Chapter 3.4 - The Diagnostic Headache Diary - A Headache Expert System

Diagnosis and management of headache disorders in osteopathic practice: A qualitative study

1. Heidi K. Blume, MD, MPH 1. Division of Pediatric Neurology, Seattle Children’s Hospital and Research Institute, Seattle, WA. * Abbreviations: CSF: : cerebrospinal fluid ICH: : intracranial hemorrhage ICP: : intracranial pressure IIH: : idiopathic intracranial hypertension NDPH: : new daily persistent headache NSAID: : nonsteroidal anti-inflammatory drug SVT: : sinus venous thrombosis TAC: : trigeminal autonomic cephalalgia Headaches are common in children; while most are caused by a benign problem or primary headache disorder, headaches can be a sign of a serious underlying condition. Pediatricians must be aware of the most recent recommendations for evaluating and managing headaches. After reading this article, readers should be able to: 1. Understand the evaluation of a child who has headache. 2. Recognize the diagnostic criteria for pediatric migraine. 3. Recognize “red flags” for elevated intracranial pressure or other underlying conditions in the child who has headache. 4. Discuss treatment strategies for migraine, tension, and chronic headache disorders. Headaches are common in children and adolescents and are a frequent chief complaint in office and emergency department visits. The vast majority of childhood headaches are due to a primary headache disorder, such as migraine, or an acute, relatively benign process, such as viral infection. However, clinicians also need to consider other causes of headaches in children. Even when headaches are benign, they may cause significant dysfunction for the child and family and must be managed appropriately to minimize disability and optimize function. In this review, we discuss the epidemiology of childhood headache, evaluation of the child who has headaches, when to consider secondary headache syndromes, and the diagnosis and management of primary headache disorders such as migraine and tension-type headaches. Acute and chronic headaches are relatively common in children and adolescents, although estimates of the precise prevalence of headache and migraine vary widely. Depending on the study definition of headache, population involved, and time periods studied, 17% to 90% of children report headaches, with an overall prevalence of 58% reporting some form of headache in the past year. (1 …

This review provides an overview of the current and future role of artificial intelligence (AI) and virtual reality (VR) in addressing the complexities inherent to the diagnosis, classification, and management of headache disorders. Through machine learning and natural language processing approaches, AI offers unprecedented opportunities to identify patterns within complex and voluminous datasets, including brain imaging data. This technology has demonstrated promise in optimizing diagnostic approaches to headache disorders and automating their classification, an attribute particularly beneficial for non-specialist providers. Furthermore, AI can enhance headache disorder management by enabling the forecasting of acute events of interest, such as migraine headaches or medication overuse, and by guiding treatment selection based on insights from predictive modeling. Additionally, AI may facilitate the streamlining of treatment efficacy monitoring and enable the automation of real-time treatment parameter adjustments. VR technology, on the other hand, offers controllable and immersive experiences, thus providing a unique avenue for the investigation of the sensory-perceptual symptomatology associated with certain headache disorders. Moreover, recent studies suggest that VR, combined with biofeedback, may serve as a viable adjunct to conventional treatment. Addressing challenges to the widespread adoption of AI and VR in headache medicine, including reimbursement policies and data privacy concerns, mandates collaborative efforts from stakeholders to enable the equitable, safe, and effective utilization of these technologies in advancing headache disorder care. This review highlights the potential of AI and VR to support precise diagnostics, automate classification, and enhance management strategies for headache disorders.

The aim of our study was to investigate the prevalence of sleep disorders in chronic headache patients and to evaluate the role of psychiatric comorbidity in the association between chronic headache and sleep complaints. The prevalence of sleep disorders in chronic headache has been seldom investigated, although from the earliest description chronic headache has been associated with sleep disturbances. On the contrary, mood disorders are commonly associated with both sleep disturbances and chronic headache--each of which are, in turn, core features of mood disorders. Therefore, it may be important to discriminate between sleep problems that can be attributed to a comorbid psychiatric disorder, and those specifically associated with headache. Only a few studies investigating the association of chronic headache with sleep difficulties have also taken into account to consider the possible role of anxiety and depression. A total of 105 consecutive patients with daily or nearly daily headache and 102 patients with episodic headache, matched by age, sex, and type of headache at onset, underwent a structured direct interview about their sleep habits and psychiatric diseases. In total, 80 out of 105 patients with chronic headache received a diagnosis of medication overuse headache, 21 patients were classified as chronic migraine and 4 as chronic tension-type headache without drug overuse. Patients with chronic headache showed a high prevalence of insomnia, daytime sleepiness, and snoring with respect to controls (67.7% vs 39.2%, 36.2% vs 23.5%, and 48.6% vs 37.2%, respectively). Forty-five patients with chronic headache (42.9%) had psychiatric comorbidity (anxiety and/or depressive disorders), vs 27 episodic headache patients (26.5%). Multivariate analysis disclosed that low educational level, lower mean age at headache onset, and insomnia are independently associated with chronic headache. Patients with chronic headache had a high prevalence of sleep complaints. Insomnia may thus represent an independent risk factor for headache chronification. Recognition of sleep disorders, alone or in association with depression or anxiety, may be useful in episodic headache patients to prevent chronification.

To review contemporary issues of health care disparities in headache medicine with regard to race/ethnicity, socioeconomic status (SES), and geography and propose solutions for addressing these disparities. An Internet and PubMed search was performed and literature was reviewed for key concepts underpinning disparities in headache medicine. Content was refined to areas most salient to our goal of informing the provision of equitable care in headache treatment through discussions with a group of 16 experts from a range of headache subspecialties. Taken together, a multitude of factors, including racism, SES, insurance status, and geographical disparities, contribute to the inequities that exist within the health care system when treating headache disorders. Interventions such as improving public education, advocacy, optimizing telemedicine, engaging in community outreach to educate primary care providers, training providers in cultural sensitivity and competence and implicit bias, addressing health literacy, and developing recruitment strategies to increase representation of underserved groups within headache research are proposed as solutions to ameliorate disparities. Neurologists have a responsibility to provide and deliver equitable care to all. It is important that disparities in the management of headache disorders are identified and addressed.

Primary headache disorders are the most common complaints worldwide. The socioeconomic and personal impact of headache disorders is enormous, as it is the leading cause of workplace absence. Headache patients’ consultations are increasing as the population has increased in size, live longer and many people have multiple conditions, however, access to specialist services across the UK is currently inequitable because the numbers of trained consultant neurologists in the UK are 10 times lower than other European countries. Additionally, more than two third of headache cases presented to primary care were labelled with unspecified headache. Therefore, an alternative pathway to diagnose and manage patients with primary headache could be crucial to reducing the need for specialist assessment and increase capacity within the current service model. Several recent studies have targeted this issue through the development of clinical decision support systems, which can help non-specialist doctors and general practitioners to diagnose patients with primary headache disorders in primary clinics. However, the majority of these studies were following a rule-based system style, in which the rules were summarised and expressed by a computer engineer. This style carries many downsides, and we will discuss them later on in this dissertation. In this study, we are adopting a completely different approach. The use of machine learning is recruited for the classification of primary headache disorders, for which a dataset of 832 records of patients with primary headaches was considered, originating from three medical centres located in Turkey. Three main types of primary headaches were derived from the data set including Tension Type Headache in both episodic and chronic forms, Migraine with and without Aura, followed by Trigeminal Autonomic Cephalalgia that further subdivided into Cluster headache, paroxysmal hemicrania and short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing. Six popular machine-learning based classifiers, including linear and non-linear ensemble learning, in addition to one regression based procedure, have been evaluated for the classification of primary headaches within a supervised learning setting, achieving highest aggregate performance outcomes of AUC 0.923, sensitivity 0.897, and overall classification accuracy of 0.843. This study also introduces the proposed HydroApp system, which is an M-health based personalised application for the follow-up of patients with long-term conditions such as chronic headache and hydrocephalus. We managed to develop this system with the supervision of headache specialists at Ashford hospital, London, and neurology experts at Walton Centre and Alder Hey hospital Liverpool. We have successfully investigated the acceptance of using such an M-health based system via an online questionnaire, where 86% of paediatric patients and 60% of adult patients were interested in using HydroApp system to manage their conditions. Features and functions offered by HydroApp system such as recording headache score, recording of general health and well-being as well as alerting the treating team, have been perceived as very or extremely important aspects from patients’ point of view. The study concludes that the advances in intelligent systems and M-health applications represent a promising atmosphere through which to identify alternative solutions, which in turn increases the capacity in the current service model and improves diagnostic capability in the primary headache domain and beyond.

Background: Headache disorders, particularly migraine, are a leading cause of disability among active-duty military personnel, significantly affecting operational readiness and fitness for duty. Despite their high prevalence, limited data exist on how headache disorders are managed within military primary care systems. This study aimed to evaluate diagnostic confidence, treatment strategies, and structural challenges in the management of headache disorders from the perspective of military primary care physicians. Methods: A prospective, nationwide cross-sectional survey was conducted between May and July 2023 among all active-duty military physicians in primary care roles. An anonymous 15-item questionnaire assessed diagnostic practices, therapeutic approaches, referral pathways, perceived knowledge gaps, and suggestions for system improvements. The survey was distributed across military medical centers and outpatient clinics in Germany. Results: Ninety military physicians participated. Migraine and tension-type headache were commonly encountered, with 70% having treated at least one headache patient in the week prior to the survey. Diagnostic confidence was high for migraine (83.4%) and tension-type headache (77.8%) but lower for medication-overuse headache (65.5%) and cluster headache (47.8%). Acute treatment was widely implemented, but only 27.8% of respondents regularly initiated preventive therapies. Awareness of clinical guidelines was limited: only 23.3% were familiar with the ICHD-3, and just 58.9% with national headache treatment guidelines. Respondents expressed strong demand for targeted education, practical diagnostic tools, and improved interdisciplinary coordination. Conclusions: Headache disorders are a prevalent and clinically significant issue in military primary care. While military physicians show high engagement, important gaps exist in preventive treatment, guideline familiarity, and access to specialist care. Structured training, standardized treatment protocols, and system-level improvements are essential to optimize headache care and maintain operational readiness.

A headache is defined as “pain found in the head above the orbito-meatal line and or nuchal ridge” and widely affects both males and females globally. Chiropractic treatment and the management of headaches is substantial, with one in five new patients’ chief complaint being a headache and, thus, the use of chiropractic care in the management and treatment of headaches is popular. The term “self-perceived preparedness” refers to how people view themselves in terms of confidence and competency with regard to certain skills. Self-perceived preparedness is essential as it relates to one’s confidence and the ability to accurately diagnose and manage headache disorders. There is a definite scarcity in South African literature as to the self-perceived preparedness of students in the diagnosis and management of headache disorders. In a South African chiropractic context, the literature, with regard to students’ confidence, awareness and self-assessment of skills is lacking. There are a number of advantages that can come from exploring the concept of self-perceived preparedness. The benefits include, but are not limited to, the assessment of whether or not the curricula goals have been achieved, the readiness of chiropractic students to confidently and correctly diagnose and manage patients sufficiently, and the different aspects that can lead to one feeling unprepared. Aim The aim of this study was to explore and describe the self-perceived preparedness of the chiropractic students’ in the diagnosis and management of headache disorders. Methodology This study design employed a qualitative, explorative and descriptive design. Purposeful sampling was utilised and individual, semi-structured interviews were conducted with 13 Master’s degree students in the chiropractic programme. These interviews took place “in person” and an interview guide was utilised in each interview. The interviews were conducted over a week from the 18th to the 23rd of September 2023. The questions surrounded the topics of self-perceived preparedness, confidence, challenges (whether educational or personal) and the effect of clinical exposure on one’s confidence and skills. The interviews were analysed and themes were extracted utilising Tesch’s eight-step approach of data analysis. Results The chief themes that emerged from the data collection included the level of preparedness, educational and environmental challenges, as well as the positive role that clinical exposure had on students’ views of their self-perceived preparedness. The participants felt largely unprepared to deal clinically with headache disorders. This stemmed from the feeling of isolation within academia, lack of support from staff and clinicians, lack of practical aspects within the curriculum and the COVID-19 pandemic, which resulted in a lack of in-person interaction. Conclusion The findings of this study highlighted the lack of confidence and feeling of under-preparedness to deal with headache disorders within a clinic setting by chiropractic Master’s students. This was mainly attributed to educational and environmental challenges. However, the exposure students gained within a clinical environment greatly improved their feeling of overall self-perceived preparedness

The prevalence of chronic daily headache in association with regular use of analgesics is about 2%. Whether regular use of analgesics has a causal or consequential relationship to daily headache has not been established. A causal relationship has been suggested consequent to the observation of improvement or resolution of headache following analgesic withdrawal in patients attending headache clinics, but this observation has not been validated by controlled trials. The aim of our investigation was to determine whether regular use of analgesics is associated with the development of chronic daily headache de novo and to characterize the clinical phenotype of those headaches by carefully studying chronic daily headache in patients with regular use of analgesics for a nonheadache indication. Patients attending a rheumatology-monitoring clinic of second-line agents were interviewed by a training neurologist with regard to their analgesic and headache history. Headache classification was according to the criteria of the International Headache Society. Daily headache characteristics were surveyed via a standardized questionnaire, and headache features were further explored by a trained medical interviewer. Of 110 patients presenting to a rheumatology-monitoring clinic, 73% had a diagnosis of rheumatoid arthritis, 23% had seronegative arthritis, and 4% comprised a miscellaneous group. One hundred three were using one or more analgesics regularly for their arthritis. Of this group, 8 (7.6%) reported a history of chronic daily headache, each of whom reported a history of migraine. The onset of migraine occurred before the onset of chronic daily headache in 7 patients and at about the same time as the chronic daily headache in 1 patient. In those with onset of migraine prior to chronic daily headache, the mean interval before the onset of headache was 30 years (range, 10 to 50 years). Regular use of analgesics preceded the onset of daily headache in 5 patients by a mean of 5.4 years (range, 2 to 10 years). In 1 patient, analgesic use and the development of daily headache occurred at about the same time. In 1 patient, the onset of daily headache preceded regular use of analgesics by almost 30 years. Five of those with regular use of analgesics had been taking an opiate-based preparation in combination with a nonsteroidal anti-inflammatory agent in 4. Two had been on a combination of acetaminophen (paracetamol) and a nonsteroidal anti-inflammatory drug. The minimum number of tablets per week was 7, and the mean was 48 (range, 7 to 87). Of those patients who did not have daily headache, 41% had a history of migraine and 27% reported a history of tension-type headache. These findings suggest that individuals with primary headache, specifically migraine, are predisposed to developing chronic daily headache in association with regular use of analgesics.

Establishing an open and honest physician-patient relationship is essential for the proper evaluation and management of headache disorders. Obtaining a complete headache and medical history is the most important part of the initial diagnostic evaluation. This history should include information about headache onset, pain intensity, character of the pain, presence of aura, associated autonomic symptoms, and trigger factors. Special attention must be paid to the frequency of analgesic use, both prescription and over-the-counter, to identify analgesic rebound headache. A thorough neurologic examination must also be performed; if it is normal, there is usually no need for special tests. Headaches are classified as either primary or secondary. Primary headaches have no structural or metabolic cause, while secondary headaches are caused by an underlying pathologic or metabolic process. Migraine, tension-type, cluster, and analgesic-rebound headaches are all primary headache disorders. Secondary headaches are caused by conditions such as increased intracranial pressure, pseudotumor cerebri, subdural and intracerebral hematomas, hypertension, meningitis, temporal arteritis, Lyme disease, and brain tumors. Accurate diagnosis of headache is essential to determine the appropriateness of further testing and to guide proper treatment of the patient's condition.

The WHS classification of Head, Neck and Face pain, Edition 1 Version 1 (WHS-MCH1) is the official document of the World Headache Society. It was conceptualized and developed by the Society’s Classification Committee. The work began with a clean slate to create a comprehensive, updated and holistic classification of headache disorders; where ‘headache’ was defined as any pain above the shoulders, thus including head, neck and face pain. This new classification reflects a scientifically robust understanding of disease and also places patient experience in the qualia of pain. It is a training manual to be used at the bedside and office as an aid to the diagnosis and management of headache disorders. The dynamic nature of this first ever live classification of headaches also means that ultra-rapid updates, or versions, will be available electronically. It is not a disease criteria but a classification criteria (1) and is useful to pick extended spectra and ‘mimickers’ of diseases. Although increased sensitivity usually comes at the expense of reduced specificity, an expanded spectrum of diseases in this case also means increased specificity. WHS-MCH1 is a syndromic classification. A syndrome is a recognizable complex of symptoms and physical findings which may have more than one aetiology. Although disease is nominalist and culture-relativistic (2), a syndrome based approach reflects the discipline of first widening the view of possibilities before analysing each to formulate a diagnostic hypothesis. Such an approach provides a useful framework for organizing the complexity of clinical experience in order to derive inferences about outcome and guide decisions about treatment. WHS-MCH1 has a vertical grouping designed for use by clinicians of all levels of experience; this is linked to the horizontal groupings which are syndrome-based. The syndrome groups are also interlinked to one another. This design enables clinicians to efficiently create the ‘big picture’ so as not to miss any diagnosis. Axis 1 and 2 are the vertical and horizontal grouping categories, respectively. Axis 3 is the patient narrative of bothersome symptoms and level of impairment. Axis 4 are biomarkers that may be derived from investigations and this is the best example of the continuum of better understanding of disease-defining markers. Axis 5 is an objective impairment scale that clinicians may choose based on availability. The World Headache Society hopes that the use of such a robust and inclusive framework will lead to better patient outcomes and improved patient and clinician satisfaction with the investigative and diagnostic process. Keywords: Classification; Syndromes; Headache disorders; Neck pain; Facial pain; Aaxis classification; Head pain; Face pain; Headache; Multiaxis

The European Neurological Network is a European Economic Community supported project. The purpose of the project was to develop a multimedia educational tool for general practitioners in order to improve their management of sleep disorders, epilepsy and headache. The project involves approximately one hundred engineers and physicians from Belgium, Denmark, England, Finland, France, Germany, Italy, Portugal and Spain. This paper concerns the multimedia educational tool on headache. The system consists of five different modules, i.e. classification, clinical data, headache tutorial, diagnostic headache diary and nomenclature. It is possible to move between the modules both vertically and horizontally. The headache classification of the International Headache Society is provided in full text as a work of reference. This classification is used world wide and has been adopted by International Classification of Diseases 10 Neurological Adaptation (ICD-10 NA) and the World Health Organisation. The clinical data concentrate on migraine and tension-type headache, the two most common headache disorders, but data on familial hemiplegic migraine, cluster headache, drug-induced headache and secondary headaches are also available. The headache tutorial consists of case records that the user can test their diagnostic abilities on. The diagnostic headache diary is an expert system on headache diagnostics. It can be filled in during a consultation in order to provide the headache diagnosis or it can be printed and used by the headache patient to record headache attacks and medicine consumption. The nomenclature module provides an explanation of words and expressions used in the system.

BackgroundChronic headache causing severe headache-related disability for those affected by the disease is under- or misdiagnosed in many cases and therefore requires easy access to a specialist for optimal health care management.ObjectiveThe goal of the research is to determine whether video consultations are noninferior to face-to-face consultations in treating chronic headache patients referred to a specialist in Northern Norway.MethodsPatients included in the study were recruited from general practice referrals to a specialist at a neurological department in Northern Norway (Tromsø) and diagnosed according to the International Headache Society classification system. In a randomized controlled design, the 1-year remission rate of chronic headache (change from ≥15 to <15 headache days per month during the last 3 months), patient satisfaction with a specialist consultation, and need for follow-up consultations by general practitioners were compared between groups consulted by video and face-to-face in a post hoc analysis. Data were collected by interview (baseline) and questionnaire (follow-up).ResultsFrom a baseline cohort of 402 headache patients consecutively referred from general practice to a specialist over 2.5 years, 58.0% (233/402) were classified as chronic headache and included in this study. Response rates were 71.7% (86/120) in the video group and 67.3% (76/113) in the face-to-face group. One-year remission from chronic headache was achieved in 43.0% (37/86) in the video group and 39.5% (30/76) in the face-to-face group (P=.38). Patient satisfaction with consultations were 86.5% (32/37; video) and 93.3% (28/30; face-to-face; P=.25). A total of 30% (11/37) in the video group and 53% (16/30) in the face-to-face group consulted general practitioners during the follow-up period (P=.03), and median number of consultations was 1 (IQR 0-13) and 1.5 (IQR 0-15), respectively (P=.19).ConclusionsOne-year remission rate from chronic headache was about 40% regardless of consultation form. Likewise, patient satisfaction with consultation and need for follow-up visits in general practice post consultation was similar. Treating chronic headache patients by using video consultations is not inferior to face-to-face consultations and may be used in clinical neurological practice.Trial RegistrationClinicalTrials.gov NCT02270177; https://clinicaltrials.gov/ct2/show/NCT02270177

In the past years a unifying definition of refractory headache (rH) has been extensively discussed [1,2] but, to date, has not been agreed upon. It is widely agreed, that refractoriness, for whatever category and disease, implies a high burden with tremendous impact in health related quality of life (HRQoL) [3]. Despite that fact, an overall accepted definition of rH would be more than important for managing and triaging patients to an appropriate level of care and for determining eligibility for epidemiological and clinical studies. So far, there are different and non-conclusive categories that try to describe refractoriness. In the understanding of refractoriness particular in headache patients several important issues have to be addressed: First, it is of importance to emphasize the difficulty that refractoriness in headache may just represent more or less treatable version(s) of many different disorders, rather than a unique disease or group of disorders. Second, the same patient might be identified as refractory at one time, but treatment responsive at another. Therefore it may be of crucial importance to evaluate acute and prophylactic treatment response, baseline headache severity, partial response versus an all-or-none response, and the possibility of any variability in the treatment response over time for each headache disorder and patient from the very first on. Some evidence supports the hypothesis that baseline headache attack intensity has an impact on determination of treatment response [4]. It may also be hypothesized that patients with high baseline headache frequency were more likely to be drug resistant, meaning that it is harder to eradicate many headache attacks than a few. Without recording baseline frequency and severity rate, it is almost impossible to know whether there has been partial or no response to treatment. But that’s the crucial point: clinicians have the need for medical treatment mostly before severity of headache and frequency of disease can be determined. When headache attacks are not completely controlled, the conclusion may be that the administered drug is not effective and that the patient therefore is “resistant”. Third, as in other conditions [5] the definition of responder or non-responder enormously differs among both clinicians and investigators. All these considerations lead to variability in clinical and epidemiological research results, both being of importance to increase our knowledge in the understanding of rH. What are the critical issues so far: (i) there is no standardized definition of rH; (ii) at the time of first diagnosis headache patients do not necessarily become refractory immediately, nor do they mandatorily remain refractory throughout the course of their disease; (iii) due to the necessity that most patients should be treated rapidly after diagnosis response to medication often is assessed without a pretreatment baseline and it remains unclear whether or not so-called refractory patients have had a substantial response to treatment; (iv) headache pain and associated symptoms are frequently intermittent, making this disease different from others that have been examined for treatment resistance; (v) the natural history is not known. For all these purposes the Board of the European Headache Federation (EHF) felt the need to develop new consensus criteria that define refractory chronic migraine (rCM) and refractory chronic cluster headache (rCCH). These new definitions of rCM and rCCH, which were agreed upon within the EHF, allows us to separate patients into categories of refractory and non-refractory, being important for clinicians, clinical and epidemiological trials. The EHF is aware of that still many challenges are on the road in identifying which patients are really treatment resistant and to what degree. It is a misconception that a patient necessarily will fall into one of the two categories and stay there. From a clinical perspective a large number of patients may fit each category for periods of time. But patients may also move in both directions, from refractory to responsive and the opposite. E.g. after neuromodulation, many patients will become headache free but have to continue with prophylactic medication to prevent headache recurrence. These patients have shifted from being treatment resistant to being treatment sensitive. To define treatment response - EHF claims the need to go into patient categorization - one term does not fit all. We badly need the same definitions of rH, better information about pretreatment headache rate and severity, more precise information about prior acute and prophylactic treatment response and scientific data regarding the natural history of drug response.

(1) Background: Headache disorders are among the most disabling medical conditions but the supply with experienced providers is outpaced by the demand for service. It is unclear to what extent particularly patients in rural regions are affected by limited access to comprehensive care. Furthermore, it is unknown what role general practitioners (GPs) play in headache care. (2) Methods: First-time consultations to a specialised headache clinic at a tertiary care centre were asked to participate. Their socio-demographic background, general and headache-specific medical history, disability and quality of life (QoL) were assessed. Additionally, 176 GPs in neighbouring districts were contacted regarding headache management. (3) Results: We assessed 162 patients with first-time consultations (age 46.1 ± 17.0 years, 78.1% female), who suffered from migraine (72%), tension type, cluster and secondary headaches (each 5–10%). About 50% of patients received a new headache-diagnosis and 60% had treatment inconsistent with national guidelines. QoL was significantly worse in all domains compared to the general population. About 75% of GPs see headache patients at least several times per week, and mostly treat them by themself. (4) Conclusions: More than every second headache patient was neither correctly diagnosed nor received guideline adherent treatment. Headache-related disability is inferior to what is expected from previous studies. Access to specialised health care is more limited in rural than in urban regions in Germany and GPs request more training.