The Healthcare Solution to Headache

  • Timothy J. SteinerEmail author
  • Rigmor Jensen
  • Zaza Katsarava
  • Derya Uluduz
  • Michela Tinelli
  • Hallie Thomas
  • Lars Jacob Stovner
Part of the Headache book series (HEAD)


This chapter builds on Chap.  14, describing structured headache services as the healthcare solution to headache.

Where headache services exist at all, their focus is usually, inappropriately, on specialist care, while compartmentalized divisions between primary and secondary care create multiple inefficiencies. The model described here seeks vertical integration while recognizing that headache services not only must but readily can be delivered for the most part in primary care. It is a cost-effective solution and almost certainly cost-saving in all economies.

Political will is needed for change to happen. This is the greatest challenge.


Headache disorders Barriers to care Public health Health policy Structured headache services Change management Needs assessment Service organization and delivery Primary care Specialized centres Education Economic analysis Cost-effectiveness Global Campaign against Headache 


  1. 1.
    World Health Organization. Headache disorders and public health. Education and management implications. Geneva: WHO (WHO/MSD/MBD/00.9); 2000.Google Scholar
  2. 2.
    World Health Organization. Headache disorders. Fact sheet no. 277. Geneva: WHO; 2003.Google Scholar
  3. 3.
    World Health Organization. Headache disorders. Ch 3.3 in: Neurological disorders: public health challenges. Geneva: WHO; 2007. p. 70–84.Google Scholar
  4. 4.
    World Health Organization and Lifting The Burden. Atlas of headache disorders and resources in the world 2011. Geneva: WHO; 2011.
  5. 5.
    Vos T, Abajobir AA, Abate KH, Abbafati C, Abbas KM, Abd-Allah F, Abdulkader RS, Abdulle AM, Abebo TA, Abera SF, Aboyans V, Abu-Raddad LJ, Ackerman IN, Adamu AA, Adetokunboh O, Afarideh M, Afshin A, Agarwal SK, Aggarwal R, Agrawal A, Agrawal S, Ahmadieh H, Ahmed MB, Aichour MTE, Aichour AN, Aichour I, Aiyar S, Akinyemi RO, Akseer N, Al Lami FH, Alahdab F, Al-Aly Z, Alam K, Alam N, Alam T, et al. Global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet. 2017;390:1211–59.CrossRefGoogle Scholar
  6. 6.
    Steiner TJ, Stovner LJ, Vos T, Jensen R, Katsarava Z. Migraine is first cause of disability in under 50s: will health politicians now take notice? J Headache Pain. 2018;19:17.PubMedPubMedCentralCrossRefGoogle Scholar
  7. 7.
    GBD 2017 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet. 2018;392:1789–858.CrossRefGoogle Scholar
  8. 8.
    Headache Classification Committee of the International Headache Society. The International Classification of Headache Disorders, 3rd edition. Cephalalgia. 2018;38:1–211.Google Scholar
  9. 9.
    Steiner TJ, Gururaj G, Andrée C, Katsarava Z, Ayzenberg I, Yu SY, Al Jumah M, Tekle-Haimanot R, Birbeck GL, Herekar A, Linde M, Mbewe E, Manandhar K, Risal A, Jensen R, Queiroz LP, Scher AI, Wang SJ, Stovner LJ. Diagnosis, prevalence estimation and burden measurement in population surveys of headache: presenting the HARDSHIP questionnaire. J Headache Pain. 2014;15:3.PubMedPubMedCentralCrossRefGoogle Scholar
  10. 10.
    Hopkins A, Menken M, De Friese GA. A record of patient encounters in neurological practice in the United Kingdom. J Neurol Neurosurg Psychiatry. 1989;52:436–8.PubMedPubMedCentralCrossRefGoogle Scholar
  11. 11.
    Wiles CM, Lindsay M. General practice referrals to a department of neurology. J Roy Coll Physicians. 1996;30:426–31.Google Scholar
  12. 12.
    Laughey WF, Holmes WF, MacGregor AE, Sawyer JPC. Headache consultation and referral patterns in one UK general practice. Cephalalgia. 1999;19:328–9.CrossRefGoogle Scholar
  13. 13.
    Rasmussen BK, Jensen R, Olesen J. Impact of headache on sickness absence and utilisation of medical services: a Danish population study. J Epidemiol Community Health. 1992;46:443–6.PubMedPubMedCentralCrossRefGoogle Scholar
  14. 14.
    Dowson A, Jagger S. The UK migraine patient survey: quality of life and treatment. Curr Med Res Opin. 1999;15:241–53.PubMedCrossRefPubMedCentralGoogle Scholar
  15. 15.
    Lipton RB, Scher AI, Steiner TJ, Kolodner K, Liberman J, Stewart WF. Patterns of health care utilization for migraine in England and in the United States. Neurology. 2003;60:441–8.PubMedCrossRefPubMedCentralGoogle Scholar
  16. 16.
    Takeshima T, Ishizaki K, Fukuhara Y, Ijiri T, Kusumi M, Wakutani Y, Mori M, Kawashima M, Kowa H, Adachi Y, Urakami K, Nakashima K. Population-based door-to-door survey of migraine in Japan: the Daisen study. Headache. 2004;44:8–19.PubMedCrossRefPubMedCentralGoogle Scholar
  17. 17.
    Radtke A, Neuhauser H. Prevalence and burden of headache and migraine in Germany. Headache. 2009;49:79–89.PubMedCrossRefPubMedCentralGoogle Scholar
  18. 18.
    Katsarava Z, Mania M, Lampl C, Herberhold J, Steiner TJ. Poor medical care for people with migraine in Europe—evidence from the Eurolight study. J Headache Pain. 2018;19:10.PubMedPubMedCentralCrossRefGoogle Scholar
  19. 19.
    Antonaci F, Valade D, Lanteri-Minet M, Láinez JM, Jensen J, Steiner TJ. Proposals for the organisation of headache services in Europe. Intern Emerg Med. 2008;3:S25–8.PubMedCrossRefGoogle Scholar
  20. 20.
    Steiner TJ, Antonaci F, Jensen R, Lainez MJ, Lanteri-Minet M, Valade D. Recommendations for headache service organisation and delivery in Europe. J Headache Pain. 2011;12:419–26.PubMedPubMedCentralCrossRefGoogle Scholar
  21. 21.
    American Association for the Study of Headache, International Headache Society. Consensus statement on improving migraine management. Headache. 1998;38:736.CrossRefGoogle Scholar
  22. 22.
    Andrée C, Stovner LJ, Steiner TJ, Barré J, Katsarava Z, Lainez JM, Lair M-L, Lanteri-Minet M, Mick G, Rastenyte D, Ruiz de la Torre E, Tassorelli C, Vriezen P, Lampl C. The Eurolight project: the impact of primary headache disorders in Europe. Description of methods. J Headache Pain. 2011;12:541–9.PubMedPubMedCentralCrossRefGoogle Scholar
  23. 23.
    Steiner TJ, Stovner LJ, Katsarava Z, Lainez JM, Lampl C, Lantéri-Minet M, Rastenyte D, Ruiz de la Torre E, Tassorelli C, Barré J, Andrée C. The impact of headache in Europe: principal results of the Eurolight project. J Headache Pain. 2014;15:31.PubMedPubMedCentralCrossRefGoogle Scholar
  24. 24.
    Ayzenberg I, Katsarava Z, Sborowski A, Chernysh M, Osipova V, Tabeeva G, Steiner TJ. Headache-attributed burden and its impact on productivity and quality of life in Russia: structured healthcare for headache is urgently needed. Eur J Neurol. 2014;21:758–65.PubMedPubMedCentralCrossRefGoogle Scholar
  25. 25.
    Ayzenberg I, Katsarava Z, Sborowski A, Obermann M, Chernysh M, Osipova V, Tabeeva G, Steiner TJ. Headache yesterday in Russia: its prevalence and impact, and their application in estimating the national burden attributable to headache disorders. J Headache Pain. 2015;16:7.PubMedPubMedCentralCrossRefGoogle Scholar
  26. 26.
    Braschinsky M, Haldre S, Kals M, Iofik A, Kivisild A, Korjas J, Koljal S, Katsarava Z, Steiner TJ. Structured education can improve primary-care management of headache: the first empirical evidence, from a controlled interventional study. J Headache Pain. 2016;17:24.PubMedPubMedCentralCrossRefGoogle Scholar
  27. 27.
    Manandhar K, Risal A, Linde M, Steiner TJ. Health-care utilization for headache disorders in Nepal: a population-based door-to-door survey. J Headache Pain. 2018;19:116.PubMedPubMedCentralCrossRefGoogle Scholar
  28. 28.
    Wang SJ, Fuh JL, Young YH, Lu SR, Shia BC. Frequency and predictors of physician consultations for headache. Cephalalgia. 2001;21:25–30.PubMedCrossRefPubMedCentralGoogle Scholar
  29. 29.
    Lampl C, Buzath A, Baumhackl U, Klingler D. One-year prevalence of migraine in Austria: a nation-wide survey. Cephalalgia. 2003;23:280–6.PubMedCrossRefPubMedCentralGoogle Scholar
  30. 30.
    Lipton RB, Scher AI, Kolodner K, Liberman J, Steiner TJ, Stewart WF. Migraine in the United States: epidemiology and patterns of health care use. Neurology. 2002;58:885–94.PubMedCrossRefGoogle Scholar
  31. 31.
    Edmeads J, Findlay H, Tugwell P, Pryse-Phillips W, Nelson RF, Murray TJ. Impact of migraine and tension-type headache on life-style, consulting behaviour, and medication use: a Canadian population survey. Can J Neurol Sci. 1993;20:131–7.PubMedCrossRefGoogle Scholar
  32. 32.
    Liu R, Yu S, He M, Zhao G, Yang X, Qiao X, Feng J, Fang Y, Cao X, Steiner TJ. Health-care utilization for primary headache disorders in China: a population-based door-to-door survey. J Headache Pain. 2013;14:47.PubMedPubMedCentralCrossRefGoogle Scholar
  33. 33.
    Manandhar K, Risal A, Linde M, Steiner TJ. The burden of headache disorders in Nepal: estimates from a population-based survey. J Headache Pain. 2016;17:3.PubMedCentralCrossRefPubMedGoogle Scholar
  34. 34.
    Linde M, Steiner TJ, Chisholm D. Cost-effectiveness analysis of interventions for migraine in four low- and middle-income countries. J Headache Pain. 2015;16:15.PubMedPubMedCentralCrossRefGoogle Scholar
  35. 35.
  36. 36.
  37. 37.
    Saylor D, Steiner TJ. The global burden of headache. Semin Neurol. 2018;38:182–90.PubMedCrossRefGoogle Scholar
  38. 38.
    Lipton RB, Diamond S, Reed M, Diamond M, Stewart WF. Migraine diagnosis and treatment: results from the American migraine study II. Headache. 2001;41:638–45.PubMedCrossRefGoogle Scholar
  39. 39.
    Salomon JA, Vos T, Hogan DR, Gagnon M, Naghavi M, Mokdad A, Begum N, Shah R, Karyana M, Kosen S, Farje MR, Moncada G, Dutta A, Sazawal S, Dyer A, Seiler J, Aboyans V, Baker L, Baxter A, Benjamin EJ, Bhalla K, Bin Abdulhak A, Blyth F, Bourne R, Braithwaite T, Brooks P, Brugha TS, Bryan-Hancock C, Buchbinder R, Burney P, Calabria B, Chen H, Chugh SS, Cooley R, Criqui MH, et al. Common values in assessing health outcomes from disease and injury: disability weights measurement study for the Global Burden of Disease Study 2010. Lancet. 2012;380:2129–43.PubMedCrossRefPubMedCentralGoogle Scholar
  40. 40.
    Westergaard ML, Hansen EH, Glumer C, Olesen J, Jensen RH. Definitions of medication-overuse headache in population-based studies and their implications on prevalence estimates: a systematic review. Cephalalgia. 2014;34:409–25.CrossRefGoogle Scholar
  41. 41.
    Stovner LJ, Hagen K, Jensen R, Katsarava Z, Lipton R, Scher AI, Steiner TJ, Zwart J-A. The global burden of headache: a documentation of headache prevalence and disability worldwide. Cephalalgia. 2007;27:193–210.CrossRefGoogle Scholar
  42. 42.
    Lyngberg AC, Rasmussen BK, Jørgensen T, Jensen R. Secular changes in health care utilization and work absence for migraine and tension-type headache: a population based study. Eur J Epidemiol. 2005;20:1007–14.PubMedCrossRefPubMedCentralGoogle Scholar
  43. 43.
    World Health Organization International Conference on Primary Health Care. Declaration of Alma-Ata. Geneva: WHO; 1978.Google Scholar
  44. 44.
    Tarino E, Webster EG. Primary health care concepts and challenges in a changing world. Alma-Ata revisited. Geneva: WHO; 1995.Google Scholar
  45. 45.
    Coulter A. Shifting the balance from secondary to primary care. BMJ. 1995;311:1447–8.PubMedPubMedCentralCrossRefGoogle Scholar
  46. 46.
    Walley J, Lawn JE, Tinker A, de Francisco A, Chopra M, Rudan I, Bhutta ZA, Black RE and the Lancet Alma-Ata Working Group. Primary health care: making Alma-Ata a reality. Lancet. 2008;372:1001–7.PubMedCrossRefGoogle Scholar
  47. 47.
    World Health Organization and United Nations Children’s Fund (UNICEF) Global Conference on Primary Health Care. Declaration of Astana. From Alma-Ata towards universal health coverage and the sustainable development goals. Astana, Kazakhstan: WHO/UNICEF; 2018.Google Scholar
  48. 48.
    Steiner TJ, Jensen R, Katsarava Z, Linde M, MacGregor EA, Osipova V, Paemeleire K, Olesen J, Peters M, Martelletti P on behalf of the European Headache Federation and Lifting The Burden: the Global Campaign against Headache. Aids to management of headache disorders in primary care (2nd edition). J Headache Pain. 2019;20:57.Google Scholar
  49. 49.
    Harpole LH, Samsa GP, Jurgelski AE, Shipley JL, Bernstein A, Matchar DB. Headache management program improves outcome for chronic headache. Headache. 2003;43:715–24.PubMedCrossRefPubMedCentralGoogle Scholar
  50. 50.
    Lake AE, Saper JR, Hamel RL. Comprehensive inpatient treatment of refractory chronic daily headache. Headache. 2009;49:555–62.PubMedCrossRefPubMedCentralGoogle Scholar
  51. 51.
    Göbel H, Heinze A, Heinze-Kuhn K, Henkel K, Roth A, Rüschmann HH. Development and implementation of integrated health care in pain medicine: the nationwide German headache treatment network. Schmerz. 2009;23:653–70.PubMedCrossRefPubMedCentralGoogle Scholar
  52. 52.
    Jensen R, Zeeberg P, Dehlendorff C, Olesen J. Predictors of outcome of the treatment programme in a multidisciplinary headache center. Cephalalgia. 2010;30:1214–24.PubMedCrossRefPubMedCentralGoogle Scholar
  53. 53.
    Diener H, Gaul C, Jensen R, Göbel H, Heinze A, Silberstein S. Integrated headache care. Cephalalgia. 2011;31:1039–47.PubMedCrossRefPubMedCentralGoogle Scholar
  54. 54.
    Saper JR, Lake AE, Madden SF, Kreeger C. Comprehensive tertiary care for headache: a 6-month outcome study. Headache. 1999;39:249–63.PubMedCrossRefPubMedCentralGoogle Scholar
  55. 55.
    Lemstra M, Stewart B, Olszynski WP. Effectiveness of multidisciplinary intervention in the treatment of migraine: a randomized clinical trial. Headache. 2002;42:845–54.PubMedCrossRefPubMedCentralGoogle Scholar
  56. 56.
    Rothrock JF, Parada VA, Sims C, Key K, Walters NS, Zweifler RM. The impact of intensive patient education on clinical outcome in a clinic-based migraine population. Headache. 2006;46:726–31.PubMedCrossRefPubMedCentralGoogle Scholar
  57. 57.
  58. 58.
    Masruha MR, Souza JA, Barreiros H, Piovesan EJ, Kowacs F, Queiroz LP, Ciciarelli MC, Peres MFP. Distribution of “Brazilian headache specialists”. Analyses of Brazilian Headache Society members. Einstein. 2007;5:48–50.Google Scholar
  59. 59.
    Ferris TG, Chang Y, Blumenthal D, Pearson SD. Leaving gatekeeping behind—effects of opening access to specialists for adults in a health maintenance organization. NEJM. 2001;345:1312–7.PubMedCrossRefPubMedCentralGoogle Scholar
  60. 60.
    Jones R, Lamont T, Haines A. Setting priorities for research and development in the NHS: a case study on the interface between primary and secondary care. BMJ. 1995;311:1076–80.PubMedPubMedCentralCrossRefGoogle Scholar
  61. 61.
    Preston C, Cheater F, Baker R, Hearnshaw H. Left in limbo: patients views on care across the primary/secondary interface. Qual Health Care. 1999;8:16–21.PubMedPubMedCentralCrossRefGoogle Scholar
  62. 62.
    UK Department of Health. Guidelines for the appointment of general practitioners with special interests in the delivery of clinical services: headaches. London: Department of Health; 2003.Google Scholar
  63. 63.
    Hedenrud T, Jonsson P, Linde M. Beliefs about medicines and adherence among Swedish migraineurs. Ann Pharmacother. 2008;42:39–45.PubMedCrossRefPubMedCentralGoogle Scholar
  64. 64.
    Mulleners WM, Whitmarsh TE, Steiner TJ. Noncompliance may render migraine prophylaxis useless, but once-daily regimens are better. Cephalalgia. 1998;18:52–6.PubMedCrossRefPubMedCentralGoogle Scholar
  65. 65.
    Braschinsky M, Haldre S, Kals M, Arge M, Saar B, Niibek M, Katsarava Z, Steiner TJ. Structured education to improve primary-care management of headache: how long do the benefits last? A follow-up observational study. Eur J Neurol. 2018;25:497–502.PubMedCrossRefPubMedCentralGoogle Scholar
  66. 66.
    Linde M, Gustavsson A, Stovner LJ, Steiner TJ, Barré J, Katsarava Z, Lainez JM, Lampl C, Lantéri-Minet M, Rastenyte D, Ruiz de la Torre E, Tassorelli C, Andrée C. The cost of headache disorders in Europe: the Eurolight project. Eur J Neurol. 2012;19:703–11.CrossRefGoogle Scholar
  67. 67.
    Hu XH, Markson LE, Lipton RB, Stewart WF, Berger ML. Burden of migraine in the United States: disability and economic costs. Arch Intern Med. 1999;159:813–8.CrossRefGoogle Scholar
  68. 68.
    Yu S, Liu R, Zhao G, Yang X, Qiao X, Feng J, Fang Y, Cao X, He M, Steiner T. The prevalence and burden of primary headaches in China: a population-based door-to-door survey. Headache. 2012;52:582–91.CrossRefGoogle Scholar
  69. 69.
    Selekler MH, Gökmen G, Steiner TJ. Productivity impact of headache on a heavy-manufacturing workforce in Turkey. J Headache Pain. 2013;14:88.PubMedPubMedCentralCrossRefGoogle Scholar
  70. 70.
    Selekler HM, Gökmen G, Alvur TM, Steiner TJ. Productivity losses attributable to headache, and their attempted recovery, in a heavy-manufacturing workforce in Turkey: implications for employers and politicians. J Headache Pain. 2015;16:96.PubMedPubMedCentralCrossRefGoogle Scholar
  71. 71.
    Mbewe E, Zairemthiama P, Paul R, Birbeck GL, Steiner TJ. The burden of primary headache disorders in Zambia: national estimates from a population-based door-to-door survey. J Headache Pain. 2015;16:36.PubMedCentralCrossRefPubMedGoogle Scholar
  72. 72.
    Steiner TJ, Rao GN, Kulkarni GB, Gururaj G, Stovner LJ. Headache yesterday in Karnataka state, India: prevalence, impact and cost. J Headache Pain. 2016;17:74.PubMedPubMedCentralCrossRefGoogle Scholar
  73. 73.
    Zebenigus M, Tekle-Haimanot R, Worku DK, Thomas H, Steiner TJ. The burden of headache disorders in Ethiopia: national estimates from a population-based door-to-door survey. J Headache Pain. 2017;18:58.PubMedPubMedCentralCrossRefGoogle Scholar
  74. 74.
    Vos T, Flaxman AD, Naghavi M, Lozano R, Michaud C, Ezzati M, Shibuya K, Salomon JA, Abdalla S, Aboyans V, Abraham J, Ackerman I, Aggarwal R, Ahn SY, Ali MK, Alvarado M, Anderson HR, Anderson LM, Andrews KG, Atkinson C, Baddour LM, Bahalim AN, Barker-Collo S, Barrero LH, Bartels DH, Basáñez MG, Baxter A, Bell ML, Benjamin EJ, Bennett D, Bernabé E, Bhalla K, Bhandari B, Bikbov B, Bin Abdulhak A, et al. Years lived with disability (YLD) for 1160 sequelae of 289 diseases and injuries 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380:2163–96.PubMedPubMedCentralCrossRefGoogle Scholar
  75. 75.
    Kulkarni GB, Rao GN, Gururaj G, Stovner LJ, Steiner TJ. Headache disorders and public ill-health in India: prevalence estimates in Karnataka state. J Headache Pain. 2015;16:67.PubMedPubMedCentralCrossRefGoogle Scholar
  76. 76.
    Rao GN, Kulkarni GB, Gururaj G, Stovner LJ, Steiner TJ. The burden attributable to headache disorders in India: estimates from a community-based study in Karnataka state. J Headache Pain. 2015;16:94.PubMedPubMedCentralCrossRefGoogle Scholar
  77. 77.
    Ayzenberg I, Katsarava Z, Sborowski A, Chernysh M, Osipova V, Tabeeva G, Yakhno N, Steiner TJ. The prevalence of primary headache disorders in Russia: a countrywide survey. Cephalalgia. 2012;32:373–81.CrossRefGoogle Scholar
  78. 78.
    Mbewe E, Zairemthiama P, Yeh H-H, Paul R, Birbeck GL, Steiner TJ. The epidemiology of primary headache disorders in Zambia: a population-based door-to-door survey. J Headache Pain. 2015;16:30.PubMedPubMedCentralCrossRefGoogle Scholar
  79. 79.
    World Health Organization. Cost effectiveness and strategic planning (WHO-CHOICE).
  80. 80.
    Steiner TJ, Lipton RB on behalf of Lifting The Burden: The Global Campaign against Headache. The Headache-Attributed Lost Time (HALT) indices: measures of burden for clinical management and population-based research. J Headache Pain. 2018;19:12.Google Scholar
  81. 81.
    World Health Organization. Noncommunicable diseases. 2018.

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Timothy J. Steiner
    • 1
    • 2
    Email author
  • Rigmor Jensen
    • 3
  • Zaza Katsarava
    • 4
    • 5
    • 6
    • 7
  • Derya Uluduz
    • 8
  • Michela Tinelli
    • 9
  • Hallie Thomas
    • 1
  • Lars Jacob Stovner
    • 1
    • 10
  1. 1.Department of Neuromedicine and Movement ScienceNTNU Norwegian University of Science and TechnologyTrondheimNorway
  2. 2.Division of Brain SciencesImperial College LondonLondonUK
  3. 3.Department of Neurology, Danish Headache CentreUniversity of Copenhagen, Rigshospitalet GlostrupGlostrupDenmark
  4. 4.Evangelical Hospital UnnaUnnaGermany
  5. 5.Department of NeurologyUniversity of Duisburg-EssenEssenGermany
  6. 6.EVEX Medical CorporationTbilisiGeorgia
  7. 7.IM Sechenov First Moscow State Medical University (Sechenov University)MoscowRussian Federation
  8. 8.Neurology Department, Cerrahpaşa School of MedicineIstanbul UniversityIstanbulTurkey
  9. 9.Personal Social Services Research UnitThe London School of Economics and Political ScienceLondonUK
  10. 10.Norwegian Advisory Unit on Headaches, Department of Neurology and Clinical NeurophysiologySt Olavs University HospitalTrondheimNorway

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