Does primary-care use of the HURT questionnaire aid the reduction of headache burden? Lessons for study design from an evaluation in primary care of the Arabic version

Background: The Headache Under-Response to Treatment (HURT) questionnaire is a self-administered outcome measure designed to assess and promote effectiveness of headache management in primary care. It links responses indicative of suboptimal treatment to specific clinical actions to improve outcomes. We aimed in this study to test whether integrating HURT into assessment and follow-up in primary care in Saudi Arabia improved headache management. Methods: With IRB approval, primary-care physicians (PCPs) were recruited from two health-care centres in Riyadh. After basic training in headache care, they were randomly assigned to either of two groups: one, with further instruction on its use, incorporating HURT into their management of patients with headache (intervention group), the other applying standard care without HURT (control group). Patients were randomised on presentation to a PCP in one or other group, thereby randomly receiving care directed by HURT or not. The primary outcome measures, estimated using the Headache-Attributed Lost Time (HALT) index, were reductions in lost productivity from paid work and household chores after 3 and 5 months’ follow-up. Results: A total of 28 PCPs participated. The study was stopped early, because of slow recruitment, after enrolment of 171 patients (84 control, 87 intervention) of 420 planned. Baseline characteristics were well matched between the groups. Patients in both groups benefited from the care they received, with no significant difference in the primary endpoint between groups after 5 months (5.2 versus 5.7 days lost; p=0.4). Patients’ understanding of their diagnosis reportedly improved in the intervention group during follow-up. Conclusion: The study failed in its purpose but delivered useful lessons for future study design in a difficult field of enquiry. First, the training we gave all PCPs, in order to balance the treatment groups, may have rendered HURT largely redundant as a management aid intended for non-experts. Second, the study demonstrates again the difficulty of conducting experiments of this sort in primary care, where interest in headache and motivation to conduct headache research are largely lacking. The second is the more intractable problem. *Correspondence to: TJ Steiner, Department of Neuromedicine and Movement Science, NTNU Norwegian University of Science and Technology, Trondheim, Norway, E-mail: t.steiner@imperial.ac.uk