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 Turner Chairman 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 physician MIPCA 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 Ancillary staff Primary care Core team MIPCA 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 Primary care physician Practice nurse Ancillary staff Primary care Associate teamCore team MIPCA 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

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 Complementary practitioner Patient Primary care physician Practice nurse Physician with expertise in headache: GP; PCT; specialist Ancillary staff Primary care Specialist care Associate teamCore team MIPCA 2002

Diagnosis Assess severity Treatment plan Consultation Follow-up Headache management 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) Headache severity Months 5 10 a. Chronic tension-type headache 123

Chronic daily headache (CDH) Headache severity Months 5 10 b. Migraine superimposed over CTTH 123

Chronic daily headache (CDH) Headache severity Weeks 5 10 c. Chronic migraine 123

CDH - presentation A history of headaches lasting >4 hours, occurring on >15 days per month 1 May be associated with overuse of symptomatic headache medications (MOH) 2 –Analgesics, opioids, ergots, triptans May be associated with a history of head/neck injury 3 1. Headache Classification Committee. Cephalalgia 1988;8 (Suppl 7): Diener H-C, Katsarava Z. Curr Med Res Opin 2001;17 (Suppl 1): 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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 YesNo 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. Doctor 2003; in press 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. Doctor 2003; in press 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 Dowson AJ. Doctor 2003; in press

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 to 3637 to 5354 to 9495 to Patients (%) Williams D et al. Curr Med Res Opin 2002;18:1-9 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 Williams D et al. Curr Med Res Opin 2002;18:1-9

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 Williams D et al. Curr Med Res Opin 2002;18:1-9

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 Williams D et al. Curr Med Res Opin 2002;18:1-9

Discussion Development of an algorithm for CDH management

Cluster headache Headache severity Weeks

Cluster headache - presentation A history of headaches lasting > 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

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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 YesNo Exclude sinister Headache (<1%) Consider short-lasting Headaches (<1%) Dowson AJ et al. Curr Med Res Opin 2002;18:414-39

Consider short-lasting Headaches (<1%) Excruciating Frequency: several attacks/day Occurrence: Clusters or chronic min Red/watering eyes Blocked 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 care access/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 principles Screening 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.

Strategy: Principles of care - 2 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.

Strategy: Principles of care - 3 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

Differential diagnosis Simple diagnostic screen –MIPCA algorithm Confirmatory diagnostic appraisal –IHC criteria: 92-page document! –Simpler algorithms needed for specific headache subtypes

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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 YesNo Exclude sinister Headache (<1%) Consider short-lasting Headaches (<1%) Dowson AJ et al. Curr Med Res Opin 2002;18:414-39

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 headaches Headache 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 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 care n = 36,000 Primary care Specialist n = 600 Specialist care n = 350 Patient Overall pyramid of care n = 15 approx interested in headache

Primary care headache team

Pharmacist Community nurse Optician Dentist Complementary practitioner Patient Primary care physician Practice nurse Physician with expertise in headache: GP; PCT; specialist Ancillary staff Primary care Specialist care Associate teamCore team Dowson AJ et al. Curr Med Res Opin 2002;18:414-39

Primary care specialist (GPSIH) team GPSIH Specialist nurse Clinical psychologist Neurologist Primary care team Patient Physical therapist

Pathways of care

Diagnosis Assess severity Treatment plan Consultation Follow-up Headache management 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 * Based on the draft GPSI framework on epilepsy; RCGP 2002

Core activities - 2* 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 * Based on the draft GPSI framework on epilepsy; RCGP 2002

Core activities - 3* 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 * Based on the draft GPSI framework on epilepsy; RCGP 2002

Competencies - 1* Accurate diagnosis Appropriate referral (two-way) Knowledge of pharmaceutical treatments Optimal management with modern therapies * Based on the draft GPSI framework on epilepsy; RCGP 2002

Competencies - 2* Understand psychosocial aspects Understand natural history of headache Able to provide follow-up Understand roles of support organisations * Based on the draft GPSI framework on epilepsy; RCGP 2002

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? * Based on the draft GPSI framework on epilepsy; RCGP 2002

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 * Based on the draft GPSI framework on epilepsy; RCGP 2002

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 * Based on the draft GPSI framework on epilepsy; RCGP 2002 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 * Based on the draft GPSI framework on epilepsy; RCGP 2002

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) * Based on the draft GPSI framework on epilepsy; RCGP 2002

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 * Based on the draft GPSI framework on epilepsy; RCGP 2002

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 * Based on the draft GPSI framework on epilepsy; RCGP 2002

Local guidelines* Referral to GPSIH Direct referral to consultant neurologist Response time Exclusion criteria Treatment and monitoring Care for women * Based on the draft GPSI framework on epilepsy; RCGP 2002

Summary* Core competencies, facilities and training Defined activities Support and ongoing training Governance, monitoring and audit Adapting to local needs and practices * Based on the draft GPSI framework on epilepsy; RCGP 2002