care? A case-cohort study using electronic primary care records.

In the UK, 4% of general practitioner consultations are for headache, yet the natural history of these presentations is unknown. The objective of this study was to describe the outcome of new headache presentations to the general practitioner. This was a prospective case-control study in adults over a period of 1 year using data from the General Practitioner Research Database, UK. Records of patients who presented with primary headache (migraine, tension-type headache, cluster headache) or undifferentiated headache (no further descriptor) were examined for the subsequent year for subarachnoid haemorrhage, primary brain tumour, benign space-occupying lesion, temporal arteritis, stroke and transient ischaemic attack. We identified 21,758 primary headaches and 63,921 undifferentiated headaches. The likelihood ratio was 29 (9.9, 92) for a subarachnoid haemorrhage after an undifferentiated headache and increased with age. The 1-year risk of a malignant brain tumour with new undifferentiated headache was 0.15%, rising to 0.28% above the age of 50 years. For primary headache the risk was 0.045%. The risk for a benign space-occupying lesion was 0.05% for an undifferentiated and 0.009% for a primary headache. The risk of temporal arteritis was the highest of the conditions studied, 0.66% in the undifferentiated and 0.18% in the primary headache group. Accepting the limitations of this approach, our data can inform management guidelines for new presentations of headache in primary care and confirm the need for follow-up, even if a primary headache diagnosis is made.

Developing a research agenda in headache service delivery: proceed with caution.

With a recognition that the management of headache remains far from ideal, there may be more immediate potential to reduce the burden of illness from developments in the delivery of headache services. There is a paucity of evidence in this area and a danger that an expanding research agenda will be dominated by inappropriate methodological frameworks that have been so successful in developing medical treatments. The prevailing scientific methods are underpinned by statistical approaches that are aggregative in nature and assume independence of system elements, an approach that may have limited utility in the analysis of complex systems such as headache care delivery. This review calls for a shift in headache research resources to organizational development and briefly outlines alternative methodological considerations.

An introduction to the basic principles of health economics for those involved in the development and delivery of headache care.

Against a background of increasing demands on limited resources, health economics is gaining an increasing impact on decision making and a basic understanding of the subject is important for all those involved in headache research and service delivery at whatever level. This paper is not intended as a review of the literature in the area of headache economics but discusses some general principles of health economics from the perspective of headache, with a focus on cost of illness studies and economic evaluation.

Migraine--new perspectives from chaos theory.

Converging from a number of disciplines, non-linear systems theory and in particular chaos theory offer new descriptive and prescriptive insights into physiological systems. This paper briefly reviews an approach to physiological systems from these perspectives and outlines how these concepts can be applied to the study of migraine. It suggests a wide range of potential applications including new approaches to classification, treatment and pathophysiological mechanisms. A hypothesis is developed that suggests that dysfunctional consequences can result from a mismatch between the complexity of the environment and the system that is seeking to regulate it and that the migraine phenomenon is caused by an incongruity between the complexity of mid brain sensory integration and cortical control networks. Chaos theory offers a new approach to the study of migraine that complements existing frameworks but may more accurately reflect underlying physiological mechanisms.

Introduction to health economics for the medical practitioner.

Against a background of increasing demands on limited resources, health economics is exerting an influence on decision making at all levels of health care. Health economics seeks to facilitate decision making by offering an explicit decision making framework based on the principle of efficiency. It is not the only consideration but it is an important one and practitioners will need to have an understanding of its basic principles and how it can impact on clinical decision making. This article reviews some of the basic principles of health economics and in particular economic evaluation.

A methodological framework to derive the cost of the GP consultation.

With an emphasis on a primary care-led NHS, the cost of a GP consultation will be a major element in any economic analysis. No standardized methodology is available for deriving this cost, and there are a wide range of estimates. Wherever possible, local unit costs should be derived from individual practice information, particularly when local circumstances are relevant to a study, but unless standardized methodology is used, studies undertaken in different settings or at different times will not be compatible. This paper proposes a framework which will enable each practice to determine their unit consultation costs and offers data that can be used where local information is not available.

The prevalence and treatment of headache sufficient to impact on the quality of life of undergraduate students entering university.

AIM OF STUDY: Headache has a significant impact on public health in terms of quality of life and economic consequences, but in primary care, needs often remain unmet in terms of recognition, diagnosis and treatment. Our aim was to measure the prevalence of headache sufficient to affect the quality of life of undergraduate students who were entering the University of Exeter. METHOD: 1124 consecutive undergraduate entrants aged 21 and under who registered at the Student Health Centre at the beginning of the academic year were invited to complete a questionnaire during their registration procedure. We used the Headache Impact Score to measure effect of headache on quality of life. RESULTS: A completed questionnaire was received from 1057 (94%) students registering at the Health Centre. 212 (21%) of these students had headaches that affected the quality of their life. Of these, 95 (45%) had seen a doctor previously about their headaches and 28 (13%) had headaches on more than 15 days a month. Less than 5% were taking prescription medication. The headache impact score was 56 indicating a substantial impact on quality of life of students. CONCLUSION: Headache has a considerable impact on the quality of life of students entering University which we speculate may have a deleterious effect on educational attainment. This study has confirmed the findings of other population groups that morbidity from headache is often unrecognised and under treated.

A cost consequence study of the impact of a dermatology-trained practice nurse on the quality of life of primary care patients with eczema and psoriasis.

BACKGROUND: The practice nurse is central to the development of a primary care-led National Health Service. Skin diseases can have a major impact on patients' lives but general practitioners (GPs) lack many of the skills of practical dermatology care and support. AIM: To determine whether a primary care dermatology liaison nurse should be introduced by our health authority. We identified the resources consumed and the benefits that accrued from a practice nurse who had received training in practical dermatology care. METHOD: A cost consequence study in parallel with a randomised controlled trial was undertaken in a group of nine GPs and 109 patients between the ages of 18 and 65 years who had a diagnosis of psoriasis or eczema. RESULTS: Although there was a significant improvement in our primary outcome measure within group, when compared with the control group significance was not achieved. There was no significant change in the Euroqol measure but the clinical instrument showed a significant change when compared with control. On entry, our qualitative data identified three main themes--the embarrassment caused by these skin conditions, the wish for a cure rather than treatment, and concern over the long-term effects of steroids. On completion, 20% of patients expressed that they had received a positive benefit from the clinic. CONCLUSION: This study demonstrates the difficulties of obtaining relevant information to facilitate decisions on how resources should be allocated in primary care. Not all questions can be answered by large multi-centred trials and studies themselves have an opportunity cost consuming resources that could otherwise be spent on direct health care. Often, local resource decisions will be based on partial evidence-yielding solutions that are satisfactory rather than optimum but which are, nevertheless, better than decisions taken with no evidence at all.