Headache Specialists Research Articles

Vestibular Migraine

A temporal overlap between vestibular symptoms, such as vertigo and head movement intolerance, and migraine symptoms, such as headache, photophobia, and phonophobia, is a requisite diagnostic criterion for the diagnosis of vestibular migraine (VM). Diagnostic criteria for VM have been proposed by an International Vestibular Research Group (the Bárány Society) and a headache research group (International Headache Society); however, in practice, it is still acceptable to divide patients suspected of VM into “definite VM” and “probable VM” groups. Here, a neuro-otologist and a headache specialist consider VM from their own points of view using four real cases, two from a dizzy clinic and two from a headache clinic, with expert opinions and arguments according to the current literature. The management is summarized on the basis of mechanism and comorbidity and the importance of prophylactic medication.

The role and impact of the headache nurse specialist.

In the current paper, we aim to emphasize the pivotal role of the specialist headache nurse whose scope of work is clearly defined and detailed in western medical practice within tertiary care.

PND4 CHARACTERISTICS OF MIGRAINE PATIENTS IN PORTUGUESE HEADACHE SPECIALIST CENTERS

Real-world evidence about the characteristics of patients suffering from migraine in Portugal is scarce. We aimed to describe the characteristics of patients visiting headache specialized centers in Portugal. BECOME study is a non-interventional study conducted across 17 European countries and Israel between Nov2017-Aug2018 entailing Part-1 (cumulative hospital data) and Part-2 (patient-level data). In Part-1, all patients visiting the participating headache specialist centers over a 3-month prospective period were screened for frequency of prior prophylactic treatment failures (TF), monthly migraine days (MMD), and other characteristics. Results from the Portuguese sample included in Part-1 are reported. Six Portuguese headache specialized centers participated in the study (3 public and 3 private). About 586 patients with migraine visited these centers during Part-1 period: 49.5%/23.3%/11.5% reported TF1+/TF2+/TF3+ and 70.1%/41.9%/20.0% reported ≥4 MMD/≥8 MMD/≥15 MMD (≥15 headache days per month at least 8 of which are migraine days). More than one-third (39.3%) of patients with migraine were visiting the centers for the first time over the 3-month period of Part-1. About 14% of the patients had suspected overuse headache. Percentage of patients with medication overuse was found to be 13.5%. This study helps to understand the real-world characteristics of migraine patients visiting headache specialist centers in Portugal. Almost one-quarter of the patients reported ≥2 prior prophylactic treatment failures and 20% reported ≥15 migraine monthly days, demonstrating the high burden of disease and unmet need with current prophylactic migraine treatments.

Poor patient awareness and frequent misdiagnosis of migraine: findings from a large transcontinental cohort.

Although migraine is the second most disabling condition worldwide, there is poor awareness of it. The objective was to assess the awareness of migraine and previous diagnostic and therapeutic consultations and treatments in a large international population of migraineurs. This was a multicentre study conducted in 12 headache centres in seven countries. Each centre recruited up to 100 patients referred for a first visit and diagnosed with migraine. Subjects were given a structured clinical questionnaire-based interview about the perceptions of the type of headache they suffered from, its cause, previous diagnoses, investigations and treatments. In all, 1161 patients completed the study. Twenty-eight per cent of participants were aware that they suffered from migraine. Sixty-four per cent called their migraine 'headache'; less commonly they used terms such as 'cervical pain' (4%), tension headache (3%) and sinusitis (1%). Eight per cent of general practitioners and 35% of specialists (of whom 51% were neurologists and/or headache specialists) consulted for migraine formulated the correct diagnosis. Before participating in the study, 50% of patients had undergone X-ray, computed tomography and/or magnetic resonance imaging of the cervical spine and 76% underwent brain and/or cervical spine imaging for migraine. Twenty-eight per cent of patients had received symptomatic migraine-specific medications and 29% at least one migraine preventive medication. Although migraine is a very common disease, poor awareness of it amongst patients and physicians is still an issue in several countries. This highlights the importance of the promotion of migraine awareness to reduce its burden and limit direct and indirect costs and the risk of exposure to useless investigations.

Management of Childhood Migraine by Headache Specialist vs Non‐Headache Specialists

This study aims to compare the management practices of a headache specialist with non-headache specialists in the treatment of children with migraine. The use of appropriate rescue medications and prophylactic agents, application of neuroimaging, and short-term outcomes are compared in children treated by the two groups of physicians. A retrospective cohort study was conducted by utilizing the electronic medical records of children 3-18 years of age with migraine, who were evaluated at a tertiary care children's hospital from 2016 to 2018. Of the 849 patients who met the study criteria, 469 children were classified as having chronic migraine or high-frequency episodic migraine and were followed-up on at least 1 occasion by the neurologists. Imaging was obtained in 66.5% of all children with migraine. The headache specialist used 5-HT agonists ("triptans") for migraine management in 56.7% (76/135) of cases compared to non-headache specialists who prescribed them in 28.7% (96/334) of cases (P<.001). Of the children with chronic migraine, the headache specialist evaluated 135 patients while the non-headache specialists treated 334 children. Non-headache specialists prescribed prophylaxis in the form of natural supplements more frequently (63.8% of cases) compared to the headache specialist (38.5% of children) (P<.001). Moreover, prophylaxis with prescription drugs was utilized more often by headache specialist (66.7%) than non-headache specialists (37.4%) (P<.001). Imaging appears to be commonly recommended by both headache specialists and non-headache specialists in children with migraine. The headache specialist was more likely to use triptans as rescue medications for pediatric migraine. Outcomes in the short-term were not statistically different whether children were being managed by the headache specialist or the non-headache specialists.

Primary headache and migraine in headache specialists - does personal history of doctors matter?

Migraine is a common disorder affecting more than 10% of the population. The prevalence of migraine among physicians and, in particular, among headache specialists is widely unknown as is the impact of suffering from migraine on the attitudes towards migraine and on treatment recommendations of physicians. We designed a survey among headache specialists and neurologists and compared the results to general pain specialists and general practitioners. A standardized interview in randomly selected samples of these four groups of physicians was performed. The interview included data on the prevalence of migraine and other primary headache disorders in the physician groups, self-report on their own treatment, attitudes towards migraine, and treatment recommendations for migraine. The prevalence rates were also compared to an age- and sex-matched German general population sample. The lifetime prevalence of migraine was higher in headache specialists (53.0%) than in general neurologists (43.0%), pain specialists (21.7%), general practitioners (19.3%), and in the general age- and sex-matched population (16.8%). Cluster headache prevalence was high in neurologists (1.9%) and in headache specialists (1.3%); episodic tension-type headache prevalence was significantly lower in general practitioners (19.5%). One reason, among others, was that being a migraine (or cluster headache) patient more often prompted the sufferers to become a specialist in neurology. Physicians with migraine rated the biopsychosocial concept of lower importance for migraine than did physicians without migraine. The self-treatment of migraine in physicians differs from the treatment recommendations to the patients. For example, only 36.4% of the headache specialists with migraine take triptans whereas 94.4% recommend triptans to their patients. We conclude that being a headache specialist or a neurologist is associated with an increased migraine or cluster headache prevalence. This personal history of migraine leads to a more somatic view of migraine as a disorder and to different treatment recommendations as compared to self-treatment.

Migraine patients\u2019 journey until a tertiary headache center: an observational study

BackgroundMigraine diagnosis is based on clinical aspects and is dependent on the experience of the attending physician. This study aimed to describe the patients journey profile until they start their experience in a tertiary headache center.MethodsIn a cross-sectional study, medical charts from migraine patients were reviewed to describe which treatments, procedures and follow-up strategies are performed until the first appointment with a headache specialist. Patients from both sexes, ≥18 years old, which came to their first visit from March to July 2017 were included. Sociodemographic information, headache characteristics, diagnostic methods previously used, clinical history, family history and the treatments previously used were assessed in the first appointment with a specialist. Patient Health Questionnaire-9 and General Anxiety Disorder-7 were also applied. Descriptive analyses were performed to describe the sample profile and statistical tests were used to evaluate factors associated with the type of migraine (chronic or episodic).ResultsThe sample consisted of 465 patients. On average, the pain started 17.1 (SD = 11.4) years before the first appointment with a headache specialist. Most of patients were classified as having chronic migraine (51.7%), with an average frequency of 15.5 (SD = 9.9) days per month. Regarding patients’ journey until a specialist, most patients were submitted to laboratory tests (74.0%), cranial tomography (66.8%) and magnetic resonance imaging (66.8%) as diagnostic methods, and preventive drugs (70.2%) and acupuncture (61.0%) as treatments. After stratification by migraine type as episodic or chronic, patients with chronic migraine were submitted to more magnetic resonance imaging test, acupuncture, psychotherapy, used preventive drugs, and reported to have used topiramate without beneficial effects.ConclusionsBrazilian patients with migraine experiment a long journey until getting to a headache specialist and are submitted to a great number of unnecessary exams, especially those with chronic migraine.

Message Framing and the Willingness to Pursue Behavioral Therapy: A Study of People With Migraine.

Behavioral treatments for migraine prevention are safe and effective but underutilized in migraine management. Health message framing may be helpful in guiding patients with treatment decision making. The authors assessed associations between message framing and the willingness to seek migraine behavioral treatment among persons with a diagnosis of migraine headache. A total of 401 individuals (median age=34 years [interquartile range, 12 years]) who screened positive for migraine, as determined by the American Migraine Prevalence and Prevention questionnaire, were assessed. Participants were randomly assigned to receive one of four message frames using TurkPrime: specific loss framing (N=101), specific gain framing (N=98), nonspecific loss framing (N=102), and nonspecific gain framing (N=100). The message frames were initially piloted for 56 participants and then revised by a headache specialist, with input from a communications specialist, and randomly distributed to the larger sample. More than two-thirds of participants (70.3%) were women. The median number of headache days per month was 5 (interquartile range, 5.3). Some of the participants (12.5%) had previously used evidence-based behavioral therapy for migraine. No significant differences in the willingness to pursue behavioral treatment for migraine between the four message framing groups were found. The median for all four types of message frames was 4 (interquartile range, 1; Kruskal-Wallis H, p=0.41). Findings revealed that message framing was not associated with willingness to seek behavioral therapy for migraine.

Shortcomings and missed potentials in the management of migraine patients - experiences from a specialized tertiary care center

BackgroundMigraine is a common and severely disabling neurological disorder affecting millions of patients in Europe. Despite the availability of evidence-based national and international guidelines, the management of migraine patients often remains poor, which is often attributed to a low availability of headache specialists. The aim of this study was to investigate the adherence to national guidelines and to assess the possible potential of optimized therapy regimens in migraine patients.MethodsWe collected data of migraine patients presenting to our out-patient clinic via standardized questionnaires regarding headache, diagnostics and experience with previous treatments. We also assessed the efficacy of treatment started by our center.Results1,935 migraine patients were included between 2010 and 2018. In the 12 months before consulting our headache clinic 89.5% of the patients had consulted a general practitioner and 74.9% had consulted a neurologist because of their migraine. Nevertheless, 50% of the patients underwent unnecessary diagnostics and 34.2% had not been treated according to evidence-based treatment guidelines. Out of 1,031 patients who had not been prescribed a preventative treatment 627 (60.8%) had in average 3 or more migraine attacks per month and thus qualified for a preventative treatment. These patients missed in the 3 months prior to consultation on average 5 work or school days. Initiating a preventative treatment was effective in 71.2% of the patients, that provided follow-up data.ConclusionsOur data suggest, that many migraine patients to this day do not receive state-of-the-art therapy. Adherence to national and international European guidelines could improve the outcome in migraine patients. Future research should try to answer why guidelines are not followed.

Availability of Effective Evidence-Based Symptomatic Treatments for Cluster Headache in the EU Countries-A Survey of the European Headache Alliance and European Headache Federation.

To assess the reimbursement options and accessibility of three effective medicines for cluster headache (CH) (subcutaneous sumatriptan, oxygen, and zolmitriptan spray) across the European Union (EU). A brief survey investigating the availability of symptomatic treatments for CH was sent by email in January 2017 to at least one headache specialist for every single country in the EU. The questionnaire was completed by 26 headache specialists (93% of the EU countries, representing 99.75% of the European population) and by 10 CH patients representative of patient organizations. Oxygen was reimbursable for 63% of the CH population. Oxygen device was reimbursable for 50% of the CH EU population. Subcutaneous sumatriptan was reimbursable for 66% and was accessible without restrictions for 45% of the CH EU population. Zolmitriptan spray was reimbursable for 23.7% and accessible without restrictions for 30.9% of the CH EU population. Only 47% of the EU population had unrestricted access to effective CH treatments, with unacceptable inequalities between eastern countries and the rest of Europe. Headache societies and patient associations should pressure European and national health authorities to improve the availability of effective symptomatic treatments for CH.

The pain of a migraine

A short documentary on migraine was released on BBC iplayer on 17 May, 2019, but is there anything new to report? Currently, treatment options vary wildly in their effectiveness in different patients, and the chances of finding a full cure are “slim”, says Jessica Briscoe, a headache specialist and general practitioner based at the National Migraine Centre (London, UK). While research is ongoing, those who experience migraines, having exhausted all avenues of available treatment, are still waiting for that life-changing drug. In fact, with a migraine, it is a waiting game. Until the migraine leaves, everyday life stops.

Real-world healthcare resource utilization related to migraine treatment failure: a panel-based chart review in France, Germany, Italy, and Spain

Aims: This retrospective chart review examined the six-month migraine-related healthcare resource use (HRU) among European patients who had ≥4 migraine days per month and previously failed at least two prophylactic migraine treatments.Methods: Neurologists, headache specialists, and pain specialists in France, Germany, Italy, and Spain who treated ≥10 patients with migraine in 2017 were recruited (April–June 2018) to extract anonymized patient-level data. Eligible physicians randomly selected charts of up to five adult patients with clinically-confirmed migraine, ≥4 migraine days in the month prior to the index date, and had previously failed at least two prophylactic migraine treatments. Treatment failure was defined as discontinuation due to lack of efficacy and/or tolerability. Demographic and disease characteristics as of the index date, and migraine-related HRU incurred during the 6-month study period, were recorded.Results: A total of 104 physicians contributed 168 charts for patients (63% female). On average, patients were 38 years old and failed 2.3 prophylactic treatments as of the index date. During the study period, 83% of patients had ≥1 outpatient visit for migraine in the physician’s office, and 27% went to the ER/A&E. Approximately 5% of patients were hospitalized for migraine, with an average of one hospitalization and an average length of stay of 3 days. Approximately 39% of patients had ≥1 blood test, 22% had ≥1 magnetic resonance imaging, 17% had ≥1 electroencephalogram, and 13% had ≥1 computerized tomography scan. Visits to other healthcare providers were common.Limitations: This study is subject to the limitations of chart review studies, such as errors in data entry.Conclusions: Across four European countries, the HRU burden of migraine among patients who previously failed at least two prophylactic treatments was high, indicating a need for more effective prophylactic treatments to appropriately manage migraine and reduce the HRU burden attributable to this common disorder.

Non-invasive Brain Stimulation in Pediatric Migraine: A Perspective From Evidence in Adult Migraine.

Pediatric migraine remains still a challenge for the headache specialists as concerns both diagnostic and therapeutic aspects. The less ability of children to describe the exact features of their migraines and the lack of reliable biomarker for migraine contribute to complicate the diagnostic process. Therefore, there's need for new effective tools for supporting diagnostic and therapeutic approach in children with migraine. Recently, promising results have been obtained in adult headache by means of application of neurostimulation techniques both for investigating pathophysiological mechanisms and also for therapeutical applications. Non-invasive brain stimulation (NIBS) techniques like transcranial magnetic stimulation (TMS) and transcranial direct current stimulation (tDCS) indeed proved to be generally safe and showing also some evidence of efficacy particularly for the symptomatic treatment. On such basis, in the last years increasing interest is rising in scientific pediatric community to evaluate the potential of such approaches for treatment pediatric headaches, particularly in migraine, even if the evidence provided is still very poor. Here we present a perspective for application of TMS and tDCS technique in children migraine principally based on evidence coming by studies in adults.

Prevention, education and counselling: the worldwide role of the community pharmacist as an epidemiological sentinel of headaches.

Headache disorders are the third among the worldwide causes of disability, measured in years of life lost to disability. Given the pharmacies' importance in general in headache patient and, in particular in migraine patient management, various studies have been carried out in recent years dealing with this issue. Indeed, in 2014, our research group first analysed publications on a number of studies conducted worldwide. As five years have passed since our first analysis of the literature and having carried out a number of specific studies in Italy since 2014, we wish to analyse once again the studies carried out globally on this topic to evaluate how the situation has evolved in the meantime. The key words used for the bibliographic search were "community pharmacy" and "headache"; we considered articles published between 2014 and 2018. The selected studies regarded Sweden USA, Belgium, Ireland, Jordan and Ethiopia. From the analysis of the international research papers, it is evident that, despite the time that has passed since the previous analyses and the general agreement that pharmacists find themselves in an ideal position to offer adequate levels of counselling to headache patients, the knowledge of pharmacists is not yet sufficient. Clearly, there is a strong need to develop training programmes specifically focused on this subject. Regarding Italy, a national study, commenced in 2016, was designed as a cross-sectional survey employing face-to-face interviews between pharmacist and patient using a questionnaire drawn up by experts in compliance with best practice from scientific literature. Six hundred ten pharmacists followed a specific training course; 4425 questionnaires were correctly completed. The use of pharmacies as epidemiological sentinels, given their capillarity and daily contact with the local population in Italy, enabled us to obtain an epidemiological snapshot closer to the real-life situation compared to specialist headache centres. Over the course of this study, data on headaches were gathered in Italian pharmacies with the highest levels of numerosity in the world.

Development and validation of the ID-EC - the ITALIAN version of the identify chronic migraine

BackgroundCase-finding tools, such as the Identify Chronic Migraine (ID-CM) questionnaire, can improve detection of CM and alleviate its significant societal burden. We aimed to develop and validate the Italian version of the ID-CM (ID-EC) in paper and as a smart app version in a headache clinic-based setting.MethodsThe study investigators translated and adapted to the Italian language the original ID-CM questionnaire (ID-EC) and further implemented it as a smart app. The ID-EC was tested in its paper and electronic version in consecutive patients referring to 9 Italian tertiary headache centers for their first in-person visit. The scoring algorithm of the ID-EC paper version was applied by the study investigators (case-finding) and by patients (self-diagnosis), while the smart app provided to patients automatically the diagnosis. Diagnostic accuracy of the ID-EC was assessed by matching the questionnaire results with the interview-based diagnoses performed by the headache specialists during the visit according to the criteria of International Classification of Headache Disorders, III edition, beta version.ResultsWe enrolled 531 patients in the test of the paper version of ID-EC and 427 in the validation study of the smart app. According to the clinical diagnosis 209 patients had CM in the paper version study and 202 had CM in the smart app study. 79.5% of patients returned valid paper questionnaires, while 100% of patients returned valid and complete smart app questionnaires. The paper questionnaire had a 81.5% sensitivity and a 81.1% specificity for case-finding and a 30.7% sensitivity and 90.7% specificity for self-diagnosis, while the smart app had a 64.9% sensitivity and 90.2% specificity.ConclusionsOur data suggest that the ID-EC, developed and validated in tertiary headache centers, is a valid case-finding tool for CM, with sensitivity and specificity values above 80% in paper form, while the ID-EC smart app is more useful to exclude CM diagnosis in case of a negative result. Further studies are warranted to assess the diagnostic accuracy of the ID-EC in general practice and population-based settings.

Chronic Headache Education and Self-management Study (CHESS) \u2013 a mixed method feasibility study to inform the design of a randomised controlled trial

BackgroundSelf-management support programmes are effective in a range of chronic conditions however there is limited evidence for their use in the treatment of chronic headaches. The aim of this study was to test the feasibility of four key aspects of a planned, future evaluative trial of a new education and self-management intervention for people with chronic headache: 1) recruiting people with chronic headache from primary care; 2) a telephone interview for the classification of chronic headaches; 3) the education and self-management intervention itself; and 4) the most appropriate patient reported outcomes (PROMS).MethodsParticipants were identified and recruited from general practices in the West Midlands of the UK. We developed a nurse-led chronic headache classification interview and assessed agreement with an interview with headache specialists. We developed and tested a group based education and self-management intervention to assess training and delivery receipt using observation, facilitator, and participant feedback. We explored the acceptability and relevance of PROMs using postal questionnaires, interviews and a smartphone app.ResultsFourteen practices took part in the study and participant recruitment equated to 1.0/1000 registered patients. Challenges to recruitment were identified. We did 107 paired headache classification interviews. The level of agreement between nurse and doctor interviews was very good. We piloted the intervention in four groups with 18 participants. Qualitative feedback from participants and facilitators helped refine the intervention including shortening the overall intervention and increasing the facilitator training time. Participants completed 131 baseline questionnaires, measurement data quality, reliability and validity for headache-specific and generic measures was acceptable.ConclusionThis study indicated that recruiting people with chronic headache from primary care is feasible but challenging, our headache classification interview is fit for purpose, our study intervention is viable, and that our choice of outcome measures is acceptable to participants in a future randomised controlled trial (RCT).Trial registrationISRCTN, ISRCTN79708100. Registered 16th December 2015, http://www.isrctn.com/ISRCTN79708100

Development and validation of a telephone classification interview for common chronic headache disorders

BackgroundFor a trial of supportive self-management for people with chronic headache we needed to develop and validate a telephone classification interview that can be used by a non-headache specialist to classify common chronic headache types in primary care. We aimed to specifically: exclude secondary headaches other than medication overuse, exclude primary headache disorders other than migraine and tension type headache (TTH), distinguish between chronic migraine and chronic TTH, and identify medication overuse headache.MethodsWe held a headache classification consensus conference to draw on evidence and expertise to inform the content of a logic model underpinning the classification interview. Nurses trained to use the logic model did telephone classification interviews with participants recruited from primary care. Doctors specialising in headache did a second validation interview.ResultsTwenty-six delegates attended the headache classification conference including headache specialist doctors, nurses and lay representatives (with chronic headache). We trained six nurses to do the classification interviews and completed 107 paired interviews, median days between interviews was 32 days (interquartile range 21–48 days). We measured level of agreement between the nurse and doctor interviews using proportion of concordance, simple kappa and prevalence-adjusted bias-adjusted kappa (PABAK). Proportion of concordance of agreement between nurse and doctor interviews was 0.76, simple kappa coefficient κ 0.31 (95% CI, 0.09 to 0.52), and PABAK 0.51 (95% CI, 0.35 to 0.68), a moderate agreement. In a sensitivity test following review of headache characteristics recorded, concordance was 0.91, κ = 0.53 (95% CI, 0.28 to 0.79), and PABAK = 0.81 (95% CI, 0.70 to 0.92), a very good agreement.ConclusionWe developed and validated a new evidence-based telephone classification interview that can be used by a non-headache specialist to classify common chronic headache types in primary care.

Differences in Characteristics and Comorbidity of Cluster Headache According to the Presence of Migraine.

Background and PurposeCluster headache (CH) can present with migrainous symptoms such as nausea, photophobia, and phonophobia. In addition, an overlap between CH and migraine has been reported. This study aimed to determine the differences in the characteristics of CH according to the presence of comorbid migraine.MethodsThis study was performed using data from a prospective multicenter registry study of CH involving 16 headache clinics. CH and migraine were diagnosed by headache specialists at each hospital based on third edition of the International Classification of Headache Disorders (ICHD-3). We interviewed patients with comorbid migraine to obtain detailed information about migraine. The characteristics and psychological comorbidities of CH were compared between patients with and without comorbid migraine.ResultsThirty (15.6%) of 192 patients with CH had comorbid migraine, comprising 18 with migraine without aura, 1 with migraine with aura, 3 with chronic migraine, and 8 with probable migraine. Compared to patients with CH without migraine, patients with CH with comorbid migraine had a shorter duration of CH after the first episode [5.4±7.4 vs. 9.0±8.2 years (mean±standard deviation), p=0.008], a lower frequency of episodic CH (50.0% vs. 73.5%, p=0.010), and a higher frequency of chronic CH (13.3% vs. 3.7%, p=0.033). Psychiatric comorbidities did not differ between patients with and without comorbid migraine. The headaches experienced by patients could be distinguished based on their trigeminal autonomic symptoms, pulsating character, severity, and pain location.ConclusionsDistinct characteristics of CH remained unchanged in patients with comorbid migraine with the exception of an increased frequency of chronic CH. The most appropriate management of CH requires clinicians to check the history of preceding migraine, particularly in cases of chronic CH.

Changing face of orofacial pain: The diagnostic impact of working with Neurology on an orofacial pain clinic

This study assessed the impact of collaborative working with a headache neurologist on diagnoses of patients attending orofacial pain (OFP) clinic. Patient diagnostic data was collected from adult patients attending an Orofacial Pain Service from January 2013 to January 2017. A liaison headache neurologist was appointed late 2015; OFP clinics were co-run with the neurologist specialist thereafter. Overall, 639 patients attended the service; 315 in 2013–2015 and 324 in 2016–2017. Compared to 2013–2015, there were increased rates of diagnoses related to neurovascular (27.5% vs. 19.0%; P=.012) and musculoskeletal pain (36.9% vs. 26.0%; P=.003) in the 2016–2017 cohort and decreased rates of neuropathic (55.6% vs. 70.2%; P<.001) and atypical/idiopathic pain (1.3% vs. 5.4%; P=.003) diagnoses. There was a trend towards an increased rate of comorbid diagnoses (26.3% vs. 20.3%; P=.077), especially those relating to headache conditions. The findings suggest that introduction of a specialist headache neurologist into the OFP clinic widened its remit of assessment, increasing recognition of (co-morbid) neurovascular-related pain and decreasing atypical/idiopathic pain diagnoses in patients with complex OFP. The increase rate of musculoskeletal pain diagnosis in the later cohort is likely attributable to service expansion and normalisation of diagnostics reportedly seen in other OFP services.Statement of clinical relevance: Orofacial pain is a complex diagnosis, it requires a multidisciplinary approach that includes neurological input.

Illness perception in people with primary and secondary chronic headache in the general population

BackgroundChronic headache (headache ≥15 days/month) is a leading cause of disability. Illness perception, beliefs and cognitive models are likely central for patient understanding of their chronic pain condition and are associated with treatment outcome. However, these factors are insufficiently described in chronic headache. ObjectiveTo describe illness perception, and to explore the effect of background variables and headache characteristics on illness perceptions in primary and secondary chronic headaches in the general population. Methods30,000 persons aged 3044 from the general population were screened for chronic headache by a mailed questionnaire. Those with self-reported chronic headache were interviewed by headache specialists. The questionnaire response rate was 71%, and the interview participation rate was 74%. The International Classification of Headache Disorders III was applied. Illness perception was assessed by the Revised Illness Perception Questionnaire (IPQ-R). The statistical approach was exploratory. Results405 of the 516 eligible participants (78%) completed the IPQ-R. Confirmatory factor analysis showed good internal validity in chronic headache. People believed their chronic headache to be long-lasting, with negative life consequences including emotional distress. Severe headache-related disability was associated with more perception of chronicity, more perceived consequences, emotional load and illness identity and less illness coherence. People with secondary chronic headache scored significantly higher on chronicity and life consequences, and had less personal control than those with primary chronic headache. ConclusionChronic primary and secondary headache is associated with a high symptom burden and chronicity with large perceived negative consequences for daily living, suggesting multidisciplinary management may be necessary.