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Table 1 “Do Not Do” Recommendations in headache. Results of the consensus search panel

From: Low-value care practice in headache: a Spanish mixed methods research study

CodeDefinitionEvidence
NHC-01Do not recommend painkillers (NSAIDs, paracetamol, and others) more than 15 days per month in a primary headache that does not respond to treatment.
Numerator: Number of patients with primary headache (ICD-10-ES G44.2, G44.53, G44.83, G44.84 and G44.85) who have continuous pharmacological treatment of more than 15 days with NSAIDs/acetaminophen. ATC GROUPS: ergotics: N02CA02, N02CA52; acetaminophen: N02BE01; AAS: N02BA01; NSAIDs: M01A
Denominator: Total number of patients treated for primary headache.
Diener et al. Pathophysiology, prevention, and treatment of medication overuse headache. Lancet Neurol. 2019;18(9):891–902.
Diener et al. Chronic headache due to overuse of analgesics and anti-migraine agents. Dtsch Arztebl Int. 2018;115:365–370.
Becker et al. Medication overuse headache in Canada. Cephalalgia. 2008;28(11):1218–20.
Cheung et al. Medication overuse headache. Curr Neurol Neurosci Rep. 2015;15(1):509.
Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia. 2013;33(9):629–808.
NHC-02Do not withdraw preventive treatment in patients with primary headaches before 8 weeks if the efficacy and therapeutic dose is adequate.
Numerator: Number of patients with preventive treatment ATC GROUPS Beta blockers: C07AA05, C07AA12, C07AB03, C07AB02; Antiepileptics: N03AX11, N03AG01; Renin-angiotensin inhibiting drugs: C09AA03, C09CA06; N07CA03; Antidepressants: N06AA09, N06AX16; Botulinum Toxin: M03AX01 not meeting criteria
Denominator: Total patients being treated for primary migraine headache with (G43.1) and without aura (G43.0), chronic migraine (G43.3) and cluster headache (G44.0)
SIGN 155. Pharmacological management of migraine. A national clinical guideline. February 2018
Hepp et al. Persistence and switching patterns of oral migraine prophylactic medications among patients with chronic migraine: A retrospective claims analysis. Cephalalgia 2017,37(5):470–485.
NHC-03Do not perform neurophysiological studies to establish the diagnosis of migraine or tension headache.
Numerator: Number of patients who have undergone neurophysiological studies (ICD-10-ES 4A00)
Denominator: Total number of patients under treatment for primary migraine headache with (G43.1) and without aura (G43.0), chronic migraine (G43.3), cluster headache (G44.0) and tension headache (G44.2).
Guías diagnósticas y terapéuticas de la Sociedad Española de Neurología 2015;3. Guía oficial de práctica clínica en cefaleas. Editores: P Pozo Rosich, D Ezpeleta. Luzán5. Madrid 2015. ISBN: 978–84–15,198-99-4.
Gronseth GS, Greenberg MK. The utility of the electroencephalogram in the evaluation of patients presenting with headache: a review of the literature. Neurology 1995;45(7):1263–1267.
NHC-04Do not perform neuroimaging studies on patients with tension headache, migraine without aura, and those with typical and episodic aura without alarm signs.
Numerator: Number of neuroimages (CIE-10-ES BW28, BW38) performed in patients with the diagnoses of Tension Headache (G44.2), Migraine without aura (G43.00), and Migraine with aura (G43.1) and Headache (R51)
Denominator: Total number of neuroimages performed in the service per headache (CIE-10-ES R51)
Becker et al. Guideline for primary care management of headache in adults. Can Fam Physician. 2015;61(8):670–679.
Ezpeleta D, Pozo-Rosich P, eds. Guía oficial de práctica clínica en cefaleas de la Sociedad Española de Neurología 2015; ediciones SEN.
Guía práctica diagnóstico terapéutica de la cefalea del adulto y el niño en urgencias 2016. Guías diagnóstico-terapéuticas de la Sociedad Española de Neurología. Editores: A Macaya, P Pozo-Rosich. Luzán5. Madrid 2016. ISBN: 978–84–7989-867-0.
NHC-05Do not refer patients from primary care with a diagnosis of primary headache without having prescribed symptomatic treatment with triptans or standard preventive treatment.
Numerator: Number of patients referred without preventive treatment guidelines Beta-blockers: C07AA05, C07AA12, C07AB03, C07AB02; Antiepileptics: N03AX11, N03AG01; Renin-angiotensin inhibitor drugs: C09AA03, C09CA06; N07CA03; Antidepressants: N06AA09, N06AX16; Botulinum toxin: M03AX01 not met.
Denominator: Diagnosis of migraine without aura, migraine with aura, and others not specified (ICD-10-ES G43.00, G43.10, G43.70, G43.90).
Guías diagnósticas y terapéuticas de la Sociedad Española de Neurología 2015. 3. Guía oficial de práctica clínica en cefaleas. Editores: P Pozo Rosich, D Ezpeleta. Luzán5. Madrid 2015. ISBN: 978–84–15,198-99-4.
Gago-Veiga et al. How and when to refer patients diagnosed with primary headache and craniofacial neuralgia in the emergency department or primary care: recommendations of the Spanish Society of Neurology’s Study Group. Neurologia 2017. pii: S0213–4853(17)30268–2.
NHC-06Do not perform complementary neuroimaging tests on an urgent basis on patients who do not meet the established alarm criteria.
Numerator: Number of neuroimages (ICD-10-ES BW28, BW38) performed on patients in the emergency department who do not meet any alarm criteria
Denominator: Total number of neuroimages performed on patients with primary headache: migraine with (G43.1) and without aura (G43.0), chronic migraine (G43.3) and cluster headache (G44.0) in the emergency department.
Expert panel on Neurologic Imaging. ACR Appropriateness Criteria: Headache, revised 2019.
Do et al. Red and orange flags for secondary headaches in clinical practice: SNNOOP10 list. Neurology. 2019;92(3):134–144.
Guía práctica diagnóstico terapéutica de la cefalea del adulto y el niño en urgencias 2016. Guías diagnóstico-terapéuticas de la Sociedad Española de Neurología. Editores: A Macaya, P Pozo-Rosich. Luzán5. Madrid 2016. ISBN: 978–84–7989-867-0.
NHC-07Do not use opiates as a symptomatic treatment for primary headache.
Numerator: Number of patients with opioid indication ATC GROUPS (N02AA)
Denominator: Total number of patients evaluated in the service for primary migraine headache with (G43.1) and without aura (G43.0), chronic migraine (G43.3) and cluster headache (G44.0).
Guías diagnósticas y terapéuticas de la Sociedad Española de Neurología 2015. Guía oficial de práctica clínica en cefaleas. Editores: P Pozo Rosich, D Ezpeleta. Luzán5. Madrid 2015. ISBN: 978–84–15,198-99-4.
Guía práctica diagnóstico terapéutica de la cefalea del adulto y el niño en urgencias 2016. Guías diagnóstico-terapéuticas de la Sociedad Española de Neurología. Editores: A Macaya, P Pozo-Rosich. Luzán5. Madrid 2016. ISBN: 978–84–7989-867-0.
Becker WJ. Acute migraine treatment in adults. Headache. 2015;55(6):778–793.
Evers S, Afra J, Frese A, Goadsby PJ, Linde M, May A, Sandor PS, European Federation of Neurological Societies. EFNS guideline on the drug treatment of migraine-revised report of an EFNS task force. Eur J Neurol. 2009;16(9):968–981.
  1. NHC: “Do not Do” in headache (translation from Spanish “No Hacer en Cefalea”)
  2. ATC Anatomical Therapeutic Chemical Classification System, ICD International Classification of Diseases
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