This website is intended for healthcare professionals

Letter to the editors

Posted in Editor's introduction on 2nd Aug 2019


We read with interest and sympathy Elaine Bell’s struggle to find a treatment for her chronic migraine (ACNR 2019;18:20). She is not alone. On the contrary, her story is sadly entirely typical of the ‘journeys’ made by thousands of chronic headache patients in the UK in search of an effective intervention.

In a recent study of over 200 patients seen for the first time in three secondary and one tertiary care headache clinics in England,1 the time to referral for expert help was around 10 years and patients had typically consulted their GPs because of headaches on about 10 occasions by the time of referral. Only a third had been given a specific headache diagnosis in primary care – a requisite for appropriate treatment – but about 65% had been referred to a variety of other specialists, very largely inappropriately. All these patients in fact, had ‘migraine’ but less than half had been offered triptans; and while migraine prophylaxis was indicated this was prescribed in only a minority, often in a haphazard and ineffective fashion. By contrast, compound analgesics and particularly opioid based drugs were used widely and frequently.

The situation in another common headache scenario, post traumatic headache (PTH) following accidental head injury, is still more discouraging. In a recent study, 75% of 109 head and neck injury cases (94% classified as ‘minor’) developed PTH which persisted in 70% at the time of assessment some two years after injury. The phenotypic diagnosis on evaluation was ‘migraine’ or ‘probable migraine’ in 90%; yet 41% had received no treatment at all for this headache problem in primary care.

Despite her long and frustrating search for help, Elaine Bell was at least offered a number of potentially effective treatments and she currently reports ongoing benefit from botox. This treatment has been validated for chronic migraine3 and is recommended by NICE. There is also now some understanding of its possible mechanism in pain control.4 In a recent ‘real life’ prospective study of 254 chronic migraine patients, 94% of whom had failed to respond to or were intolerant of several migraine prophylactics, two thirds showed a significant and meaningful response to botox, notably with twice as many headache free days compared to the pre-treatment state.5

While Elaine Bell is quite right in that with regard to the management of chronic migraine there is no “one-size-fits-all” intervention we believe that botox should be considered more often and earlier in the treatment strategy. But more importantly, headache diagnosis and management needs urgent revision in primary care.

Russell JM Lane, MD, FRCP, Medicolegal Neurologist, Chilbolton, Hampshire.
Paul TG Davies, MD, FRCP, Retired Neurologist, Pattishall, Northamptonshire.
Fayyaz Ahmed, MD, FRCP, MBA, Consultant Neurologist Hull Royal Infirmary.
Conflict of interest statement: None declared

1. Davies PTG, Lane RJM, Astbury T et al. The long and winding road: the journey taken by headache sufferers in search of help. Primary Health Care Research and Development 2018. doi: 10.1017/S1463423618000324.
2. Lane R, Davies P. Post traumatic headache (PTH) in a cohort of UK compensation claimants. Cephalalgia 2019;39:641-7.
3. Dodick DW, Turkel CC, DeGryse RE et al. OnabotulinumtoxinA for treatment of chronic migraine: pooled results from the double-blind, randomized, placebo-controlled phases of the PREEMPT clinical programme. Headache 2010;50:921-36.
4. Do TP, Hvedstrup J, Schytz HW. Botulinum toxin: a review of the mode of action in migraine. Acta Neurol. Scand. 2018;137:442-51.
5. Khalil M, Zafar HW, Quarshie V, Ahmed F. Prospective analysis of the use of OnabotulinumtoxinA (Botox) in the treatment of chronic migraine; real-life data in 254 patients from Hull, UK. J Headache Pain 2014;15:54. (