Neurology services in need of new headache pathways to improve productivity

Clinical neurology services, afflicted by a chronic lack of capacity, face a continuing flood of headache referrals. Coupled with an often inappropriate thirst for brain imaging leading to scanning sometimes exceeding commissioned activity, perhaps headache should be regarded not just a symptom for the patient but for the NHS too.

Headache has consistently accounted for approximately 20 per cent of outpatient referrals to neurology over many years. Recent local audits have shown headache to account for 20-30 per cent of neurological referrals, reflecting findings from published studies: migraine or “tension type headache” constituted 20.3 per cent of 3,020 new patient referrals to one Gloucestershire neurologist in 1984-6, while in a recent Scottish multicentre study, headache constituted 19 per cent of 3,781 new referrals to general neurology clinics in 2002-4.

Headache represents the largest single category of outpatient neurology referral, contributing to the ongoing battle with prevailing referral demands (e.g. 18-week pathway remains a part of many current PCT-acute trust contracts), while neurology capacity remains low by comparison with other European countries (1 neurologist per 150,000 population in the UK; 1 per 20,000 population in Holland).

An all too frequent superficial fix is to reach for ever more neurology waiting list initiative clinics, which arguably merely serves to perpetuate the problem rather than working towards a more sustainable long term solution.

Patient – and often GP – expectations are often that a brain scan will be undertaken. But why?

“The pressure to do a quick MRI is omnipresent. Thus almost every patient who walks into the emergency room with a headache invariably gets scanned. In our current world a doctor who images a patient with headache only in the presence of red flags such as focal neurological findings on examination or an atypical history is perceived to be a bad doctor. That I am afraid is the reality.”

Rather dispiriting observations by an American neurologist writing in a UK neurology journal, in response to comments concerning the dangers associated with the identification and management of incidental findings on MRI.

Such incidental findings are certainly the cause of considerable patient anxiety. In a recent study examining direct access to MRI by GPs, this was found not to be cost effective, with 20 per cent scanned patients being referred to neurology anyway within six months of their scan, and any cost saving achieved through a minor reduction in overall new outpatient referrals being offset by the scanning costs.

Headache will very infrequently be due to any underlying serious cause such as a brain tumour. Even when more stringent ‘two-week rule’ guidelines (for suspected cancer) are applied, brain tumours are unusual. For example, local cancer network data reveal that malignancies were identified in only 12 (2.8 per cent) of 431 suspected brain tumour two-week rule referrals over the past four years. It is surely ridiculous to scan all headache patients, regardless of clinical features and presence or absence of “red flags”, simply because of an expectation of scanning on the part of the patient or their GP. Patients should be encouraged to accept a clinical diagnosis – especially in the context of obvious migraine, for example.

We don’t really know how best to manage the current situation. Managing expectations – particularly in respect of brain scanning, and also in terms of the need for neurology referral – is clearly likely to be crucial. This means that improved education and confidence among GPs in respect of headache management will be important. Hopefully, greater opportunities exist currently and in the near future for improved joint working between commissioning consortia leads, GPs and secondary care.

Some localities have evolved GP with special interest services for headache such that general neurology outpatient lists are said to have relatively few headache referrals. Others are implementing headache pathways with improved guidance to GPs concerning initial headache management. It is important that such pathways make particular reference to medication overuse headache which frequently arises in patients with migraine but appears to be under recognised.

Service development on a sustainable basis in respect of headache is likely to include a combination of headache pathways and primary or intermediate care settings for headache, with a reduction in the proportion of headache patients ultimately referred to neurology. Whether any reduction in the demand for often unnecessary neurology referral – and even more unnecessary brain imaging – will be realised is another matter, but we can hope.