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Chronic migraine management at the interface between primary and secondary care

The content below is extracted from the NHS Getting It Right First Time review of neurology.5

The full report can be accessed here

Most patients with headache have either migraine or another primary headache disorder. Many can self-manage their headaches or manage them with support from their GPs.

Help for GPs to begin appropriate management and avoid unnecessary referral includes:

  • diagnosis and management guidelines (eg NICE, BASH, NHS)
  • site-specific locally applicable guidance
  • referral assessment advice

Development of an easily accessible local headache pathway may improve headache management.

Managing migraine in some patients may require the involvement of secondary care neurology services.

The balance between management in primary and secondary care may vary, depending on:

  • pressures on other aspects of primary care
  • limited capacity of neurology outpatient departments

“The challenge for commissioners is that most headaches referred to secondary care end up with a diagnosis of migraine and/or medication overuse headache, which is best managed in the community, which is easier for patients to access and cheaper for the healthcare economy” 

NHS RightCare6

Using the standard ‘choose and book’ electronic referral service (e-RS), patients who have been referred by the GP will have selected their appointment time before the neurologist is able to review and assess the referral letter. While convenient for patients, this method limits the flexibility neurologists have to manage each referral (eg by providing direct advice or redirecting to a more specialist clinic). One solution is to triage outpatient referrals using the Referral Assessment Service within the NHS e-RS.

GIRFT Recommendation 4

Implement advice and guidance and a triaging system of outpatient referrals to ensure effective management of referrals, offer earlier management advice, improve clinic waiting times and reduce DNAs.

Most patients who attend hospital for headache are managed in A&E or in an acute medical unit.

On average, 9% of patients are readmitted with headache within 12 months. There is considerable variation in this readmission rate between sites.

GIRFT Recommendation 16

Ensure regular review of readmission rates for headaches to understand and address variation, to ensure the pathway for these patients is optimised.

(a) Review readmission rates for headache and carry out local audit of any high rates

BASH: British Association for the Study of Headache; CCGs: clinical commissioning groups; CM: chronic migraine; DNA: ‘did not attend’ appointment; IQR: interquartile range; NICE: National Institute for Health and Care Excellence.

BOTOX® (botulinum toxin type A) is indicated for the prophylaxis of headaches in adults with chronic migraine (headaches on at least 15 days per month of which at least 8 days are with migraine).7



  1. Allergan. Data on file. 014
  2. Allergan. Data on file. INT/0423/2016
  3. Aurora S K, Winner P et al. OnabotulinumtoxinA for treatment of chronic migraine: pooled analyses of the 56-week PREEMPT clinical program. Headache 2011;51(9):1358-1373
  4. Blumenfeld A M, Stark R J et al. Long-term study of the efficacy and safety of OnabotulinumtoxinA for the prevention of chronic migraine: COMPEL study. J Headache Pain 2018;19(1):13
  5. Getting It Right First Time. Neurology. Available at: Accessed April 2022
  6. NHS RightCare. Headache and Migraine Toolkit optimising a headache and migraine system. Available at: Accessed April 2022
  7. BOTOX® Summary of Product Characteristics. Available at: Accessed April 2022

Please refer to the BOTOX® Summary of Product Characteristics for further information on adverse events, contraindications and special warnings and precautions for use.


Adverse events should be reported. Reporting forms and information can be found at

Adverse events should also be reported to AbbVie on [email protected] 


Date of preparation: April 2022. UK-BCM-220074.



Case study – development of a headache pathway5

The Walton Centre NHS Foundation Trust, Liverpool

The Walton Centre, a regional neuroscience centre, developed a headache pathway in collaboration with local CCGs and prescribing committees.

The pathway provides General Practitioners (GPs) with:

  • guidance on the diagnosis and management of common headache syndromes, including migraine
  • information about ‘red flags’ – signs or symptoms which might require further investigation/ referral
  • assurance that most patients presenting with headache can be safely diagnosed and managed within primary care

An extensive educational programme was used to promote awareness and engagement in local GPs.

Outcome: after 12 months, referrals had been reduced by 20%, and GPs reported a high level of satisfaction.

Prescribing information and adverse event reporting

Reference: 5. Getting It Right First Time Neurology. Accessed April 2022

Case study – a triage service in a unified hub and spoke region5

Greater Manchester Neurosciences Centre, Salford Royal NHS Foundation Trust

All outpatient referrals (approximately 50,000 per year) are triaged daily by consultant neurologists, in commissioner-funded, job-planned sessions.

Eliminating delay and unnecessary referrals:

  • Clinically urgent cases are prioritised
  • Appropriate cases are fast-tracked to specialist clinics
  • Investigations are booked at the point of triage
  • Advice can be given directly to the referring doctor without the need for an outpatient appointment

A structured questionnaire is given to most patients being referred for headache.

Eliminating delay and unnecessary referrals:

  • A confident diagnosis can usually be made based on questionnaire answers
  • A treatment plan is sent to patient and referring doctor

Outcome: 15%-20% of patients triaged are treated without a clinic appointment, and there is a low number of re-referrals. This has helped to balance demand and supply for neurology outpatient services.

Prescribing information and adverse event reporting

Reference: 5. Getting It Right First Time Neurology. Accessed April 2022