Headache disorders in primary care – interview with Tim Steiner, founder of Lifting the Burden

The European Headache Federation and Lifting The Burden, the two societies affiliated with The Journal of Headache and Pain, have just published the 2nd edition of the consensus article ‘Aids to management of headache disorders in primary care’. In light of this we have invited Tim Steiner, the founder and a director and trustee of Lifting The Burden, to explain the aims, process of development and benefits of the updated consensus article they are hoping to achieve for patients as well as physicians.

Why was the consensus article developed?

Timothy J Steiner

Almost everyone has occasional headache – a symptom often regarded as “normal”. Headache disorders, of which the International Classification of Headache Disorders (ICHD) recognizes over 200 types or sub-types, are also very common: they affect about 40% of adults, and almost as many children and adolescents.

These disorders, which include migraine, tension-type headache (TTH) and medication-overuse headache (MOH), are more of a problem. They are major causes of ill health, collectively the second highest cause of disability worldwide.

They should be managed in primary care – for several compelling reasons.

The first is that they need to be managed somewhere. These few disorders are responsible for almost all burden attributed to headache.

The second is in the numbers. Specialist health services have only a tiny fraction of the capacity required for the needs of so many people, and this should be reserved for the small proportion who require them.

Third, the management of migraine, TTH and MOH is generally not difficult, requiring neither specialist skills nor investigations.

Nonetheless, non-specialists receive only limited training in the diagnosis and treatment of headache. The purpose of these Aids to Management, combining educational materials with practical management aids, is to help primary-care physicians correctly diagnose these few disorders, manage them well when they can, recognize warnings of serious headache disorders, and refer for specialist care whenever but only when necessary.

The Aids to Management are a product of the Global Campaign against Headache, a worldwide program of action conducted in collaboration with the World Health Organization for the benefit of people with headache. They update the first edition published 11 years ago, and, like the first edition, were developed in partnership with the European Headache Federation.

Tell us more about the process and efforts of getting this document together

The process, taking more than a year, was in four stages.

First, the writing group reviewed all treatment guidelines, recommendations and management aids known to be in use in Europe.

Second, the group distilled and harmonized these, always preferring evidence-based recommendations to those without explicit support, and resolving discordance between recommendations by reference to original evidence and expert consensus.

Third came review by a wider consultation group drawn from 36 countries, including headache experts, primary-care physicians and lay advocates from member organisations of the European Headache Alliance.

Fourth was final editing by the writing group in the light of all comments received.

What is included?

The ‘European principles of management of headache disorders in primary care’ are the core of the content. Its 11 sections (one in four subsections) are stand-alone, and each may be separately downloaded as a practical management aid as well as an educational resource.

Then there is a set of practical aids. An abbreviated version of ICHD provides diagnostic criteria for the relatively few headache disorders relevant to primary care. A headache diary also assists diagnosis, and a headache calendar supports follow-up.

A measure of headache impact, the HALT-90 Index, can be employed in pre-treatment assessment of illness severity. Its derivative, the HALT-30 Index, may be more useful in follow-up, along with the HURT questionnaire, an outcome measure designed to guide follow-up.

Any of seven information leaflets may be offered to patients to improve their understanding of their headache disorders and their management. Each of these may also be separately downloaded.

All of these need translating into many languages. Last among the materials are translation protocols, developed to ensure that translations are unchanged in meaning from the English-language originals.

Lifting the Burden and the European Headache Federation offer these Aids to Management without restriction for non-commercial use, as is the case for all products of the Global Campaign against Headache.

What benefits for patients and physicians are you hoping to achieve with the consensus article?

Will they bring these benefits? We believe so – if they are used!

We hope for benefits for both physicians and patients. For the former, the Aids to Management are designed expressly to assist primary-care physicians deliver appropriate care more efficiently and more cost-effectively for a group of disorders that are very common and very disabling. For the latter, there should be better outcomes for the many people with headache who need medical treatment. The focus is Europe, but these aids may be useful to a much wider population.

Will they bring these benefits? We believe so – if they are used! It is well known that many guidelines are ignored, but these materials are unique in their focus on primary care. This may be surprising, because it is in primary care more than anywhere that management supports of this type are needed.


Timothy J Steiner is Emeritus Professor of Medicine (Headache and Global Public Health) in the Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway.

He is the founder, and a director and trustee, of Lifting The Burden, a UK-registered charity in official relations with the World Health Organization, and the architect and Director of the Global Campaign against Headache, conducted by Lifting The Burden as its principal activity.

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