The diagnosis and management of acute cluster headache in the out-of-hospital environment

Abstract

Cluster headaches are the most painful form of primary headache and the most common of a group of headaches known as trigeminal autonomic cephalalgias (TACs) ( Imai, 2013 ). It is estimated that 25 million days are lost from work or school because of migraine each year ( National Institute for Health and Care Excellence, 2013 ), and a potential cost of £956 million to health services due to service use, and £4.8 billion due to lost employment each year ( McCrone et al, 2011 ). Given the burden upon health services and the wider economy, a number of strategic drivers for enhancing general management of headaches have been produced with explicit aims of reducing inappropriate referrals and admissions. This article reviews the current literature and discusses the appropriateness of non-specialist clinicians working in out-of-hospital, and in primary, urgent and emergency care, such as paramedics, safely diagnosing and managing cluster headaches in the community, while also considering the balance of possible risks and fiscal benefits in doing so. It concludes that community practitioners could safely manage recurrent episodes of cluster headaches within the community, with good referral and consultation pathways being put in place. However, caution should be paid to discharging those patients presenting with first bout of cluster headache without specialist clinical assessment. Furthermore, while there is some evidence to suggest that this community management may be cost effective, this conclusion cannot be definitely drawn without the authors undertaking a full cost–benefit analysis, which was not within the scope of this paper.