Article Text

Original research
Management of chronic headache with referral from primary care to direct access to MRI compared with Neurology services: an observational prospective study in London
  1. Tiago Rua1,2,
  2. Asif Mazumder3,
  3. Yvonne Akande2,
  4. Charikleia Margariti2,
  5. Juliana Ochulor4,
  6. Joanna Turville2,
  7. Reza Razavi5,
  8. Janet L Peacock6,
  9. Paul McCrone1,
  10. Vicky Goh7,
  11. James Shearer6,
  12. Shazia Afridi4
  1. 1King’s Health Economics, King’s College London, London, UK
  2. 2Clinical Imaging and Medical Physics, Guy’s and Saint Thomas’ NHS Foundation Trust, London, UK
  3. 3Neuroradiology Group, Department of Radiology, Lambeth Wing, Guy’s and St Thomas’ Hospitals NHS Foundation Trust, London, UK
  4. 4Neurology Department, Guy’s and Saint Thomas’ NHS Foundation Trust, London, UK
  5. 5Imaging Science Division, King’s College London, London, UK
  6. 6Division of Primary Care and Public Health Sciences, King’s College London, London, UK
  7. 7School of Biomedical Engineering and Imaging Sciences, King’s College London, London, UK
  1. Correspondence to Tiago Rua; tiago.rua{at}


Objectives To evaluate the cost, accessibility and patient satisfaction implications of two clinical pathways used in the management of chronic headache.

Intervention Management of chronic headache following referral from Primary Care that differed in the first appointment, either a Neurology appointment or an MRI brain scan.

Design and setting A pragmatic, non-randomised, prospective, single-centre study at a Central Hospital in London.

Participants Adult patients with chronic headache referred from primary to secondary care.

Primary and secondary outcome measures Participants’ use of healthcare services and costs were estimated using primary and secondary care databases and questionnaires quarterly up to 12 months postrecruitment. Cost analyses were compared using generalised linear models. Secondary outcomes assessed: access to care, patient satisfaction, headache burden and self-perceived quality of life using headache-specific (Migraine Disability Assessment Scale and Headache Impact Test) and a generic questionnaire (5-level EQ-5D).

Results Mean (SD) cost up to 6 months postrecruitment per participant was £578 (£420) for the Neurology group (n=128) and £245 (£172) for the MRI group (n=95), leading to an estimated mean cost difference of £333 (95% CI £253 to £413, p<0.001). The mean cost difference at 12 months increased to £518 (95% CI £401 to £637, p<0.001). When adjusted for baseline and follow-up imbalances between groups, this remained statistically significant. The utilisation of brain MRI improved access to care compared with the Neurology group (p<0.001). Participants in the Neurology group reported higher levels of satisfaction associated with the pathway and led to greater change in care management.

Conclusion Direct referral to brain MRI from Primary Care led to cost-savings and quicker access to care but lower satisfaction levels when compared with referral to Neurology services. Further research into the use of brain MRI for a subset of patient population more likely to be reassured by a negative brain scan should be considered.

Trial registration number NCT02753933.

  • chronic headache
  • migraine
  • direct access
  • magnetic resonance imaging
  • cost analysis

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  • Contributors TR, AM, YA, JT, RR, JLP, PM and SA contributed to conception and design of data. TR, YA, CM and JO contributed to acquisition of data. TR, JLP, PM and JS involved in analysis and interpretation of data. TR, AM, JLP, PM, VG, JS and SA involved in drafting the manuscript. TR, AM, YA, CM, JT, RR, JLP, PM, VG, JS and SA contributed to final approval of the completed manuscript.

  • Funding This work was supported by the Guy’s and St Thomas’ Charity.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval The Health Research Authority and Research Ethics Committee (West of Scotland—REC 4) approved the study research on 12 April 2016 (REC reference 16/WS/0028).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon reasonable request. Extra data can be accessed via the Dryad data repository at with the doi: 10.5061/dryad.d7wm37pzn.

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