Awareness of headache and of national headache society activities among primary care physicians – a qualitative study

Although headache is one of the most common symptoms in primary care [1, 2], the quality of headache diagnosis and treatment still leaves room for improvement [3, 4]. In response to this need the International Headache Society (IHS) recently initiated a Primary Care Interest Group to promote improvement of the clinical management of migraine and headache [5]. What could be the additional contribution of the national societies? The Swiss Headache Society (SHS) was founded in 1995 to bring together medical specialists, primary care physicians, and scientists with a special interest in headache. Its goals are to promote headache research, improve the diagnosis and treatment of headaches, foster cooperation between physicians and other health-care providers, and provide education for both patients and physicians. Among other activities, the SHS publishes its therapeutic recommendations every two years in the form of a brochure, holds annual national meetings, and maintains an internet-based information platform for patients and physicians.

Studies looking at the effect of international and national societies on the behaviour of primary care physicians are limited. There is some research looking at the interaction of primary care physicians with national and international guidelines [6, 7]. However, an extensive literature search did not reveal any data relating to the awareness of national (headache) societies by general practitioners. We conducted a survey targeting primary care practices (PCP) in the German- and French-speaking parts of Switzerland. The main topics addressed were the physicians’ caseload of headache patients; their behaviour in dealing with such patients with respect to treatment, referrals to specialists, and direct ordering of magnetic resonance imaging (MRI); and furthermore their interest in pursuing continuing medical education about headache, both in general and, specifically, from the SHS.

We were pleasantly surprised to find that 62% of the primary care physicians were acquainted with the Swiss Headache Society, but we still consider this figure too low from the point of view of a national society. However, there might be a bias in regard of PCPs agreeing to the interview, having some interest in headache and/or knowing the Swiss Headache Society. Many physicians reported that they avoided referring their headache patients to specialists - more than 20% said they did not treat headache patients at all. Of course, most patients with primary headaches can receive adequate treatment in primary care if they are not too severely affected and if good clinical guidelines are available; also, very experienced primary care physicians may need to call on their specialist colleagues less often than others. Nonetheless, in a study conducted in the United Kingdom, Kernick et al. reported that 70% of patients presenting to GPs with new-onset primary headaches did not receive a diagnosis [3], which might be due to the fact that primary healthcare often deals with early undifferentiated stages of illnesses. An earlier study in a Swiss tertiary care centre revealed a similarly high number of incorrect or unspecified diagnoses [9]. The clinical problem of headache demands appropriate medical attention, and it seems that the cooperation between primary care physicians and headache specialists still needs to be improved.

The large percentage of primary care physicians who said they themselves ordered MRI scans for their headache patients (over 80%) was also an unexpected finding, with potential implications for health-care costs. In an earlier Swiss case-control-study, far fewer imaging studies were ordered than this figure would suggest (16% of patients in general practice had a CT scan, 4.4% an MRI scan) [10]. Moreover, a recent, small-scale study from the U.K. about direct access to MRI in a primary care setting [11] led to the conclusion that GPs who know the correct indications for MRI can appropriately select patients with chronic headaches for neuroimaging, without any loss of diagnostic accuracy, and with the potentially significant benefits of earlier diagnosis, more appropriate onward referral, and even, in the end, lower costs. Patients also seemed to appreciate being referred for an MRI by their GP without needing to see a specialist first. No study, however, has yet addressed the potential harm done by incidental findings in neuroimaging studies that are performed on headache patients without a proper indication.

We found that primary care physicians want more information about headache, especially if it is directly applicable in everyday practice, yet few of them were interested in actively downloading such information from the Swiss Headache Society’s homepage (though half gave us their e-mail address so that we could send them more information electronically). The physicians seemed rather passive, compared to patients: a recent Japanese study revealed that most headache patients would consult websites for information - a greater percentage than would consult health professionals directly [12].

Our survey yielded information on primary care physicians’ awareness of headache. We were surprised by the high percentages of PCPs who ordered MRIs directly and who did not refer their headache patients to specialists. These findings suggest that our national headache society and perhaps those in other countries as well, should work to improve the cooperation between headache specialists and primary care providers, with the goal of better care for patients with headache.