The programme consists of three actions, not necessarily proceeding in sequence.
Action 1: to raise awareness of need for improvement
The evidence needed for an awareness campaign is already available [
1,
2,
10], and entirely sufficient to support a chain of four arguments:
-
the humanitarian burdens – pain, suffering and disability – of headache disorders are high [
1,
2,
10];
-
the consequential societal costs in productivity losses are very high [
4]: in Russia, they account for 1.75% of GDP [
11], which is over one third of all expenditure on health care [
20];
-
greater investment in health care for headache should be cost-saving overall because lost-productivity costs of headache hugely outweigh health-care costs [
2,
4];
-
health-care resources currently allocated to headache are used wastefully [
2,
11‐
16], and could be more effectively redeployed, limiting the investment needed.
This evidence, and much more that is to come (see later), must be brought to the attention of government, whose awareness and recognition of the scale and scope of the problem are needed to secure investment in State health services.
Action 2: to design and implement a model for efficient and equitable headache-related health care in Sverdlovsk Oblast
LTB, in collaboration with the European Headache Federation (EHF), has developed a three-tier model for headache services in Europe [
3]. It is based in primary care, with referral channels upwards and educational support downwards. Within the model, about 90% of headache patients are managed in primary care (level 1); about 1% require specialist care (level 3); the intermediate 9-10%, whilst not requiring this, nonetheless present diagnostic or management difficulties that call for a higher level of expertise (level 2) than can be expected of the average PCP. Except in emergencies, entry is at level 1: a key feature of the model is that each lower level has a gatekeeper role to the level(s) above, which, when the model is fully in place, ensures both efficiency and equitable access.
The action required is to implement this model, adapting it as necessary and building it into the present health-care system of Sverdlovsk Oblast.
Action 3: educational initiatives
These initiatives, undertaken hand-in-hand with and in support of action 2, must be aimed at PCPs at level 1, general (or non-headache specialist) neurologists at level 2, pharmacists and the general public (people with headache). Curricula for professional training should be endorsed by the Russian Headache Research Society (RHRS). Teaching should be given by specialists, with support from USMU and, ideally, from the Ministry of Health, and accredited for continuing medical education (CME) purposes.
The amount of knowledge required by PCPs at level 1 is not great in order to enable effective management of most people with headache, but it must be imparted to large numbers of PCPs. A 1-day (6-hour) course at this level should focus on the presentation, aetiology, diagnosis and management according to European guidelines [
8] of the three most common and important headache disorders in public-health terms (migraine, TTH and MOH). Nonetheless, it should also include other headache disorders likely to be encountered in primary care, which need to be correctly recognised, and provide clear guidance on when to refer. The course should be repeated until all PCPs within the scheme have been reached.
A higher level of knowledge is required by neurologists at level 2. A 1-day (6-hour) advanced course to supplement the level-1 course should cover cluster headache, a range of other primary headache disorders that are more difficult to diagnose and/or manage, some secondary headaches and comorbid disorders.
Specialist knowledge for level 3 requires theoretical and practical training provided by national and international experts. The curriculum must cover all headache disorders.
High-street pharmacists are often the first (and sometimes only) source of information to the public about headache disorders and treatments for them. Their training should cover recognition and treatment of the common headache disorders, the dangers of medication overuse, and warning indications of serious headache. Evening courses of 2 hours are most likely to be taken up.
Public education through the media, organized by RHRS, should focus on the recognition of different headache types, their causation and steps that might be taken to prevent them, appropriate and inappropriate use of medication, and when to seek professional advice.