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Recommendations for specialist headache clinics and service provision

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 are seen in general neurology clinics.

GIRFT recommends that specialist clinics be established locally with the correct capacity and frequency to reflect the local need, with specialist clinics for the most common neurological disorders to be available at all but the smallest sites.

The specialist overseeing the clinic need not be based at that specific site.

GIRFT Recommendation 9

Establish specialist clinics for the most common neurological disorders locally at all sites, with network links to regional or national services

(a) Establish specialist treatment clinics to provide special injection services or other minor procedures

Including BOTOX® injection for chronic migraine.

Patients with chronic neurological disorders should have access to appropriate specialist nurses or advanced practitioners, irrespective of their geographical location. However, only 25 specialist headache nurses were reported to GIRFT across England, 16 of whom were based at N1 sites.

GIRFT Recommendation 10

Ensure that patients with chronic neurological disorders have access to specialist nurses or other advanced practitioners working as part of an integrated multidisciplinary team, with appropriate administrative support.

(a) Integrate specialist nursing and advanced practitioner resource within the neurology service to enhance and maintain specialist skills

(b) Develop credential proposals for consideration by Health Education England, with a view to standardising training for advanced practitioners (including specialist nurses) and covering both general neurology and disease‑specific support.

Management of severe migraine such as chronic migraine is changing with the introduction of treatments such as BOTOX® and anti-CGRP monoclonal antibodies.

There is geographical variation in the provision of BOTOX®. It is available at most neuroscience and neurology centres, and is typically administered by a consultant neurologist or a headache specialist nurse.

GIRFT recommends that BOTOX® clinics for headache should be available locally to patients, and should make use of all appropriately qualified healthcare practitioners.

GIRFT Recommendation 18

Review and improve local provision of treatments for chronic neurological conditions to ensure patients can access care as close to home as possible

(b) Review pathways to ensure that BOTOX® clinics for chronic migraine are available at sites close to patients’ homes.

Where possible, appropriately qualified healthcare practitioners should be trained to provide BOTOX® injections for those patients with stable treatments, with appropriate clinical governance

CGRP: calcitonin gene-related peptide; CM: chronic migraine. 

*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).6

GIRFT classification of neurology sites5

N1: Neuroscience centre with both neurology inpatients and neurosurgery

N2: Neurology centre with inpatient neurology beds

N3: District general hospital neurology centre where neurologists are based but without inpatient neurology beds

N4: Site with visiting neurologists only (neurologists based elsewhere)

N5: Site without access to visiting neurologists

Prescribing information and adverse event reporting

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

Case study – training physician associates and pharmacists to provide specialist neurology care5

St George’s University Hospitals NHS Foundation Trust, London

St George’s Hospital has augmented its neurology workforce by training physician associates and extended-role pharmacists in providing specialist care.

Physician associates:

  • take a 2-year university course (available throughout the UK)
  • provide administration and assessment for patients, develop an investigation and management plan, and discuss treatment with a medical colleague
  • can request most tests and, with training, carry out a wide range of procedures, including BOTOX® injections for chronic migraine

Prescribing information and adverse event reporting

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



  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. 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-220073.