200

Headache Medicine, v.2, n.4, p.200-203, Oct/ Nov/Dec. 2011

Prevalence of headaches in individuals referred

from primary care to secondary care

Prevalência de cefaleia em indivíduos encaminhados da atenção

primária para a secundária

ABSTRACTABSTRACT

ABSTRACT

Background:Background:

Background: Improve the quality of public health is a growing

necessity today. Identifying reasons for medical referral (from

general to specialized care) is a prelude for developing

educational initiatives that have this goal.

Objective:Objective:

Objective: To

estimate the prevalence of headaches as a cause of referral

from the primary to the secondary level of public medical care.

Methods: Methods:

Methods: First-time referrals from four primary care units to

neurology care were assessed.

Results:Results:

Results: Sample consisted of

587 individuals referred to neurology consultation. Headache

was the cause of referral in 31.2% of the individuals; 79.2%

of the headache cases were in women. Rates for other diseases

were lower and are presented for benchmarking.

Conclusion:Conclusion:

Conclusion:

Headache represented an important cause of demand for

neurological care. Education initiatives on principles of

headache management are necessary and may translate into

decreased referral rates to neurologists.

Keywords: Keywords:

Keywords: Headache; Primary health care; Secondary health

care

RESUMORESUMO

RESUMO

Introdução:Introdução:

Introdução: Melhorar a qualidade da saúde pública é uma

necessidade crescente nos dias atuais. Identificar os motivos

de encaminhamento médico (da atenção generalista para a

especializada) é um prelúdio para o desenvolvimento de ini-

ciativas educacionais que tenham este objetivo.

Objetivo:Objetivo:

Objetivo:

Estimar a prevalência de cefaleias como causa de encami-

nhamento do nível primário para o secundário, de assistên-

cia médica, na saúde pública.

Métodos:Métodos:

Métodos: Num primeiro mo-

ORIGINAL ARTICLEORIGINAL ARTICLE

ORIGINAL ARTICLE

Joismar Manuel Rodrigues

, Vanessa Vilela Caires

, Kátia Beatriz Costa Fontoura

Teresa Cristina Santos Silva

, Simone Fonseca Goulart

, Cláudia Marcucci Rocha

, Antônio Lúcio Teixeira

Ariovaldo Alberto da Silva Junior

Universidade José do Rosário Vellano – Unifenas, Belo Horizonte, MG, Brazil

Faculdade de Ciências Médicas, Belo Horizonte, MG, Brazil

Rodrigues JM, Caires VV, Fontoura KB, Silva TC, Goulart SF, Rocha CM, Teixeira AL, Silva Junior AA

Prevalence of headaches in individuals referred from primary care to

secondary care. Headache Medicine. 2011;2(4):200-3

mento, os encaminhamentos de quatro unidades de atenção

primária para a atenção neurológica foram avaliados.

Re-Re-

Re-

sultados:sultados:

sultados: A amostra consistiu em 587 indivíduos referen-

ciados para consulta em neurologia. Cefaleia respondeu por

31,2%; 79,2% dos casos de cefaleia foram em mulheres. As

porcentagens de outros motivos de atendimento foram mais

baixas e são apresentadas para comparação.

Conclusão:Conclusão:

Conclusão:

Iniciativas educacionais voltadas para o manejo das cefaleias

são necessárias e podem resultar na diminuição das taxas de

encaminhamento para neurologistas.

alavrasalavras

alavras

chave:chave:

chave: Dor; Cefaleia; Ocitocina; Síndrome do

túnel do carpo

INTRODUCTION

The Brazilian Public Health System (PHS) provides

universal medical access to the population. It is structured

in three levels of care. The primary care consists of basic

health units (BHUs), being the typical "entry door" into the

system.

(1)

It accounts for the preventive care, as well as for

treatment (by family physicians or general practitioners).

An important component of the primary care in the PHS is

the family heath program (FHP), which mainly focuses on

preventive and educational health strategies. A recent study

demonstrated that 85% of the families seeking medical

care in the PHS do it so trough the FHP,

(2)

which is largely

Headache Medicine, v.2, n.4, p.200-203, Oct/ Nov/Dec. 2011 201

responsible for referrals to the secondary level of care.

The secondary care consists of specialty clinics, and patients

are to be referred by the primary care doctors into this

level.

(2)

The tertiary care consists of subspecialty and high

complexity hospitals. It has been suggested that a

considerable proportion of referrals to the secondary

neurological care is due to headaches.

(3)

The Brazilian PHS follows the structural

recommendations of the World Health Organization

(WHO) to the BRIC countries (Brazil, Russia India and

China).

(4,5)

The system seems to be effective in providing

primary care,

(6)

and important successes are reported in

the control of diabetes and hypertension.

(7,8)

Nonetheless,

headaches have not deserved specific recommendations

from a public health perspective.

(9)

As a consequence,

unnecessary referrals to the secondary care may exist.

(10-

12)

The problem is further amplified by the recognized

difficulties in establishing a headache diagnosis at the

primary care level.

(13,14)

In the present study was assessed the prevalence of

headaches among patients referred from the primary care

system to a secondary neurology program.

METHODS

This study was conducted at subdistrict north of Belo

Horizonte, the capital of Minas Gerais state, Brazil.

Through the FHP, this subdistrict attends 193,764

inhabitants. It is structured into 19 primary care centers

and one secondary unit as main referral.

Patients should first be attended by general

practitioners. Patients in need of neurological care are

referred to secondary care units. Accordingly, in this study

we assessed reasons for referral from four primary care

units that can only refer patients to a secondary care

center.

The study was conducted from January of 2007 to

September of 2009. For referred patients we collected

demographic variables (gender, age) and reasons for

referral as follows: headache, epilepsy, fainting,

Alzheimer's disease, dementia or other memory problems,

Parkinson's disease and tremors, strokes, and other cau-

ses. We restricted our analyses to adults (17 or older).

Extracted data were entered into Epiinfo (version

3.5.1) and description of results was performed.

The study was approved by the Ethics Committee of

the University of José do Rosário Vellano (CEP/Unifenas)

and the Ethics Committee on Public Health Research, Belo

Horizonte (CEP/SMSA/BH).

RESULTS

Of 587 referrals, 183 were secondary to headaches.

Accordingly, headaches responded by 31.2% of the

referrals. Of headache patients, 79.2% were women with

a mean age of 40 years (SD= 2).

Other causes of referrals are described in Table 1.

The second most common cause of referral was epilepsy

and related syndromes (14.9%) followed by fainting (5.6%)

and Alzheimer's disease and memory problems (5.3%).

With regard to median age stratified by category the

average age was 38.5 years in epilepsy followed by 53

years for fainting and 72 years for Parkinson's disease.

This information can be seen in Table 2.

PREVALENCE OF HEADACHES IN INDIVIDUALS REFERRED FROM PRIMARY CARE TO SECONDARY CARE

202

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RODRIGUES JM, CAIRES VV, FONTOURA KB, SILVA TC, GOULART SF, ROCHA CM, ET AL

DISCUSSION

Headache was the main cause of referrals for

neurological care. With regard to age, headache and

epilepsy were the most frequent among young adults and

Alzheimer's disease and Parkinson's disease affected more

the elderly.

These results come at little surprise, since findings are

supported by the literature which suggests that headache

responds for around one third of referrals to neurological

care.

(3)

The relative frequency of referrals due to headaches

is particularly expressive when contrasted to other reasons.

For instance, epilepsy responded to less than half of the

headache referrals. Parkinson's disease responded by only

3.7%.

The expressive frequency of referrals due to

headaches has several potential explanations. First, the

prevalence of headaches in the population is far higher

than the prevalence of other neurological disorders.

However, since headaches are diagnosed based on

clinical grounds and are benign in most cases, this fact

alone unlikely explains the high proportion of referrals.

According to Galdino et al.,

(14)

the lack of dissemination

of diagnostic criteria for headaches among primary care

doctors is associated with reduced comfort in assigning

headache diagnoses and may explain the referrals.

(15)

Indeed, according to Vincent and Carvalho,

(16)

only

44.9% of the migraine cases seen by primary care doctor

in Brazil received a proper diagnosis.

Our study has clear limitations. The most important is

the lack of specific headache diagnoses, since we relied

on information obtained from the referral letters. Second,

our data may not be generalizable to other regions. We

aim to repeat this study after these educational initiatives

are conducted, in order to test the hypothesis that referral

rates will be reduced.

Accordingly, we demonstrated that high proportion

referrals to neurological cares are due to headaches in

the PHS. This may reflects the high prevalence of

headaches in the population, but also the ineffectiveness

of the primary care system in dealing with headaches.

Educational initiatives are to be created and tested in order

to change this paradigm.

REFERENCES

1. Malta DC, Santos FP. O Programa de Saúde da Família (PSF) e

os modelos de assistência à saúde no âmbito da reforma sa-

nitária brasileira. Revista Médica de Minas Gerais. 2003;

13(4):251-9.

2. Giovanella L, de Mendonça MH, de Almeida PF, Escorel S, Senna

M de C, Fausto MC, et al. Family health: limits and possibilities

for an integral primary care approach to health care in Brazil.

Cien Saude Colet. 2009;14(3):783-94.[Article in English,

Portuguese]

3. Ferri-de Barros JE, Nitrini R. [Which patients does the neurologist

assist? Basis for a curriculum in neurology]. Arq Neuropsiquiatr.

1996; 54(4):637-44.

4. Steiner TJ. Lifting the burden: The global campaign to reduce

the burden of headache worldwide. J Headache Pain.

2005;6(5): 373-7 .

5. Martelletti P, Haimanot RT, Láinez MJ, Rapoport AM, Ravishankar

K, Sakai F, et al. The Global Campaign (GC) to Reduce the

Burden of Headache Worldwide. The International Team for

Specialist Education (ITSE). J Headache Pain. 2005;6(4):261-3.

6. Escorel S, Giovanella L, Magalhães de Mendonça MH, de Castro

Maia Senna M. The Family Health Program and the construction

of a new model for primary care in Brazil. Rev Panam Salud

Publica. 2007;21(2-3):164-76. [Article in Portuguese].

7. de Paiva DC, Bersusa AA, Escuder MM. Healthcare assessment

for patients with diabetes and/or hypertension under the Family

Health Program in Francisco Morato, São Paulo, Brazil. Cad

Saude Publica. 2006;22(2):377-85.

8. Carvalho BG, Souza RKT, Soares DA, Yagi MCN. Diseases of the

circulatory system before and after the Family Health Program,

Londrina, Paraná. Arq Bras Cardiol. 2009;93(6):597-601, 645-

50. [Article in English, Portuguese].

Headache Medicine, v.2, n.4, p.200-203, Oct/ Nov/Dec. 2011 203

Correspondence

Ariovaldo Alberto da Silva JuniorAriovaldo Alberto da Silva Junior

Ariovaldo Alberto da Silva Junior

, MD, MD

, MD

Rua Bernardo Guimarães, 2154, apto. 501 – Lourdes

Belo Horizonte, MG., Brazil

juniorariovaldo@uol.com.br

9. Junior AS, Krymchantowski A, Moreira P, Vasconcelos L, Gomez

R, Teixeira A. Prevalence of headache in the entire population of

a small city in Brazil. Headache. 2009;49(6):895-9

10. Kowacs PA, Twardowschy CA, Piovesan EJ, Dal-Prá Ducci R,

Cirino RH, Hamdar F, et al. General practice physician knowledge

about headache: evaluation of the municipal continual medical

education program. Arq Neuropsiquiatr. 2009;67(3A):595-9.

11. Bigal ME, Bordini CA, Speciali JG. Etiology and distribution of

headaches in two Brazilian primary care units. Headache. 2000;

40(3):241-7.

12. Bigal ME, Bigal JO, Bordini CA, Speciali JG. Prevalence and

costs of headaches for the public health system in a town in the

interior of the state of São Paulo. Arq Neuropsiquiatr. 2001;

59(3A): 504-11.

13. Gantenbein AR, Sándor PS. Physiological parameters as

biomarkers of migraine. Headache. 2006;46(7):1069-74.

14. Galdino GS, Paz e Albuquerque TI, Medeiros JLA. Primary

headaches: a diagnostic approach by non-neurologist doctors.

Arq Neuropsiquiatr. 2007;65(3A):681-4. [Article in Portuguese].

15. Khu JV, Siow HC, HO KH. Headache diagnosis, management

and morbidity in the Singapore primary care setting: findings

from a general practice survey. Singapore Med J. 2008;49

(10):774-9.

16. Vincent MB, Carvalho JJ. Primary headache care delivery by

nonspecialists in Brazil. Brazilian Headache Care Cooperative

Group. Cephalalgia. 1999;19(5):520-4.

Received: 1/30/2011

Accepted: 11/25/2011

PREVALENCE OF HEADACHES IN INDIVIDUALS REFERRED FROM PRIMARY CARE TO SECONDARY CARE