Introduction
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to inspire and promote, or stimulate the establishment of, specialized headache centres as centres of excellence;
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to define the role of such centres within optimally structured and organized national headache services;
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to set out criteria by which such centres may be recognized as exemplary in their fulfilment of this role;
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to provide the basis for, and to initiate and motivate, collaboration and networking between such centres both nationally and internationally;
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ultimately to improve the delivery and quality of health care for headache.
Background: the need for structured headache services
Organization of headache services
Level 1. General primary care
Level 2. Special-interest headache care
Patients with: • refractory disabling headache of any type; • cluster headache and other trigeminal autonomic cephalalgias, at first presentation; • MOH involving drugs of dependence, where personality mitigates against successful withdrawal of medication, or where withdrawal attempts have failed; • high and low CSF-pressure headaches; • trigeminal and other cranial neuralgias or painful lesions of the cranial nerves; • rare primary or secondary headaches; • headaches with severe physical and/or psychological comorbidities. Cases: • of persisting diagnostic uncertainty; • where risk of serious underlying disorders demands specialist investigation; • of other probable or certain serious secondary headache. Patients who may participate in specific level-3 research projects (including clinical trials). |
Level 3. Specialized headache centres
The role of specialized headache centres
• to provide best possible level-3 clinical care for adults and/or children, having regard to the resources locally available; • to support levels 1 and 2 through medical advice; • to provide training in headache to health-care practitioners at all levels; • to contribute to the development and/or periodic review and updating of national management guidelines; • to conduct research into headache of international value and/or appropriate to the needs of the local community; • to provide empirical evidence in support and justification of their existence. |
Standards and criteria
Standard | Criterion | Verification | Target | |
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Domain A. Competence of staff | ||||
1 | Centre is staffed by headache specialists, who are sufficient but not excessive in number. | Each “headache specialist” can document:(a) advanced training (yes/no); (b) past and continuing experience in the field of headache (yes/no). Number of specialists is: (c) sufficient (yes/no); (d) not excessive (yes/no). | (a, b) internal audit of CVs and continuing professional development records; (c, d) internal audit of workload and waiting times | (a) 100% yes (b) 100% yes (c) aspirational (d) yes |
Domain B. Provision of care | ||||
2 | Centre provides dedicated care for headache patients. | Patients with headache are seen in dedicated sessions, not within general neurological or other sessions (yes/no) | internal audit of clinic lists | yes as a general rule |
3 | Centre provides patients with a clear diagnosis made at earliest opportunity, information about their headache(s), advice on management and internationally-accepted evidence-based treatment. | (a) Diagnoses are always according to ICHD-3 (yes/no). Disability assessments, diagnostic and follow-up diaries, outcome measures and patient information leaflets are: (b) all available (yes/no): (c) all routinely used (yes/no). (d) National or international management guidelines are adopted (yes/no). | (a) internal audit of patients’ records; (b) objectively verifiable; (c) internal audit of patients’ records; (d) objectively verifiable | (a) 100% yes (b) yes (c) yes (d) yes |
4 | Centre provides multidisciplinary care full-time, and competently manages disorders underlying the full range of secondary headaches. | (a) Working collaborations exist between physicians, nurses, physical therapists and psychologists (yes/no). (b) The centre is based within, or in geographical proximity to, a general hospital providing access to emergency department, neurology, neuroradiology, neurosurgery, psychiatry, ophthalmology, otorhinolaryngology, orthopaedics, rheumatology, cardiology, infectious diseases, endocrinology, paediatrics, gynaecology, dentistry (yes/no). (c) Inpatient facilities are available for patients with certain comorbidities and for those needing supervised withdrawal from medication overuse (yes/no). | (a) existence is objectively verifiable; (b) access is objectively verifiable; (c) availability is objectively verifiable | (a) yes (b) yes (c) yes |
Domain C. Quality evaluation and assurance | ||||
5 | Centre monitors quality of care in order to optimize it. | Procedures are in place for recording clinical outcomes and adverse events, and service quality indicators (Table 4), with regular audits of all (yes/no). | objectively verifiable as present and happening | yes |
Domain D. Networks and collaborations | ||||
6 | Centre maintains quality of endeavour through networking, collaboration and the sharing of experience with other international and/or national centres. | (a) Existence and operation of networks and collaboration are documented by the centre (yes/no). (b) Evidence is presented of any of the following (yes/no): • exchange of ideas relating to service organization, patient care, teaching and/or research; • exchange of staff and/or engagement in a fellowship exchange programme; • collaborative research protocols; • shared or collaborative educational programmes; • shared or common database. | (a, b) verifiable by peer review | (a) yes (b) yes to one or more |
Domain E. Teaching | ||||
7 | Centre is a principal resource for national postgraduate training in the field of headache. | Evidence is presented of recent or current engagement in at least two of the following (yes/no): • development of national management guidelines, or adaptation of international guidelines for national use; • development of learning materials for trainee headache specialists, neurologists and/or specialist nurses; • delivery of didactic teaching and/or clinical demonstrations to trainee headache specialists, neurologists and/or specialist nurses on a regular basis; • acceptance of clinical trainees on accredited attachments. | verifiable by peer review | yes to two or more |
8 | Centre provides support, through training and education, to health-care providers at levels 1 and 2. | Either: (a) a programme of training and education is offered through formal links between the centre and health-care providers at levels 1 and 2 throughout the geographical area served by the centre (yes/no); (b) where levels 1 and 2 are not in place within structured services, a programme of training and education is continuously available to local general practitioners, nurses and/or pharmacists (yes/no) | (a) objectively verifiable as in place; (b) verifiable by peer review | yes to either |
Domain F. Research | ||||
9 | Centre is a principal fount of useful research output in the field of headache. | Research is either or both: (a) of international value (yes/no); (b) appropriate to the needs of the local community (yes/no). | peer review of quantity, quality and value of publications | yes to either |
Domain G. Empirical support of existence | ||||
10 | Centre supports and justifies its existence, and the development of others, by documenting and demonstrating its utility. | Activities and achievements: (a) are documented (yes/no); (b) provide evidence of utility (yes/no). | (a) objectively verifiable; (b) verifiable by peer review | (a) yes (b) yes |
Competence of staff
Standard 1
Criteria
Provision of care
Standard 2
Criterion
Standard 3
Criteria
Standard 4
Criteria
Quality evaluation and assurance
Standard 5
Criterion
Domain A. Accurate diagnosis is essential for optimal headache care | |
A1 | Patients are asked about onset of their headaches |
A2 | Diagnosis is according to current ICHD criteria |
A3 | A working diagnosis is made at the first visit |
A4 | A definitive diagnosis is made at first or subsequent visit |
A5 | Diagnosis is reviewed during later follow-up |
A6 | Diaries are used to support or confirm diagnosis |
Domain B. Individualized management is essential for optimal headache care | |
B1 | Waiting-list times for appointments are related to urgency of need |
B2 | Sufficient time is allocated to each visit for the purpose of good management |
B3 | Patients are asked about the temporal profile of their headaches |
B4 | Treatment plans follow evidence-based guidelines, reflecting diagnosis |
B5 | Treatment plans include psychological approaches to therapy when appropriate |
B6 | Treatment plans reflect disability assessment |
B7 | Patients are followed up to ascertain optimal outcome |
Domain C. Appropriate referral pathways are essential for optimal headache care | |
C1 | Referral pathway is available from primary to specialist care |
C2 | Urgent referral pathway is available when necessary |
Domain D. Education of patients about their headaches and their management is essential for optimal headache care | |
D1 | Patients are given the information they need to understand their headache and its management |
D2 | Patients are given appropriate reassurance |
Domain E. Convenience and comfort are part of optimal headache care | |
E1 | The service environment is clean and comfortable |
E2 | The service is welcoming |
E3 | Waiting times in the clinic are acceptable to both health-care providers and patients |
Domain F. Achieving patient satisfaction is part of optimal headache care | |
F1 | Patients are satisfied with their management |
Domain G. Optimal headache care is efficient and equitable | |
G1 | Procedures are followed to ensure resources are not wasted |
G2 | Patients are not over-investigated |
G3 | Costs of the service are measured as part of a cost-effectiveness policy |
G4 | There is equal access to headache services for all who need it |
Domain H. Outcome assessment is essential in optimal headache care | |
H1 | Outcome measures are based on self-reported symptom burden (headache frequency, duration and intensity) |
H2 | Outcome measures are based on self-reported disability burden |
H3 | Outcome measures are based on self-reported quality of life |
Domain I. Optimal headache care is safe | |
I1 | Patients are not over-treated |
I2 | Systems are in place to be aware of serious adverse events |
Networks and collaborations
Standard 6
Criteria
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exchange of ideas relating to service organization, patient care, teaching and/or research;
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exchange of staff and/or engagement in a fellowship exchange programme;
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collaborative research protocols;
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shared or collaborative educational programmes;
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shared or common database.
Teaching
Standard 7
Criterion
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development of national management guidelines, or adaptation of international guidelines for national use;
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development of learning materials for trainee headache specialists, neurologists and/or specialist nurses;
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delivery of didactic teaching and/or clinical demonstrations to trainee headache specialists, neurologists and/or specialist nurses on a regular basis;
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acceptance of clinical trainees on accredited attachments.