Diagnostic Criteria
Approximate half of respondents report that diagnosis and treatment of patients with headache is challenging (Table 2). This is particularly worrying as the majority estimate 11-20% of consultations are related to headache (Table 4) – a significant proportion. Yet these findings are not surprising and in line with findings from studies conducted in other regions.11–13 As there are no biomarkers or diagnostic tests for most headache disorders, diagnosis rely on the medical history. While headache diaries in general are used for diagnosis and outcome assessment, there is an apparent inconsistent use of the ICHD (Table 3). The expectation is that residents would have a more consistent use and knowledge of diagnostic criteria over time due to accumulation of experience, but the pattern is similar for both residents in the introduction program and the main program. In an international survey of neurologists, explicit diagnostic criteria are only used in 56% of cases.6 These data confirm that these deficiencies are not necessarily corrected after completion of specialization and substantiates the need for improvement already during residency.
Treatment and Management
More than half of respondents identify lack of treatment options and efficacy as a barrier to care (Table 2). While it cannot be excluded that this is due to rare headache disorders with few evidence-based options, cost-effective treatments do exist for the largest headache burdens, i.e., migraine and tension-type headache.2–5 These findings are surprising as most residents are more than moderately confident in their self-reported knowledge of headache disorders (Table 2). Furthermore, less than two-thirds of respondents could correctly identify opioids as a potential cause of medication overuse headache, and more worrying, few respondents both in the introduction program and main program incorrectly reported prophylactic medications as a potential cause (Table 5). This misinterpretation can lead to a worse clinical outcome, and provides a possible explanation of poor use of preventive medications in eligible cases.14 Most respondents recommended one non-pharmacological interventions (Table 6), which provides a multidisciplinary approach to clinical management. However, for some of the more popular recommended options (e.g., physiotherapy, acupuncture, and diet), data on potential therapeutic gain of these therapies is discordant, and may also explain why respondents on average feel less confident in advising patients on non-pharmacological treatment options.2 These gaps in treatment and management could be related to a lacking use of available national guidelines,15 but the use of guidelines is reported to be higher than moderate (Table 3).
Primary Care and Tertiary Care
In Denmark, headache services are divided in three levels: primary care (general practitioner), specialist care (general neurology), and tertiary care (specialized headache center). Headache is the most common neurological symptom in primary care,16 and should in 90% of cases be initiated and maintained in primary care.17,18 While there are cases where specialist care can be necessary, treatment of a headache patient and repatriation to primary care should be coordinated with the general practitioner to ensure continuity of care. However, contact from primary care for professional advice on headache and collaboration with primary care for referred headache patients is deficient in the present study (Table 4). A significant consequence is unnecessary escalation and referral to tertiary care. This is also reflected by the fact that most respondents estimated up to one-fifth of patients require referral to tertiary care with one of the common reasons being diagnostic uncertainty (Table 4). For migraine, assumingly compromising the largest proportion of patients, requires only 1% of cases to be referred to tertiary care.2 Specialist services are scarce and impeded by long waiting lists.2 This is also the case in a high-income country as Denmark, where more than half of the residents estimated the waiting list to be either long or unacceptable. Furthermore, while tertiary care do provide better care due to greater expertise and access to a multidisciplinary approach,19 residents do not necessarily find it beneficial for patients to be referred (Table 4).
Barriers to Care
The most common patient and disease-related barriers were connected to diagnosis and treatment (Table 2). An unclear medical history is reported by more than half of residents as an impediment, which may also overlap with comorbidities also being reported as a common barrier.2,4,20 This is troubling as diagnosis of headache disorders rely on the medical history. Interestingly, these may be related to a high frequency of challenges in physician/patient collaboration and insufficient consultation time as both would affect obtaining a good medical history.
Headache Education
Even if headache training is not mandatory until the main program, almost half of all residents in the introduction program had already completed a formalized course in headache prior to this survey (Table 1). This likely reflects an interest and need for education already at an early career stage. The European Union of Medical Specialists categorize applied clinical knowledge in four different levels, and it is recommended that trainees obtain at level 3 and 4 within the first two years of training;21 level 4 is the ability to make a complete diagnosis and optimize treatment. As such, residents in the main program should be confident in all aspects of headache management before completion of specialization, however, not all residents had completed formalized headache training prior to the survey, and there were gaps in all explored domains. Almost one-fifth of residents in the main program reported their own knowledge as a personal barrier to care (Table 2). While this cannot be concluded based on the available data, one may speculate whether the overall low interest in headache as a sub-specialization is an important factor (Figure 1).22,23 Overall, the expectations are discordant with the actual level of self-reported knowledge.
Strengths and Limitations
This is the first national cross-sectional study of residents in neurology in Denmark. The study included approximate 40% of all residents in Denmark, which we evaluate as representative of the population as the sample included residents from both inside and outside the Capital Region of Denmark (greater Copenhagen area). Surveys may introduce recall bias, but we find no suspect systematic bias in this domain.