Table 4 Existing headache quality indicators (developed within the four studies)

McGlynn et al. [10]

 Diagnosis

History-taking

Patients with new onset headache should be asked about:

(1) the location of the pain

(2) their associated symptoms

(3) their temporal profile

(4) the degree of severity of the headache

(5) family history of headache

(6) any possible aggravating or alleviating factors

Physical examination

Patients with new onset headache should have an examination evaluating:

(1) the cranial nerves

(2) the fundi

(3) deep tendon reflexes

(4) their blood pressure

Investigations

(1) CT or MRI scanning is indicated in patients with new onset headache and an abnormal neurological examination

(2) CT or MRI scanning is indicated in patients with new onset headache and severe headache

(3) Skull X-rays should not be part of an evaluation for headache

 Treatment

Acute

(1) Patients with acute mild migraine or tension headache should have tried aspirin, Tylenol, or other nonsteroidal anti-inflammatory agents before being offered any other medication

(2) For patients with acute moderate or severe migraine headache, one of the following should have been tried before any other agent is offered: ketorolac, sumatriptan, dihydroergotamine, ergotamine, chlorpromazine, or metoclopramide

(3) Recurrent moderate or severe tension headache should be treated with a trial of tricyclic antidepressant agents, if there are no medical contraindications to use

(4) Sumatriptan and ergotamine should not be concurrently administered

(5) Opioid agonists and barbiturates should not be first-line therapy for migraine or tension headaches

(6) Sumatriptan and ergotamine should not be given in patients with a history of uncontrolled hypertension

(7) Sumatriptan and ergotamine should not be given in patients with a history of ischemic heart disease or angina

Prophylactic

(1) If patients have more than two moderate to severe migraine headache each month, then prophylactic treatment with one of the following agents should be offered: β-blockers, calcium channel blockers, tricyclic antidepressants, naproxen, aspirin, fluoxetine, valproate, or cyproheptadine

 Referral

None

 Outcome

None

Marshall et al. [9]

 Diagnosis

None

 Treatment

Acute

(1) Sumatriptan should not be prescribed for migraine in patients with angina

Prophylactic

(1) Prophylaxis treatment should be offered in patients with severe and disabling migraine

(2) The following agents should be prescribed as first line for prophylaxis of migraine unless contraindicated; beta blockers, tricyclic antidepressants, pizotifen

(3) Beta blockers should not be prescribed for migraine in patients with asthma

 Referral

(1) Patients should be referred urgently for specialist care and investigation if the presenting headache is accompanied by; suspected raised intracranial pressure, new onset seizure, focal neurological signs or papilloedema

 Outcome

None

Leas et al. [12]

 Diagnosis

Investigations

% of patients who had

(1) a computerized tomography scan

(2) a magnetic resonance imaging scan

Other

% of patients

(1) who had a diagnosis of migraine

(2) who had a diagnosis of headache not otherwise specified

(iii) with a prescription for triptan who have a diagnosis of headache not otherwise specified

 Treatment

Acute

% of patients who had a prescription for

(1) a triptan

(2) an ergot alkaloid/derivative

Prophylactic

 % of patients

(1) who had a prescription for a migraine preventive

(2) overusing triptans who have a prescription for migraine preventative

Other

% patients who had

(1) a prescription for a triptan and a migraine preventative

(2) triptan overuse

 Referral

None

 Outcome

Uptake of care

% of patients

(1) with at least 1 migraine-related emergency department visit who had a follow-up visit

(2) who had a primary-care physician visit for migraine (primary diagnosis)

(3) who had a primary-care physician visit for migraine (any diagnosis)

(4) who had a specialist visit for migraine

(5) who had an emergency department visit for migraine

(6) who had an acute hospitalization for migraine

and

Number of

(7) emergency department visits

(8) acute hospitalizations

(9) acute inpatient days

Ferrari et al. [11]

 Diagnosis

None

 Treatment

None

 Referral

None

 Outcome

Headache severity and frequency

(1) % of chronic headache sufferers who reported a decrease of at least 50 % in headache frequency at discharge from day hospital or ordinary hospital

(2) % of chronic headache sufferers overusing drugs who upon discharge from day hospital or ordinary hospital after detoxifying therapy, reduce their intake of analgesics by at least 50 %

(3) % of patients re-admitted to day hospital or ordinary hospital within 28 days of discharge

(4) % of patients referred by their general practitioner for a clinical examination within 28 days of discharge

(5) % of patients returning after discharge with side effects due to treatment prescribed

(6) % of patients returning after discharge owing to inefficacy of treatment prescribed

Uptake of care

(1) % of patients with an appointment who do not turn up for their first clinical examination

(2) % of patients with an appointment who do not turn up for their examination to complete the diagnostic picture

(3) No. of phone calls, fax messages, emails from general practitioners to the headache center