Pozo-Rosich et al. The Journal of Headache and Pain (2019) 20:73 https://doi.org/10.1186/s10194-019-1020-1 The Journal of Headache and Pain RESEARCH ARTICLE Open Access Quality assurance in specialized headache units in Spain: an observational prospective study Patricia Pozo-Rosich1,2, Alba Martínez-García3*, Julio Pascual4,5, Emilio Ignacio6, Ángel L. Guerrero-Peral7,8, José Balseiro-Gómez9, Jesús Porta-Etessam10, Germán Latorre-González11, Almudena Layos-Romero12, César Lucas13 and José J. Mira14,15 Abstract Objective: To assess the quality of the therapeutic approach in Specialized Headache Units in Spain. Methods: An observational (prospective) study was conducted. Anonymized data of 313 consecutive patients during a defined period of time were analyzed and a comparison of performance in 13 consensual quality indicators between Specialized Headache Units and neurology consultations was calculated. Specialized Units and neurology consultations represented the type of provision that Spaniards receive in hospitals. Results: The consensus benchmark standard was reached for 8/13 (61%) indicators. Specialized Headache Units performed better in the indicators, specifically in relation to accessibility, equity, safety, and patient satisfaction. Patients attended in Specialized Headache Units had more complex conditions. Conclusion: Although there is variability among Specialized Headache Units, the overall quality was generally better than in traditional neurology consultations in Spain. Keywords: Headache, Indicators, Quality assurance, Patient safety Introduction treatment or care might have, and also because of the Headache is a very common health problem that requires social and work implications that this ailment entails. an effective and coordinated response from healthcare On March 2004, the Global Campaign against provision, both from Primary Care and by Specialized Headache [3] was launched, spearheaded by the Lifting Headache Units in hospitals. the Burden (LtB) organization along with the World Diagnostic criteria and recommended treatment Health Organization, which laid the foundations for guidelines have been established [1, 2], although in international collaboration in order to reduce the frag- clinical daily practice there seems to be great differences mentation of organizational, diagnostic and therapeutic in how the response to headache is organized by the dif- approaches throughout the world and, particularly, in ferent health systems. Most regional health authorities Europe [4]. Within this cooperation framework, with the do not have established protocols for the treatment of participation of the European Headache Federation headaches, which affects, particularly, the variability of (EHF) a study was carried out to identify the dimensions the quality of health care of these patients. However, the in the quality of care for headache patients that ought to adequate treatment of headache is of interest to every- be taken into consideration. This study was carried out one because of its overall impact on people’s health and through a systematic review of the available evidence [5] well-being, the economic consequences that inadequate and consensus methods [6, 7]. For each dimension, a proposal of quality indicators was established that, in total, comprised 30 indicators grouped into 9 dimen- * Correspondence: alba.mgarcia@umh.es sions, ranging from equipment and infrastructure to 3 Calitè Research Group, Miguel Hernández University, Elche, Spain assessment of the cost of the care mechanism. Full list of author information is available at the end of the article © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. Pozo-Rosich et al. The Journal of Headache and Pain (2019) 20:73 Page 2 of 9 The proposal of LtB and EHF has been easily under- In recent years, the number of these units has increased, stood and has been considered useful for establishing although their number is still scarce. In both public and comparisons between approaches to the care afforded to private hospitals, it is more usual to have specialized headache patients by professionals in different countries. consultations in the neurology services. So far, it has been applied in 14 centers in 11 European countries (including Turkey), developing five instru- Participants ments according to this set of indicators for the collec- Three specialized units in the diagnosis and treatment of tion of information [8]. This evaluative approach has patients with headache, integrated into the neurology also been used when comparing the approaches of two services, and other four Spanish neurology services, centers of attention to headache patients in Germany agreed to participate. Table 1 describes the characteris- (89 patients) and Portugal (50 patients) [9] and for tics of them. The selection of specialized units and evaluating, in Italy [10], six units specialized in headache neurology consultations involved different hospitals’ size diagnosis and treatment (calculating the indicators based and resources and, represents the type of assistance that on the records of 360 patients). In most cases, the indi- Spaniards receive in the hospitals. cators used were related to the mechanism’s structure and to the care process. Quality indicators definition The Eurolight study [11] has analyzed the organization The 13 agreed indicators [13] were measured in order to and treatment of migraine patients in Europe. Other assess the quality of the therapeutic indications. These studies [12] have done sub-analysis using the data base indicators cover five aspects (effectiveness, patient- of the Eurolight project. In this case, a cross-sectional centered care, patient safety, accessibility and adequacy) study was carried out, although with a different sampling and were developed based on a review of the literature method depending on the country. The data allowed to on the proposal of quality indicators and the work of a compare the prevalence, use of medical services and pre- Core Group, composed of eight specialists in Neurology. scriptions to 3466 migraine patients among 10 European Table 2 shows the aspects, the definition of each indica- countries. In particular, they compared the use of tor and the data sources that allow the measurement. triptans in the symptomatic treatment of migraine by medical specialists, general practitioners and other non- Quality indicators assessment medical therapists. The number of patients suffering A three-item questionnaire was used to determine the migraine at least 5 days a month was also considered, in ease with which data could be accessed to calculate the whom a preventive treatment had been indicated by indicators, the reliability of such data and to assess the these three professional groups. suitability of the indicators that were calculated using A previous study [13], conducted in Spain, to reach a these data. The three following questions were used: consensus on outcome indicators in the diagnostic and “Easy access to the data to calculate the indicators”, therapeutic approach for Specialized Headache Units, “The data sources to calculate the indicators are reliable” defined 13 indicators that are applicable to patients with and “The relevance of the indicators that have been primary chronic headaches, the most common ailment calculated” (Appendix I). to be treated at specialist headache units in Spanish hospitals. Data collection The objective of this study was to evaluate the quality Data collection was carried out during the months of of the therapeutic approach in Specialized Headache April to June 2018. The information for the calculation Units in Spain and compare their performance with of the indicators was taken from each patient’s clinical traditional neurology consultations by using these agreed history. The information was encoded by the head of outcome indicators. each unit in each center. Data were obtained from a minimum of 45 consecutive patients (both patients who Methods attended the consultation for the first time, as well as An observational (prospective) study was conducted. patients who attended the follow-up appointment). A Anonymized data of consecutive patients during a total of 315 cases were collected and their data extracted defined period of time were analyzed. This study was following this procedure. Sample was calculated consid- approved by the Research Ethic Committee named ering 95% confidence level and 80% statistical power. CEIM Valladolid Este. For each indicator, anonymized data were collected (number of patients that met the definition of the indi- Headache specialist units cator) that allowed to quantify numerators and denomi- In Spain, traditionally most hospitals do not have nators of each of the indicators. Each Specialized specialized units in headache diagnosis and treatment. Headache Units entered data into spreadsheets, which Pozo-Rosich et al. The Journal of Headache and Pain (2019) 20:73 Page 3 of 9 Table 1 Characteristics of the Specialized Headache Units taking part in this study Fuenlabrada1 Getafe2 Albacete3 Hosp Virgen Vall d’Hebron5 San Carlos6 HCUV7 de la Arrixaca4 Number of surgeries (rooms for consultation) 1 1 1 1 1 + 1 part-time 3 + 1 part time 2 Number of patients attended in the unit per year 1000 510 600 950 3200 8000 2500 Number of neurologists 1 2 2 part-time 1 1 + 1 part-time 3 + 2 part time 2 Number of nurses 0 1 0 0 0 1 1 Specialized Headache Units NO NO NO NO YES YES YES 1 Fuenlabrada University Hospital, Fuenlabrada, Madrid 2 Getafe University Hospital, Getafe, Madrid 3 Albacete University Hospital Complex, Albacete 4 Virgen de la Arrixaca University Hospital, Murcia 5 Vall d’Hebron University Hospital, Barcelona 6 San Carlos Clinical Hospital, Madrid 7 Valladolid University Clinical Hospital, Valladolid were then transferred to the Miguel Hernández Univer- were compared with the quality standard agreed upon in sity of Elche (data collection center) where the indicators a previous study [13]. No hypotheses were statistically were calculated. tested. Data analysis A descriptive analysis and comparison of data using t- Results test were performed in function of the complexity Anonymized data were encoded from a total of 313 attended in each Specialized Headache Units. Indicators patients. In one hospital only 43 valid cases were Table 2 Indicators used in this study Definition Indicator type Dimension CEF1. Percentage of patients diagnosed with primary chronic headache who, in a period of Results Effectiveness one year, attend the Emergency Room due to headache or complications of treatment. CEF2. Percentage of patients with chronic migraine who improve in the assessment Results Effectiveness according to the MIDAS scale, pre-post measure, at three months following therapeutic intervention. CEF3. Percentage of patients with primary chronic headache who progress to episodic Results Effectiveness headache (< 15 days of pain per month) after treatment. CEF4. Percentage of patients who obtain more than 7/10 points on scales that measure Results Patient Centered Care satisfaction with the care provided. CEF5. Percentage of patients with primary chronic headache treated in the Unit with at least Results Patient Centered Care one period of sick leave due to headache in the previous three months. CEF6. Percentage of patients with primary headache receiving preventive treatment three Results Patient Centered Care months after their prescription. CEF7. Percentage of patients with primary headache in analgesic treatment for more than Process Patient Safety 10 days a month in the last 3 months in the Specialized Headache Units. CEF8. Percentage of patients with a diagnosis of primary headache in the Specialized Process Patient Safety Headache Units or Doctor’s Surgery, without repetition of neuroimaging studies in a one-year period. CEF9. Percentage of patients with primary chronic headache in non-recommended Results Patient Safety symptomatic treatment. CEF10. Percentage of patients with primary chronic headache who suffer one or more Results Patient Safety adverse events which resulted in treatment being withdrawn. CEF11. Percentage of patients with cluster headache attended within seven days from Process Accessibility the onset. CEF12. Percentage of pregnant patients with primary headache attended within 15 days Process Accessibility of the positive pregnancy test. CEF13. Percentage of patients with cluster headache episode who have home oxygen Structure Equity therapy Pozo-Rosich et al. The Journal of Headache and Pain (2019) 20:73 Page 4 of 9 encoded, as in two cases data were not complete and diagnosed with primary chronic headache attending the were discarded. Emergency Room (CEF1), with primary headache The greatest variability in the indicators analyzed without repetition of neuroimaging studies (CEF8), with (Table 3) was observed in the percentage of patients non-recommended symptomatic treatment (CEF9), Table 3 Results in the indicators analyzed in each of the participating Specialized Headache Units Indicators studied Global# Fuenlabrada1 Getafe2 Albacete3 Murcia4 Vall San HCUV7 CV d’Hebron5 Carlos6 (%) CEF1. Percentage of patients diagnosed with primary 28.7 11.1 28.9 46.7 67.4 15.6 17.8 15.6 72 chronic headache who, in a period of one year, attend the Emergency Room due to headache or complications of treatment. CEF2. Percentage of patients with chronic migraine 67.8* 86.7 64.4 66.7 67.4 53.7+ 80 57.8 15 who improve in the assessment according to the MIDAS scale, pre-post measure, at three months following therapeutic intervention. CEF3. Percentage of patients with primary chronic 67.4 77.8 60.0 64.4 83.7 66.7 66.7 53.3 15 headache who progress to episodic headache (< 15 days of pain per month) after treatment. CEF4. Percentage of patients who obtain more than 87.9 93.3 80.0 80.0 83.7 88.9 97.8 91.1 8 7/10 points on scales that measure satisfaction with the care provided. CEF5. Percentage of patients with primary chronic 14.1* 11.1 8.9 8.9 25.6 11.1+ 15.6 20 45 headache treated in the Unit with at least one period of sick leave due to headache in the previous three months. CEF6. Percentage of patients with primary headache 84.7* 77.8 75.6 84.4 76.7 100+ 86.7 93.3 8 receiving preventive treatment three months after their prescription. CEF7. Percentage of patients with primary headache in 39.6* 40 48.9 48.9 34.9 48.9+ 24.4 42.2 23 analgesic treatment for more than 10 days a month in the last 3 months in the Specialized Headache Units. CEF8. Percentage of patients with a diagnosis of 14.4 46.7 20.0 4.4 18.6 0.0 4.4 6.7 112 primary headache in the Specialized Headache Units or Doctor’s Surgery, without repetition of neuroimaging studies in a one-year period. CEF9. Percentage of patients with primary chronic 20.2* 8.9 35.6 35.6 9.3 55.6 13.3 4.5 107 headache in non-recommended symptomatic treatment. CEF10. Percentage of patients with primary chronic 30.3 46.7 37.8 35.6 25.6 44.4 13.3 8.9 49 headache who suffer one or more adverse events which resulted in treatment being withdrawn. CEF11. Percentage of patients with cluster headache 50.6 73.7 68.9 2.2 50.0 100 78.9 58.8 61 attended within seven days from the onset. CEF12. Percentage of pregnant patients with primary 24.6 4.5 31.1 20.0 97.7 100 66.7 77.8 155 headache attended within 15 days of the positive pregnancy test. CEF13. Percentage of patients with cluster headache 45.0 93.3 11.1 8.9 25.0 66.7 78.9 76.5 75 episode who have home oxygen therapy. CV coefficient of variation # Average calculated considering the data set of all the hospitals *Does not include data from the Vall d’Hebron University Hospital that applied a different timescale criterion + At 6 months 1 Fuenlabrada University Hospital, Fuenlabrada, Madrid 2 Getafe University Hospital, Getafe, Madrid 3 Albacete University Hospital Complex, Albacete 4 Virgen de la Arrixaca University Hospital, Murcia 5 Vall d’Hebron University Hospital, Barcelona 6 San Carlos Clinical Hospital, Madrid 7 Valladolid University Clinical Hospital, Valladolid Pozo-Rosich et al. The Journal of Headache and Pain (2019) 20:73 Page 5 of 9 pregnant women attended within 15 days of the positive patient undergoing oxygen therapy at home (CEF13) pregnancy test (CEF12) and patients with active cluster and, showed better response capacity (CEF11, CEF12) headaches that have home oxygen therapy (CEF13). (Table 5). These results represent that half of patients Overall, in 8/13 (61%) indicators, the consensus treated at Specialized Units need to go to the hospital benchmark standard was reached (Table 4). In five emergency departments as consequence of treatment (38%) indicators, all the units met the pre-set quality complications, comparing with traditional care; seven benchmark, in two (15%) indicators, only three units times less repeat neuroimage tests in one-year-period; of the seven participants reached the standard, in one and response capacity and benefits for specific condi- indicator (8%), only one unit met the standard and in tions were better. one indicator (8%). None of the units reached the standard (Table 4). The indicators assessment ranged between 8 to 9.5 (Appendix II). Discussion Headaches Specialized Units showed better perform- This study’s results replayed to the primary objective (if ance in the indicators than traditional headaches consul- the performance of Specialized Headache Units is better tations. Statistically significant differences suggested that than the performance of traditional practice based on Headaches Specialized Units achieve a minor number of consultations). The results also provide information re- emergency visits (CEF1), repetition of neuroimaging pro- lated to the practice of healthcare professionals treating cedures (CEF8), and adverse events (CEF10). In turn, headache and, the organization of the Healthcare system they achieve major patient satisfaction (CEF4), number to provide adequate treatment to patients suffering of patients involved in preventive treatment (CEF6), headache. Indirectly, these results contribute to enhance Table 4 Level of compliance with standards for the indicators assessed Indicators studied Indicators that meet the Benchmark* Overall compliance of benchmark standard (n/N) the standard (YES/NO) CEF1. Percentage of patients diagnosed with primary chronic headache who, in a 5/7 < 30% YES period of one year, attend the Emergency Room due to headache or complications of treatment. CEF2. Percentage of patients with chronic migraine who improve in the 7/7 > 50% YES assessment according to the MIDAS scale, pre-post measure, at three months following therapeutic intervention. CEF3. Percentage of patients with primary chronic headache who progress to 7/7 > 50% YES episodic headache (< 15 days of pain per month) after treatment. CEF4. Percentage of patients who obtain more than 7/10 points on scales that 7/7 > 70% YES measure satisfaction with the care provided. CEF5. Percentage of patients with primary chronic headache treated in the Unit 7/7 < 30% YES with at least one period of sick leave due to headache in the previous three months. CEF6. Percentage of patients with primary headache receiving preventive 7/7 > 50% YES treatment three months after their prescription. CEF7. Percentage of patients with primary headache in analgesic treatment for 1/7 < 30% NO more than 10 days a month in the last 3 months in the Specialized Headache Units. CEF8. Percentage of patients with a diagnosis of primary headache in the 0/7 > 70% NO Specialized Headache Units or Doctor’s Surgery, without repetition of neuroimaging studies in a one-year period. CEF9. Percentage of patients with primary chronic headache in non- 4/7 < 30% YES recommended symptomatic treatment. CEF10. Percentage of patients with primary chronic headache who suffer one or 5/7 < 40% YES more adverse events which resulted in treatment being withdrawn. CEF11. Percentage of patients with cluster headache attended within seven days 3/7 > 70% NO from the onset. CEF12. Percentage of pregnant patients with primary headache attended within 3/7 > 70% NO 15 days of the positive pregnancy test. CEF13. Percentage of patients with cluster headache episode who have home 4/7 > 50% NO oxygen therapy. *Source: Carrillo I, Pozo-Rosich P, Guilabert M, Ignacio E, Pascual J, Porta J, Guerrero A, Mira JJ. Portfolio of services and basic chart of quality indicators for the Specialized Headache Units. Consensus Study. Journal of Neurology. 2018;68:118-122. Pozo-Rosich et al. The Journal of Headache and Pain (2019) 20:73 Page 6 of 9 Table 5 Results in the indicators according to the complexity of cases attended in the centers participating in the study Indicators in the study Headaches Specialized Units Headaches consultations (N patients = 135) (N patients = 178) Mean Standard Deviation Mean Standard Deviation Confidence interval P-Value on the difference between means CEF1. Percentage of patients diagnosed with 16.3 37.1 38.2 48.7 12.0, 31.8 0.0001 primary chronic headache who, in a period of one year, attend the Emergency Room due to headache or complications of treatment. CEF2. Percentage of patients with chronic migraine 62.7 48.5 71.3 45.3 −2.1, 19.3 0.113 who improve in the assessment according to the MIDAS scale, pre-post measure, at three months following therapeutic intervention. CEF3. Percentage of patients with primary chronic 62.2 48.7 71.3 45.3 −1.4, 19.6 0.092 headache who progress to episodic headache (< 15 days of pain per month) after treatment. CEF4. Percentage of patients who obtain more than 92.6 26.3 84.3 36.5 −15.6, − 1.0 0.020 7/10 points on scales that measure satisfaction with the care provided. CEF5. Percentage of patients with primary chronic 14.8 35.6 13.5 34.2 −15.6, −6.5 0.738 headache treated in the Unit with at least one period of sick leave due to headache in the previous three months. CEF6. Percentage of patients with primary 92.6 26.3 78.6 41.1 −21.9, −6.0 0.0001 headache receiving preventive treatment three months after their prescription. CEF7. Percentage of patients with primary 34.8 47.8 43.3 49.7 −2.5, 19.4 0.129 headache in analgesic treatment for more than 10 days a month in the last 3 months in the Specialized Headache Units. CEF8. Percentage of patients with a diagnosis of 3.7 18.9 22.5 41.8 11.1, 26.4 0.0001 primary headache in the Specialized Headache Units or Doctor’s Surgery, without repetition of neuroimaging studies in a one-year period. CEF9. Percentage of patients with primary chronic 17.2 37.8 22.5 41.9 −3.7, 14.3 0.242 headache in non-recommended symptomatic treatment. CEF10. Percentage of patients with primary chronic 22.2 41.7 36.5 48.3 4.1, 24.5 0.005 headache who suffer one or more adverse events which resulted in treatment being withdrawn. CEF11. Percentage of patients with cluster 73.2 44.9 42.5 49.6 −48.1, −13.2 0.0001 headache attended within seven days from the onset. CEF12. Percentage of pregnant patients with 76.0 43.6 13.3 34.1 −78.4, −47.0 0.0001 primary headache attended within 15 days of the positive pregnancy test. CEF13. Percentage of patients with cluster 62.3 48.9 37.4 48.6 − 39.6, −10.1 0.001 headache episode who have home oxygen therapy. the proposal of indicators consensual to assess the simple specialized consultations, specifically with regard headache quality intervention. to measures affecting accessibility, equity, safety and patient satisfaction. Moreover, data tend to suggest that Performance of headaches specialized units the patient profile attended in Specialized Headache Comparison of indicators suggest that the performance Units was more complex than that of patients attending of Specialized Headache Units was better than that of headache consultations. Pozo-Rosich et al. The Journal of Headache and Pain (2019) 20:73 Page 7 of 9 Although the patients’ improvement measured using Future studies should assess whether the benchmarks MIDAS scale was similar between both set of patients, the used to be hereafter adequate for continuous improvement. trend was generally better in the Specialized Headache In the absence of headache biomarkers, there is a need Units. This is because these units attend more complex for a better and more objective evaluation of the quality conditions. Future studies could analyze what patient profile of headache care. This study indicates that the 13 achieves greater improvement when treated in these units. outcome indicators agreed by the headache experts [13] seem to be able to test the quality of management of Practice of healthcare professionals patients with chronic primary headaches. The variability of the indicators directly associated with the practices of the professionals is lower, which indicates, Limitations on the one hand, that the same clinical references are In each hospital there was a neurologist in charge of followed in these Specialized Headache Units and, on the encoding the data, but no specific in site revision of the other, that the differences in resources have a direct reper- data was carried out. Additionally, socio-occupational fac- cussion in the results. However, it must be considered, as tors, such as the unemployment rate, may affect any of the reflected in other studies [14, 15], that the level of com- outcome indicators assessed, where in this study these so- plexity addressed, the communication mechanisms with cial variables were not controlled. This study collected data the patient, the nursing work or the fluidity of contact during three months trying to avoid potential seasonality with primary care professionals, modulate the differences bias. However, future studies should consider other season- in the indicators, although this study does not allow to ality periods. These measures did not include infants. Indi- discern the degree of influence of each of these factors in cators did not consider potential gender differences. the results achieved. Conclusions The quality of the therapeutic approach in Specialized Organization of the Healthcare system Headache Units has not been widely evaluated in Spain. The data collected show that there is variability between Although there is a variability among Specialized hospitals and, therefore, in the results of the care received Headache Units, the findings indicated that the perform- by patients, especially in the indicators associated with the ance of Specialized Headache Units was better than that organizational policies of the health services on which of traditional specialized consultations, as well as the these hospitals depend (for example, accessibility to oxy- patient profile attended in Specialized Headache Units gen therapy or to the care of pregnant migraineurs). This were more complex than the one attended in headache result is quite similar to other studies reflecting higher consultations. Future studies could analyze what profile variability [8, 9]. In this study Specialized Headache Units of patients achieve better improvements being treated in means for an effective implementation of care needed. Specialized Headache Units. Overall, these results support the development of com- prehensive care plans for patients with headache and are added to those other studies that advocate for the Appendix I standardization of healthcare organization [16] to reduce Please rate the following statements on a scale from 0 the variability observed in the results between Specialized (completely dissatisfied) to 10 (completely satisfied): Headache Units. In addition to patient satisfaction, pa- tients’ preferences [17] could be included in the future in 1. Easy access to the data to calculate the indicators. order to choose the best treatment option for each subject. Headache quality indicators 0 1 2 3 4 5 6 7 8 9 10 The studies carried out so far with agreed indicators have focused mainly on structural and organizational 2. The data sources to calculate the indicators are reliable. issues of the healthcare process [18]. In this case, progress is made with the inclusion of outcome indica- tors and, although there are differences between the 0 1 2 3 4 5 6 7 8 9 10 indicators employed, taken as a whole, they highlight that there is unnecessary variability in therapeutic 3. The relevance of the indicators that have been management [19] and that greater organizational and calculated. clinical effort is needed to ensure an adequate level of compliance with the recommendations for offering opti- 0 1 2 3 4 5 6 7 8 9 10 mal quality care [20]. Pozo-Rosich et al. The Journal of Headache and Pain (2019) 20:73 Page 8 of 9 Appendix II Author details 1 Headache Unit, Neurology Department, Hospital Universitari Vall d’Hebron, Table 6 . Barcelona, Spain. 2Headache Research Group, Vall d’Hebron Research Mean Median CV (%) Institute (VHIR), Universitat Autònoma de Barcelona, Barcelona, Spain. 3Calitè Research Group, Miguel Hernández University, Elche, Spain. 4Marqués de Easy access to the data to calculate the 7.7 8.0 6 Valdecilla Hospital, Santander, Spain. 5Valdecilla Biomedical Research Institute indicators (IDIVAL), Santander, Spain. 6Cádiz University, Cádiz, Spain. 7Headache Unit, The data sources to calculate the indicators 8.7 9.0 6 Neurology Department, University Hospital of Valladolid, Valladolid, Spain. 8 are reliable Institute for Biomedical Research of Salamanca (IBSAL), Salamanca, Spain. 9 Neurology Department, University Hospital of Getafe, Getafe, Spain. The relevance of the indicators that have been 9.5 9.5 6 10 Headache Unit, Neurology Department, San Carlos Hospital, Madrid, Spain. calculated 11 Neurology Department, University Hospital of Fuenlabrada, Madrid, Spain. 12 CV coefficient of variation (standard deviation/mean) Neurology Department, University Hospital of Albacete, Albacete, Spain. 13 Neurology Department, Virgen de la Arrixaca University Hospital, Murcia, Spain. 14Alicante-Sant Joan Health District, Alicante, Spain. 15Health Services Abbreviations Research in Chronic Illnesses Network, REDISSEC, Alicante, Spain. EHF: European Headache Federation; LtB: Lifting the Burden Received: 25 January 2019 Accepted: 6 June 2019 Acknowledgements Not applicable. References Authors’ contributions 1. Headache Classification Committee of the International Headache Society. EI and JJM designed and planned this study, PP, JP, AG, JB, AL and JP Classification and diagnostic criteria for headache disorders, cranial collected and assured data quality, AM and JJM conducted statistical neuralgias and facial pain. Cephalalgia. 1988;8(Suppl 7):1–96 analysis, PP, JP, AG, AL, JB and JP analyzed and interpreted the data of 2. Headache Classification Committee of the International Headache Society quality indicators. PP, AM, JP and JJM wrote the first draft of the manuscript. (IHS). The international classification of headache disorders, 3rd edition All authors read and approved the final manuscript. (beta version). Cephalalgia. 2013;33:629–808 3. Steiner TJ (2004) World headache Alliance. Lifting the burden: the global campaign against headache. Lancet Neurol 3:204–205 4. Steiner TJ (2005) Lifting the burden: the global campaign to reduce the Funding burden of headache worldwide. J Headache Pain 6:373–377 This study has been supported by Allergan. 5. 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(2016) Headache service quality: evaluation of quality indicators in 14 All procedures followed were in accordance with the ethical standards specialist-care centres. J Headache and Pain. 17:111 of the responsible committee on human research (institutional and 9. Katsarava Z, Gil-Gouveia R, Jensen R, Ch G, Schramm S, Schoppe A et al national) and with the Helsinki Declaration of 1964 and its later (2015) Evaluation of headache service quality indicators: pilot amendments. implementation in two specialist-care centres. J Headache Pain. 16:53 10. Pellesi L, Benemei S, Favoni V, Lupi C, Mampreso E, Negro A et al (2017) Quality indicators in headache care: an implementation study in six Italian specialist-care centres. The Journal of Headache and Pain. 18:55 Consent for publication 11. Andrée C, Stovner LJ, Steiner TJ, Barré J, Katsarava Z, Lainez JM et al (2011) Not applicable. The Eurolight project: the impact of primary headache disorders in Europe. Description of methods. J Headache Pain. 12:541–549 12. Katsarava Z, Mania M, Ch L, Herberhold J, Steiner TJ (2018) Poor medical Competing interests care for people with migraine in Europe – evidence from the Eurolight Patricia Pozo-Rosich has received honoraria as a consultant and speaker for study. The Journal of Headache and Pain 19:10 Allergan, Amgen, Almirall, Chiesi, Eli Lilly, Medscape, Novartis, and Teva. Her 13. Carrillo I, Pozo-Rosich P, Guilabert M, Ignacio E, Pascual J, Porta J, Guerrero research group has received research grants from Allergan and has received A, Mira JJ (2018) Cartera de servicios y cuadro básico de indicadores de funding for clinical trials from Alder, electroCore, Eli Lilly, Novartis, and Teva. calidad para las Unidades de Cefalea. Estudio de Consenso. Rev Neurol Ignacio E has been a consultant for Novartis y Abbvie, with whom he is 68:118–122 currently collaborating in a research project. 14. Gracia-Naya M, Sánchez-Valiente S, Latorre-Jiménez AM, Ríos-Gómez C et al Angel L Guerrero has been speaker or scientific advisor for Allergan, Novartis (2009) Pacientes con cefalea y abuso de medicación. Indicadores de and Teva, and Primary investigator for Alder, Amgen, Lilly, Novartis and Teva. respuesta al tratamiento ambulatorio. Rev Neurol 49:225–230 J. Balseiro has been a consultant for Allergan, UCB and Biogen, with Biogen 15. Gallud J, Soler J, Cuevas D (2012) New nursing roles for the integrated is currently collaborating in a research project. management of complex chronic and palliative care patients in the region Dr. Germán Latorre González is consultant for Novartis, Chiesi, Allergan and of Valencia. Int J Integr Care 12:1–6 Teva and is currently conducting clinical research with Novartis, Allergan 16. Steiner TJ, Antonaci F, Jensen R, Lainez MJA, Lanteri-Minet M, Valade D and Teva. 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