Headache Guidelines Short on Length, Long on Utility

A series of physician guidelines for headache care recently published in Canadian Family Physician was aimed at family physicians but has applicability for physical and occupational therapists, nurses and practitioners, physician assistants, pharmacists, and psychologists, among others. The brevity of the guidelines is among its strengths, along with the breadth of issues for which care guidelines are listed.

The coordinated effort to develop the guidelines included a long list of Canadian health and clinical experts, including Toward Optimized Practice, which develops and disseminates primary care guidelines in Alberta, the Alberta College of Family Physicians, the Alberta College of Physicians and Surgeons, and the Pain Society of Alberta, as well as patient advocacy groups. The research team then collaborated with experienced medical librarians to systematically search for existing clinical practice guidelines (CPGs) published between January 2000 and May 2011. The search identified 64 sets of guidelines which were then analyzed and discussed.

The resulting collection is a sort of “best of the best” guidelines for many aspects of diagnosing and treating headache. The guidelines are broken down into easily definable boxes, including:

• General practice points for managing primary headache in adults
• Important elements of the headache history in patients presenting with headache for the first time or those with a change in headache pattern
• Approach to the physical examination of a patient presenting with headache for the first time or with a change in headache pattern
• Red flags and other potential indicators of secondary headache, labeled with: Appropriate referral or investigation should be considered.
• Comprehensive migraine management, and
• Two separate boxes on pharmacologic prophylaxis for migraine (boxes 6 and 7)
• Diagnosis and treatment of medication-overuse headache

The guidelines have proven very popular in Canada, and they appear on the Michael G. DeGroote National Pain Centre website as well as listed by the US National Guideline Clearing House. A pilot project is under way at the University of Calgary in Alberta to present the headache guideline using interactive webinars. Clinical treatment guidelines, of course, aren’t static; these will be assessed annually and updated as needed.

Among the limitations of the guideline development process was that the lack of high-quality scientific evidence for headache investigations, diagnosis, red flags, and specialist referral meant that many recommendations in these areas relied on the opinions of the Guideline Developmetn Group or the experts who developed the seed guidelines.

“However, these issues were overcome by using credible seed guidelines, scrupulously listing the evidence type and source for all recommendations, and clearly documenting the subjective contextualization process,” the paper authors wrote.

The guidelines take into account care but not cost. The authors noted that none of the seed guidelines included formal economic evaluations or cost analyses, nor did they discuss the economic implications of their recommendations.