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Cho S, Chu MK. Headache in Brain Tumors. Neurol Clin 2024; 42:487-496. [PMID: 38575261 DOI: 10.1016/j.ncl.2023.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
The prevalence of brain tumors in patients with headache is very low; however, 48% to 71% of patients with brain tumors experience headache. The clinical presentation of headache in brain tumors varies according to age; intracranial pressure; tumor location, type, and progression; headache history; and treatment. Brain tumor-associated headaches can be caused by local and distant traction on pain-sensitive cranial structures, mass effect caused by the enlarging tumor and cerebral edema, infarction, hemorrhage, hydrocephalus, and tumor secretion. This article reviews the current findings related to epidemiologic details, clinical manifestations, mechanisms, diagnostic approaches, and management of headache in association with brain tumors.
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Affiliation(s)
- Soomi Cho
- Department of Neurology, Yonsei University College of Medicine, Republic of Korea
| | - Min Kyung Chu
- Department of Neurology, Yonsei University College of Medicine, Republic of Korea.
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2
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Huzzey-Cunningham E, McWilliam M, Mahtani V, Bridge H, Breukel C, Schytz HW, Draper-Rodi J. Study to assess existing knowledge of headache disorders among registered osteopaths practising in the UK: A cross-sectional survey. INT J OSTEOPATH MED 2022. [DOI: 10.1016/j.ijosm.2022.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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3
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Tabeeva GR. Headaches in general medical practice. TERAPEVT ARKH 2022; 94:114-121. [DOI: 10.26442/00403660.2022.01.201325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 03/14/2022] [Indexed: 11/22/2022]
Abstract
The bulk of patients with primary headaches HA (cephalalgias) are observed in primary care. The optimal diagnostic algorithm implies the exclusion of potentially dangerous causes of HA and secondary cephalalgias requiring specific treatment. Verification of the form of primary HA is carried out clinically, does not require additional diagnostic methods and is based on the use of the criteria of the International Classification of Headache Disorders. Among all cephalalgias in general clinical practice, the vast majority of cases are represented by four forms: migraine, tension type headache, cluster headache, and medication overuse headache. The complex application of modern methods of pharmacological and non-pharmacological treatment with the use of preventive strategies ensures high efficiency in the management of patients with HA.
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Kristoffersen ES, Faiz KW, Hansen JM, Tronvik EA, Frich JC, Lundqvist C, Winsvold BS. The management and clinical knowledge of headache disorders among general practitioners in Norway: a questionnaire survey. J Headache Pain 2021; 22:136. [PMID: 34763647 PMCID: PMC8582095 DOI: 10.1186/s10194-021-01350-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 10/28/2021] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND General practitioners (GPs) diagnose and manage a majority of headache patients seeking health care. With the aim to understand the potential for clinical improvement and educational needs, we performed a study to investigate Norwegian GPs knowledge about headache and its clinical management. METHODS We invited GPs from a random sample of 130 Norwegian continuous medical education (CME) groups to respond to an anonymous questionnaire survey. RESULTS 367 GPs responded to the survey (73% of invited CME groups, 7.6% of all GPs in Norway). Mean age was 46 (SD 11) years, with an average of 18 (SD 10) years of clinical experience. In general the national treatment recommendations were followed, while the International Classification of Headache Disorders and other international guidelines were rarely used. Overall, 80% (n = 292) of the GPs suggested adequate prophylactic medication for frequent episodic migraine, while 28% (n = 101) suggested adequate prophylactic medication for chronic tension-type headache (CTTH). Half (52%, n = 191)) of the respondents were aware that different types of acute headache medication can lead to medication-overuse headache (MOH), and 59% (n = 217) knew that prophylactic headache medication does not lead to MOH. GPs often used MRI in the diagnostic work-up. GPs reported that lack of good treatment options was a main barrier to more optimized treatment of headache patients. CONCLUSION The knowledge of management of CTTH and MOH was moderate compared to migraine among Norwegian GPs.
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Affiliation(s)
- Espen Saxhaug Kristoffersen
- Department of General Practice, University of Oslo, PO Box 1130, Blindern, 0318, Oslo, Norway. .,Department of Neurology, Akershus University Hospital, Lørenskog, Norway. .,Department of Research and Innovation, Division of Clinical Neuroscience, Oslo University Hospital, Oslo, Norway.
| | - Kashif Waqar Faiz
- Department of Neurology, Akershus University Hospital, Lørenskog, Norway
| | - Jakob Møller Hansen
- Danish Knowledge Centre on Headache Disorders, Rigshospitalet-Glostrup, University, of Copenhagen, Glostrup, Denmark
| | - Erling Andreas Tronvik
- Department of Neuromedicine and Movement Science, NTNU Norwegian University of Science and Technology, Trondheim, Norway.,Department of Neurology, National Advisory Unit on Headaches, St. Olavs Hospital, Trondheim, Norway
| | - Jan C Frich
- Department of Health Management and Health Economics, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Christofer Lundqvist
- Department of Neurology, Akershus University Hospital, Lørenskog, Norway.,Health Services Research Unit, Akershus University Hospital, Lørenskog, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Bendik Slagsvold Winsvold
- Department of Research and Innovation, Division of Clinical Neuroscience, Oslo University Hospital, Oslo, Norway.,Department of Neurology, Oslo University Hospital, Oslo, Norway
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5
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Affiliation(s)
- Chris McKinnon
- Department of Neurosurgery, Oxford University Hospitals NHS Foundation Trust, Oxford OX3 9DU, UK
| | - Meera Nandhabalan
- Department of Clinical Oncology, Oxford University Hospitals NHS Foundation Trust
| | - Scott A Murray
- Centre for Population Health Sciences, The Usher Institute of Population Health Sciences and Informatics, Primary Palliative Care Research Group, University of Edinburgh, Edinburgh, UK
| | - Puneet Plaha
- Department of Neurosurgery, Oxford University Hospitals NHS Foundation Trust, Oxford OX3 9DU, UK
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6
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Peeters MCM, Dirven L, Koekkoek JAF, Gortmaker EG, Fritz L, Vos MJ, Taphoorn MJB. Prediagnostic symptoms and signs of adult glioma: the patients' view. J Neurooncol 2020; 146:293-301. [PMID: 31894516 DOI: 10.1007/s11060-019-03373-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 12/14/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Little is known about the symptoms glioma patients experience in the year before diagnosis, either or not resulting in health care usage. This study aimed to determine the incidence of symptoms glioma patients experienced in the year prior to diagnosis, and subsequent visits to a general practitioner (GP). METHODS Glioma patients were asked to complete a 30-item study-specific questionnaire focusing on symptoms they experienced in the 12 months before diagnosis. For each indicated symptom, patients were asked whether they consulted the GP for this issue. RESULTS Fifty-nine patients completed the questionnaires, 54 (93%) with input of a proxy. The median time since diagnosis was 4 months (range 1-12). The median number of symptoms experienced in the year before diagnosis was similar between gliomas with favourable and poor prognosis, i.e. 6 (range 0-24), as were the five most frequently mentioned problems: fatigue (n = 34, 58%), mental tiredness (n = 30, 51%), sleeping disorder (n = 24, 41%), headache (n = 23, 39%) and stress (n = 20, 34%). Twenty-six (44%) patients visited the GP with at least one issue. Patients who did consult their GP reported significantly more often muscle weakness (11 vs 3, p = 0.003) than patients who did not, which remained significant after correction for multiple testing, which was not the case for paralysis in hand/leg (10 vs 4), focussing (11 vs 6) or a change in awareness (9 vs 4). CONCLUSIONS Glioma patients experience a range of non-specific problems in the year prior to diagnosis, but only patients who consult the GP report more often neurological problems.
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Affiliation(s)
- Marthe C M Peeters
- Department of Neurology, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands.
| | - Linda Dirven
- Department of Neurology, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands.,Department of Neurology, Haaglanden Medical Center, The Hague, The Netherlands
| | - Johan A F Koekkoek
- Department of Neurology, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands.,Department of Neurology, Haaglanden Medical Center, The Hague, The Netherlands
| | - Ellen G Gortmaker
- Department of Neurology, Haaglanden Medical Center, The Hague, The Netherlands
| | - Lara Fritz
- Department of Neurology, Haaglanden Medical Center, The Hague, The Netherlands
| | - Maaike J Vos
- Department of Neurology, Haaglanden Medical Center, The Hague, The Netherlands
| | - Martin J B Taphoorn
- Department of Neurology, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands.,Department of Neurology, Haaglanden Medical Center, The Hague, The Netherlands
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Abstract
Headache is the most common neurologic symptom and affects nearly half the world's population at any given time. Although the prevalence declines with age, headache remains a common neurologic complaint among elderly populations. Headaches can be divided into primary and secondary causes. Primary headaches comprise about two-thirds of headaches among the elderly. They are defined by clinical criteria and are diagnosed based on symptom pattern and exclusion of secondary causes. Primary headaches include migraine, tension-type, trigeminal autonomic cephalalgias, and hypnic headache. Secondary headaches are defined by their suspected etiology. A higher index of suspicion for a secondary headache disorder is warranted in older patients with new-onset headache. They are roughly 12 times more likely to have serious underlying causes and, frequently, have different symptomatic presentations compared to younger adults. Various imaging and laboratory evaluations are indicated in the presence of any "red flag" signs or symptoms. Head CT is the procedure of choice for acute headache presentations, and brain MRI for those with chronic headache complaints. Management of headache in elderly populations can be challenging due to the presence of multiple medical comorbidities, polypharmacy, and differences in drug metabolism and clearance.
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Affiliation(s)
- Robert G Kaniecki
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, United States.
| | - Andrew D Levin
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
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8
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Ozawa M, Brennan PM, Zienius K, Kurian KM, Hollingworth W, Weller D, Grant R, Hamilton W, Ben-Shlomo Y. The usefulness of symptoms alone or combined for general practitioners in considering the diagnosis of a brain tumour: a case-control study using the clinical practice research database (CPRD) (2000-2014). BMJ Open 2019; 9:e029686. [PMID: 31471440 PMCID: PMC6720478 DOI: 10.1136/bmjopen-2019-029686] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVES To evaluate the utility of different symptoms, alone or combined, presented to primary care for an adult brain tumour diagnosis. DESIGN AND SETTING Matched case-control study, using the data from Clinical Practice Research Datalink (2000-2014) from primary care consultations in the UK. METHOD All presentations within 6 months of the index diagnosis date (cases) or equivalent (controls) were coded into 32 symptom groups. Sensitivity, specificity, positive predictive values (PPVs) and positive likelihood ratios were calculated for symptoms and combinations of symptoms with headache and cognitive features. Diagnostic odds ratios were calculated using conditional logistic regression, adjusted for age group, sex and Charlson comorbidity. Stratified analyses were performed for age group, sex and whether the tumour was of primary or secondary origin. RESULTS We included 8,184 cases and 28,110 controls. Seizure had the highest PPV of 1.6% (95% CI 1.4% to 1.7%) followed by weakness 1.5% (1.3 to 1.7) and confusion 1.4% (1.3 to 1.5). Combining headache with other symptoms increased the PPV. For example, headache plus combined cognitive symptoms PPV 7.2% (6.0 to 8.6); plus weakness 4.4% (3.2 to 6.2), compared with headache alone PPV 0.1%. The diagnostic ORs were generally larger for patients <70 years; this was most marked for confusion, seizure and visual symptoms. CONCLUSION We found seizure, weakness and confusion had relatively higher predictive values than many other symptoms. Headache on its own was a weak predictor but this was enhanced when combined with other symptoms especially in younger patients. Clinicians need to actively search for other neurological symptoms such as cognitive problems.
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Affiliation(s)
- Mio Ozawa
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Paul M Brennan
- Department of Clinical Neurosciences, Western General Hospital, Edinburgh, UK
| | - Karolis Zienius
- Department of Clinical Neurosciences, Western General Hospital, Edinburgh, UK
| | | | | | - David Weller
- General Practice, University of Edinburgh, Edinburgh, UK
| | - Robin Grant
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Willie Hamilton
- Primary Care Diagnostics, University of Exeter Medical School, Exeter, UK
| | - Yoav Ben-Shlomo
- Population Health Sciences, University of Bristol, Bristol, UK
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9
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Hadidchi S, Surento W, Lerner A, Liu CSJ, Gibbs WN, Kim PE, Shiroishi MS. Headache and Brain Tumor. Neuroimaging Clin N Am 2019; 29:291-300. [DOI: 10.1016/j.nic.2019.01.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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10
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Chen CH, Sheu JJ, Lin YC, Lin HC. Association of migraines with brain tumors: a nationwide population-based study. J Headache Pain 2018; 19:111. [PMID: 30442087 PMCID: PMC6755602 DOI: 10.1186/s10194-018-0944-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 11/06/2018] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Several studies examined headaches as a symptom of brain neoplasms. Nevertheless, very few studies attempted to specifically evaluate the role of headaches as a risk factor. This study aimed to investigate the risk of migraine occurrence in the preceding years among patients diagnosed with brain tumors and unaffected controls. METHODS Data were obtained from the Taiwan National Health Insurance Research Database. In total, 11,325 adults with a first-time brain tumor diagnosis were included as cases, together with 11,325 unaffected matched controls. Each individual was traced in the healthcare claims dataset for a prior diagnosis of migraines. Conditional logistic regressions were performed to calculate the odds ratio (OR) and the corresponding 95% confidence interval (CI) to present the association between brain tumors and having previously been diagnosed with migraines. RESULTS We found that among patients with and those without brain tumors, 554 (4.89%) and 235 (2.08%) individuals, respectively, were identified as having a prior migraine diagnosis. Compared to unaffected controls, patients with brain tumors experienced an independent 2.45-fold increased risk of having a prior migraine diagnosis. The risks were even higher among men (odds ratio (OR) = 3.04, 95% confidence interval (CI) = 2.29~ 4.04) and after patients who had received a prior migraine diagnosis within 3 years were excluded (OR = 1.91, 95% CI = 1.59~ 2.29). CONCLUSIONS This is the first report demonstrating the occurrence of brain tumors to be associated with a prior migraine history, for both men and women, in a population-based study.
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Affiliation(s)
- Chao-Hung Chen
- Department of Thoracic Surgery, Mackay Memorial Hospital, Taipei, Taiwan.,Research Center of Sleep Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Jau-Jiuan Sheu
- Department of Neurology, Taipei Medical University Hospital, Taipei, Taiwan.,Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Yi-Chun Lin
- Biostatistics Center, College of Management, Taipei Medical University, Taipei, Taiwan
| | - Herng-Ching Lin
- Research Center of Sleep Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan. .,School of Health Care Administration, Taipei Medical University, Taipei, Taiwan. .,Sleep Research Center, Taipei Medical University Hospital, Taipei, Taiwan.
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11
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Affiliation(s)
- Susan P Mollan
- Birmingham Neuro-Ophthalmology Unit, University Hospitals Birmingham NHS Trust, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham, UK
- Metabolic Neurology, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Institute of Translational Medicine, Birmingham Health Partners, University of Birmingham, UK
| | - David Spitzer
- PHGH Doctors, Temple Fortune Medical Centre, London, UK
| | - David J Nicholl
- Department of Neurology, City Hospital, Birmingham, UK
- Department of Neurology, University Hospitals Birmingham NHS Trust, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham, UK
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12
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Chinthapalli K, Logan AM, Raj R, Nirmalananthan N. Assessment of acute headache in adults - what the general physician needs to know. Clin Med (Lond) 2018; 18:422-427. [PMID: 30287441 PMCID: PMC6334100 DOI: 10.7861/clinmedicine.18-5-422] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Headache is common. Up to 5% of attendances to emergency departments and acute medical units are due to headache. Headache is classified as either primary (eg migraine, cluster headache) or secondary to another cause (eg meningitis, subarachnoid haemorrhage). Even in the acute setting the majority of cases are due to primary causes. The role of the attending physician is to take a comprehensive history to diagnose and treat benign headache syndromes while ruling out sinister aetiologies. This brief article summarises the approach to assessment of headache presenting in acute and emergency care.
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Affiliation(s)
| | - Anne-Marie Logan
- Atkinson Morley Regional Neurosciences Centre, St George's Hospital, London, UK
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13
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Ozawa M, Brennan PM, Zienius K, Kurian KM, Hollingworth W, Weller D, Hamilton W, Grant R, Ben-Shlomo Y. Symptoms in primary care with time to diagnosis of brain tumours. Fam Pract 2018; 35:551-558. [PMID: 29420713 PMCID: PMC6142711 DOI: 10.1093/fampra/cmx139] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Background Brain tumours often present with varied, non-specific features with other diagnoses usually being more likely. Objective To examine how different symptoms and patient demographics predict variations in time to brain tumour diagnosis. Methods We conducted a secondary analysis of brain tumour cases from National Audit of Cancer Diagnosis in Primary Care. We grouped neurological symptoms into six domains (headache, behavioural/cognitive change, focal neurology, 'fits, faints or falls', non-specific neurological, and other/non-specific) and calculated times for patient presentation, GP referral, specialist consultation and total pathway interval. We calculated odds ratios (ORs) for symptom domains comparing the slowest to other quartiles. Results Data were available for 226 cases. Median (interquartile range) time for the total pathway interval was 24 days (7-65 days). The most common presentation was focal neurology (33.2%) followed by 'fits, faints or falls' and headache (both 20.8%). Headache only (OR = 4.11, 95% CI = 1.10, 15.5) and memory complaints (OR = 4.82, 95% CI = 1.15, 20.1) were associated with slower total pathway compared to 'fits, faints or falls'. GPs were more likely to consider that there had been avoidable delays in referring patients with headache only (OR = 4.17, 95% CI = 1.14, 15.3). Conclusion Patients presenting to primary care with headache only or with memory complaints remain problematic with potentially avoidable delays in referral leading to a longer patient pathway. This may or may not impact on the efficacy and morbidity of therapies. Additional aids are required to help doctors differentiate when to refer headaches and memory complaints urgently for a specialist opinion.
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Affiliation(s)
- Mio Ozawa
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Paul M Brennan
- Translational Neurosurgery Unit, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
- Brain Tumour Research Group, University of Bristol, Institute of Clinical Neuroscience, Learning and Research Building, Southmead Hospital, Bristol, UK
| | - Karolis Zienius
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Kathreena M Kurian
- Institute of Clinical Neurosciences, University of Bristol, Southmead Hospital, Bristol, UK
| | - William Hollingworth
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - David Weller
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Willie Hamilton
- Primary Care Diagnostics, University of Exeter Medical School, College House, St Luke’s Campus, University of Exeter, Exeter, UK
| | - Robin Grant
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Yoav Ben-Shlomo
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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14
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Gray E, Butler HJ, Board R, Brennan PM, Chalmers AJ, Dawson T, Goodden J, Hamilton W, Hegarty MG, James A, Jenkinson MD, Kernick D, Lekka E, Livermore LJ, Mills SJ, O'Neill K, Palmer DS, Vaqas B, Baker MJ. Health economic evaluation of a serum-based blood test for brain tumour diagnosis: exploration of two clinical scenarios. BMJ Open 2018; 8:e017593. [PMID: 29794088 PMCID: PMC5988134 DOI: 10.1136/bmjopen-2017-017593] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVES To determine the potential costs and health benefits of a serum-based spectroscopic triage tool for brain tumours, which could be developed to reduce diagnostic delays in the current clinical pathway. DESIGN A model-based health pre-trial economic assessment. Decision tree models were constructed based on simplified diagnostic pathways. Models were populated with parameters identified from rapid reviews of the literature and clinical expert opinion. SETTING Explored as a test in both primary and secondary care (neuroimaging) in the UK health service, as well as application to the USA. PARTICIPANTS Calculations based on an initial cohort of 10 000 patients. In primary care, it is estimated that the volume of tests would approach 75 000 per annum. The volume of tests in secondary care is estimated at 53 000 per annum. MAIN OUTCOME MEASURES The primary outcome measure was quality-adjusted life-years (QALY), which were employed to derive incremental cost-effectiveness ratios (ICER) in a cost-effectiveness analysis. RESULTS Results indicate that using a blood-based spectroscopic test in both scenarios has the potential to be highly cost-effective in a health technology assessment agency decision-making process, as ICERs were well below standard threshold values of £20 000-£30 000 per QALY. This test may be cost-effective in both scenarios with test sensitivities and specificities as low as 80%; however, the price of the test would need to be lower (less than approximately £40). CONCLUSION Use of this test as triage tool in primary care has the potential to be both more effective and cost saving for the health service. In secondary care, this test would also be deemed more effective than the current diagnostic pathway.
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Affiliation(s)
- Ewan Gray
- Health Improvement Scotland, Glasgow, UK
| | - Holly J Butler
- Department of Pure and Applied Chemistry, University of Strathclyde Technology and Innovation Centre, Glasgow, UK
- ClinSpec Diagnostics Limited, University of Strathlcyde, Technology and Innovation Centre, Glasgow, UK
| | - Ruth Board
- Rosemere Cancer Centre, Lancashire Teaching Hospitals NHS Trust, Royal Preston Hospital, Preston, UK
| | - Paul M Brennan
- Department of Clinical Neurosciences, Western General Hospital, Edinburgh, UK
| | - Anthony J Chalmers
- Beatson West of Scotland Cancer Centre, Glasgow, UK
- Institute of Cancer Sciences, Wolfson Wohl Cancer Research Centre, University of Glasgow, Glasgow, UK
| | - Timothy Dawson
- Neurosurgery Department, Lancashire Teaching Hospitals NHS Trust, Royal Preston Hospital, Preston, UK
| | - John Goodden
- Neurosurgery Department, Leeds General Infirmary, Leeds, UK
| | - Willie Hamilton
- Primary Care Diagnostics, University of Exeter Medical School, College House, University of Exeter, Exeter, UK
| | - Mark G Hegarty
- Department of Pure and Applied Chemistry, University of Strathclyde Technology and Innovation Centre, Glasgow, UK
- ClinSpec Diagnostics Limited, University of Strathlcyde, Technology and Innovation Centre, Glasgow, UK
| | - Allan James
- Institute of Molecular Cell and Systems Biology, Glasgow, UK
| | - Michael D Jenkinson
- Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
- Institute of Translational Medicine, Clinical Science Centre, University of Liverpool, Liverpool, UK
| | | | - Elvira Lekka
- Neurosurgery Department, Lancashire Teaching Hospitals NHS Trust, Royal Preston Hospital, Preston, UK
| | - Laurent J Livermore
- Department of Neurosurgery, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
| | - Samantha J Mills
- Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Kevin O'Neill
- John Fulcher Neuro-Oncology Laboratory, Imperial College, London, UK
| | - David S Palmer
- ClinSpec Diagnostics Limited, University of Strathlcyde, Technology and Innovation Centre, Glasgow, UK
- WestCHEM, Department of Pure and Applied Chemistry, University of Strathclyde, Glasgow, UK
| | - Babar Vaqas
- John Fulcher Neuro-Oncology Laboratory, Imperial College, London, UK
| | - Matthew J Baker
- Department of Pure and Applied Chemistry, University of Strathclyde Technology and Innovation Centre, Glasgow, UK
- ClinSpec Diagnostics Limited, University of Strathlcyde, Technology and Innovation Centre, Glasgow, UK
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15
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Underwood R, Kilner R, Ridsdale L. Primary care management of headaches and how direct-access MRI fits: a qualitative study of UK general practitioners' views. BMJ Open 2017; 7:e018169. [PMID: 29127230 PMCID: PMC5695367 DOI: 10.1136/bmjopen-2017-018169] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 09/01/2017] [Accepted: 09/18/2017] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To develop a better understanding of general practitioners' (GPs) views and experiences of the management of patients with headaches and use of direct-access MRI scans, and observe outcomes of an educational session offered by a GP with a special interest (GPwSI) to GPs. DESIGN A qualitative study using semistructured interviews, analysed using thematic analysis. A GPwSI in headaches visited practices delivering a talk on headache medication, diagnosis and management. SETTING Sixteen (16) primary care family practices in South London, UK. PARTICIPANTS Twenty (20) GPs. RESULTS Not all GPs were aware of the availability of direct-access MRI, but all acknowledged having used referral or direct scans to manage patients' concern about their headaches. A normal scan result helped resolve uncertainty for patient and GP and helped management towards discussion of preventative treatment. However, patients with psychological and/or severe headache symptoms could not necessarily be reassured. GPs reported difficulty interpreting radiology reports, particularly incidental abnormalities. Those who received the educational talk gained knowledge in diagnosis and medication, improving their confidence in management. CONCLUSIONS Increased access to imaging, training in headache management, addressing physical and psychological symptoms and standardised reporting of scans may improve GPs' use of direct-access MRI in the future.
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Affiliation(s)
- Raphael Underwood
- Department of Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | | | - Leone Ridsdale
- Department of Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
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16
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Oyinlola JO, Campbell J, Kousoulis AA. Is real world evidence influencing practice? A systematic review of CPRD research in NICE guidances. BMC Health Serv Res 2016; 16:299. [PMID: 27456701 PMCID: PMC4960862 DOI: 10.1186/s12913-016-1562-8] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2016] [Accepted: 07/20/2016] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND There is currently limited evidence regarding the extent Real World Evidence (RWE) has directly impacted the health and social care systems. The aim of this review is to identify national guidelines or guidances published in England from 2000 onwards which have referenced studies using the governmental primary care data provider the Clinical Practice Research Datalink (CPRD). METHODS The methodology recommended by Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was followed. Four databases were searched and documents of interest were identified through a search algorithm containing keywords relevant to CPRD. A search diary was maintained with the inclusion/exclusion decisions which were performed by two independent reviewers. RESULTS Twenty-five guidance documents were included in the final review (following screening and assessment for eligibility), referencing 43 different CPRD/GPRD studies, all published since 2007. The documents covered 12 disease areas, with the majority (N =7) relevant to diseases of the Central Nervous system (CNS). The 43 studies provided evidence of disease epidemiology, incidence/prevalence, pharmacoepidemiology, pharmacovigilance and health utilisation. CONCLUSIONS A slow uptake of RWE in clinical and therapeutic guidelines (as provided by UK governmental structures) was noticed. However, there seems to be an increasing trend in the use of healthcare system data to inform clinical practice, especially as the real world validity of clinical trials is being questioned. In order to accommodate this increasing demand and meet the paradigm shift expected, organisations need to work together to enable or improve data access, undertake translational and relevant research and establish sources of reliable evidence.
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Affiliation(s)
- Jessie O. Oyinlola
- Clinical Practice Research Datalink (CPRD), Medicines and Healthcare products Regulatory Agency, 151 Buckingham Palace Road, Victoria London, SW1W 9SZ UK
| | - Jennifer Campbell
- Clinical Practice Research Datalink (CPRD), Medicines and Healthcare products Regulatory Agency, 151 Buckingham Palace Road, Victoria London, SW1W 9SZ UK
| | - Antonis A. Kousoulis
- Clinical Practice Research Datalink (CPRD), Medicines and Healthcare products Regulatory Agency, 151 Buckingham Palace Road, Victoria London, SW1W 9SZ UK
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Schmidt-Hansen M, Berendse S, Hamilton W. Symptomatic diagnosis of cancer of the brain and central nervous system in primary care: a systematic review. Fam Pract 2015; 32:618-23. [PMID: 26467645 PMCID: PMC5942539 DOI: 10.1093/fampra/cmv075] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND We performed a systematic review of diagnostic studies of symptomatic patients in primary care to quantify the risk of brain/central nervous system (CNS) cancer in patients presenting in primary care with symptoms that may indicate brain/CNS cancer. OBJECTIVE To quantify the risk of brain/CNS cancer in symptomatic patients presenting in primary care. METHODS We searched Medline, Premedline, Embase, the Cochrane Library, Web of Science and ISI Proceedings (1980 to August 2014) and PsychInfo (1980 to February 2013) for diagnostic studies of symptomatic adult patients in primary care. Study quality was assessed using QUADAS-II and data were extracted to calculate the positive predictive values (PPVs) of symptoms, singly or in combination, for brain/CNS cancer. RESULTS Six studies with 159938 patients were included. The PPVs of single symptoms were very low with only 'new-onset seizure' being above 1% in patients aged 18 years and above, rising to 2.3% in patients aged 60-69 years. In patients aged 15-24 years, the PPVs for the individual symptoms were also very low, with the highest, also for seizure, being 0.024%, similar to that in children aged 0-14 years of 0.02%. For symptom combinations, none of the PPVs were above 0.39%. CONCLUSIONS All the symptoms of brain tumours are individually low risk, apart from new-onset epilepsy. This provides a real diagnostic problem, as brain tumours have all the expected features seen with cancer diagnostic delay, with high proportions presenting as an emergency and having had multiple primary care consultations before referral, and the prognosis is poor. Improving these metrics can only be done by liberalizing investigation, although the health economics of that strategy is undetermined.
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Affiliation(s)
- Mia Schmidt-Hansen
- National Collaborating Centre for Cancer, Park House, Greyfriars Road, Cardiff CF10 3AF and
| | - Sabine Berendse
- National Collaborating Centre for Cancer, Park House, Greyfriars Road, Cardiff CF10 3AF and
| | - William Hamilton
- University of Exeter Medical School, College House, Magdalen Road, Exeter EX1 2LU, UK
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Abstract
Migraine is the most common disabling brain disorder. Chronic migraine, a condition characterized by the experience of migrainous headache on at least 15 days per month, is highly disabling. Patients with chronic migraine present to primary care, are often referred for management to secondary care, and make up a large proportion of patients in specialist headache clinics. Many patients with chronic migraine also have medication overuse, defined as using a compound analgesic, opioid, triptan or ergot derivative on at least 10 days per month. All doctors will encounter patients with chronic headaches. A basic working knowledge of the common primary headaches, and a rational manner of approaching the patient with these conditions, allows a specific diagnosis of chronic migraine to be made quickly and safely, and by making this diagnosis one opens up a substantial number of acute and preventive treatment options. This article discusses the current state of management of chronic migraine.
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Affiliation(s)
- Mark W Weatherall
- Princess Margaret Migraine Clinic, Imperial College NHS Healthcare Trust, Charing Cross Hospital, Fulham Palace Road, London W6 8RF, UK
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Abstract
"Do I have a tumor?" This is a question in every person's mind when first confronted with a new-onset headache, a question that causes considerable anxiety among patients, leading them to seek medical evaluation. This publication reviews the current literature with respect to the epidemiology, pathophysiology presentation, and treatment of headaches in association with intracranial neoplasm.
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Visser F, Rinkel GJE. Isolated headache in general practice: determinants for delay in referral in patients with subarachnoid haemorrhage. Eur J Gen Pract 2012; 18:149-53. [PMID: 22954194 DOI: 10.3109/13814788.2012.685711] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND A delay in diagnosing aneurismal subarachnoid haemorrhage (SAH) occurs in a substantial proportion of patients who present with headache as the only symptom. OBJECTIVE To identify determinants for a delay in referral in patients with SAH, who present with isolated headache to the general practitioner (GP). METHODS For all 112 patients with SAH admitted to the hospital between October 2008 and June 2009, we sent a questionnaire to the GPs asking for details presented during the initial GP visit. In this retrospective study, we included 31 patients with SAH who initially presented with isolated headache. We assessed acuteness of headache onset, history of headaches and a patient delay as determinants for delayed referral (> 2 h after a visit to the GP), by calculating risk ratios (RRs) with corresponding 95% confidence intervals (CIs). RESULTS Referral was delayed in 18 of these 31 patients. The delay occurred in all 10 patients in whom the GP was unaware of the acute onset of headache and in 8 of 21 patients in whom the GP was aware of this symptom (RR: 2.6; 95% CI: 1.5-4.5). A history of headaches (RR: 1.8; 95% CI: 1.1-3.0) and a patient delay (RR: 2.1; 95% CI: 1.0-4.5) also increased the probability of delayed referral. CONCLUSION In patients with SAH who presented with isolated headache to the GP, GP's unawareness of the acute onset of the headache, a history of headaches and late presentation by the patient increased the probability of delayed referral.
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Affiliation(s)
- Femke Visser
- Department of Neurology, Sint Lucas Andreas Hospital, Amsterdam, The Netherlands.
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Abstract
Headache is an extremely common symptom and collectively headache disorders are among the most common of the nervous system disorders, with a prevalence of 48.9% in the general population.(1) Headache affects people of all ages, races and socioeconomic status and is more common in women. Some headaches are extremely debilitating and have significant impact on an individual's quality of life, imposing huge costs to healthcare and indirectly to the economy in general. Only a small proportion of headache disorders require specialist input. The vast majority can be effectively treated by a primary care physician or generalist with correct clinical diagnosis that requires no special investigation. Primary headache disorders - migraine, tension headache and cluster headache - constitute nearly 98% of all headaches; however, secondary headaches are important to recognise as they are serious and may be life threatening. This article provides an overview of the most common headache disorders and discusses the red flag symptoms that help identify serious causes that merit urgent specialist referral. The current pathway of headache care in the UK is discussed with a view to proposing a model that might fit well in the financially constrained National Health Service (NHS) and with new NHS reforms. The role of the national society, the British Association for the Study of Headache, and the patient organisations such as Migraine Trust in headache education to the professionals and the general public in shaping headache care in the UK is described. The article concludes by summarising evidence-based management of common headache diagnoses.
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Affiliation(s)
- Fayyaz Ahmed
- Hull and East Yorkshire Hospitals NHS Trust, Hull Royal Infirmary, UK
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Should GPs have direct access to neuroradiological investigation when adults present with headache? Br J Gen Pract 2011; 61:409-11. [PMID: 21801533 DOI: 10.3399/bjgp11x578124] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
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Imai N, Kuroda R, Konishi T, Serizawa M, Kobari M. Giant cell arteritis: clinical features of patients visiting a headache clinic in Japan. Intern Med 2011; 50:1679-82. [PMID: 21841325 DOI: 10.2169/internalmedicine.50.5205] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE The first symptom of giant cell arteritis (GCA) is usually a headache. Japan has a low prevalence of GCA, and clinical features of this disorder have not been fully investigated. We conducted a retrospective evaluation of clinical features in patients with giant cell arteritis who visited a headache clinic in Japan. METHODS Clinical and demographic data were obtained from clinical examinations, face-to-face interviews, and hospital records. PATIENTS Subjects comprised 19 patients (9 men, 10 women). RESULTS Mean age at disease onset was 78.1 ± 4.8 years (range, 71-86 years). Seventeen of 19 patients (89.5%) had consulted other medical institutions before consulting our hospital, but only 2 of those patients had been diagnosed with GCA at these medical institutions. Manifestations at disease onset included headache (89.5%), ear pain (5.3%), and jaw pain (5.3%). Ocular manifestations were reported in 2 patients (10.5%). No loss of vision occurred. One patient showed trigeminal nerve palsy involving the third division of the nerve. Jaw claudication was observed in 3 patients (15.8%). Concomitant polymyalgia rheumatica was seen in 3 patients (15.8%). No patient showed upper respiratory tract symptoms, arm claudication, or aortic aneurysms. CONCLUSION Although most patients had consulted other medical institutions before consulting our hospital, they were not diagnosed with GCA at these institutions. Infrequent clinical findings of GCA and lack of symptoms other than headache may contribute to the high rate of unrecognized and misdiagnosed cases of GCA.
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Affiliation(s)
- Noboru Imai
- Department of Neurology, Japanese Red Cross Shizuoka Hospital, Japan.
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Marmura MJ, Nahas SJ. What might the ideal electronic medical record for migraine headache look like? Curr Pain Headache Rep 2010; 14:233-7. [PMID: 20425192 DOI: 10.1007/s11916-010-0107-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Electronic medical records (EMRs) have assumed a greater role in clinical practice and have the potential to improve clinical efficiency and documentation, reduce cost, and enhance clinical care. An EMR for migraine should allow customization to include fields important in migraine, such as migraine frequency and severity, weight, blood pressure, and outcome measures, such as the Migraine Disability Assessment. The physical examination should focus on common abnormalities, such as muscle spasm, allodynia, or papilledema, and allow free text to describe uncommon findings. Information from previous notes should be available for inclusion in the current visit, such as diagnoses and the plan from the previous visit. In the future, EMR will work with clinicians to recognize patterns of clinical features and medication responses within individual patients and across patients, assimilate that information with current best practices of evidence-based medicine, and suggest management considerations to improve outcomes.
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Affiliation(s)
- Michael J Marmura
- Department of Neurology, Jefferson Headache Center, Thomas Jefferson University, 111 South 11th Street, Suite 8130, Philadelphia, PA 19107, USA.
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Kernick D. Reducing the burden of headache: The International Headache Society Primary Care Interest Group. Cephalalgia 2010; 30:899-901. [PMID: 20656699 DOI: 10.1177/0333102409361216] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Abstract
The number of referrals by primary care practitioners to secondary care neurology services, particularly for headache, may be difficult to justify. Access to imaging by primary care practitioners could avoid referral without compromising patient outcomes, but the decision to refer is based on a number of complex factors. Due to the paucity of rigorous evidence in this area, available data are combined with expert opinion to offer support for GPs. The study suggests management for three levels of risk of tumour: red flags>1%; orange flags 0.1-1%; and yellow flags<0.1% but above the background population rate of 0.01%. Clinical presentations are stratified into these three groups. Important secondary causes of headache where imaging is normal should not be overlooked, and normal investigation does not eliminate the need for follow-up or appropriate management of headache.
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