08 • Career
FOCUS ON
GPs with special interest in headache off er hope in a debilitating though often neglected condition
T
HE ECONOMIC, social and personal burden of headache in the community is substantial. Migraine alone has been found to aff ect 7.6 per cent of males and 18.3 per cent of females in England. Measures of health-related quality of life in migraine suff erers 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 suff erers believe that their problem controls their life and the impact extends to family and friends. The majority of headache suff erers 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 diff erence 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 suff erers remain unmet. The British Association for the Study of Headache (BASH) has proposed
that intermediate care headache clinics staff ed by general practitioners with a special interest (GPwSI) should support GP colleagues who would continue to provide fi rst-line headache care. This development is in line with NHS
policy where the hope is that intermediate care will provide more eff ective and effi cient 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 defi ne 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 specifi c 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 qualifi ed 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 specifi c activities of headache GPwSIs depend much on the local
service confi guration. They work in a variety of settings from specialist headache clinics in primary care health centres to hospital-based clinics staff ed 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, identifi cation and care of headache. It may also involve teaching trainee GPs, qualifi ed 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 diff erent ways but would be expected to include both practical and theoretical elements. These could include: • •
• Attendance at recognised meetings/lectures/ tutorials on specifi c relevant topics
•
As a trainee or other post under the supervision of a specialist or consultant in headache in the secondary care service
Experience (current or previous) of working in relevant departments Self-directed learning with evidence of the completion of individual tasks
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