References
The diagnosis and management of acute cluster headache in the out-of-hospital environment
Abstract
Cluster headaches are the most painful form of primary headache and the most common of a group of headaches known as trigeminal autonomic cephalalgias (TACs) (
Given the burden upon health services and the wider economy, a number of strategic drivers for enhancing general management of headaches have been produced with explicit aims of reducing inappropriate referrals and admissions.
This article reviews the current literature and discusses the appropriateness of non-specialist clinicians working in out-of-hospital, and in primary, urgent and emergency care, such as paramedics, safely diagnosing and managing cluster headaches in the community, while also considering the balance of possible risks and fiscal benefits in doing so.
It concludes that community practitioners could safely manage recurrent episodes of cluster headaches within the community, with good referral and consultation pathways being put in place. However, caution should be paid to discharging those patients presenting with first bout of cluster headache without specialist clinical assessment. Furthermore, while there is some evidence to suggest that this community management may be cost effective, this conclusion cannot be definitely drawn without the authors undertaking a full cost–benefit analysis, which was not within the scope of this paper.
Cluster headaches are the most painful form of primary headache and the most common of a group of headaches known as trigeminal autonomic cephalalgias (TACs) (Imai, 2013). They can be acute or chronic, but are most commonly characterised by severe, short-lasting, episodic, unilateral pain that is orbital, supraorbital, temporal or any combination of these sites, and such attacks are typically accompanied with specific autonomic symptoms (Headache Classification Subcommittee of the International Headache Society (HCS), 2005).
The need for enhanced management of primary and medication overuse headaches is driven by their perceived prevalence and the overall burden on health systems. It is estimated that ‘25 million days are lost from work or school because of migraine each year’ (National Institute for Health and Care Excellence (NICE), 2013). Additionally, it is apparent that ‘headaches are one of the most common neurological problems presented to GPs and neurologists' (NICE, 2013). McCrone et al (2011) highlight that there is a potential cost as a result of headaches of £956 million due to service use, and £4.8 billion due to lost employment. Details of primary and secondary headaches can be found in Table 1.
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