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-center 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 health care services and costs were estimated using primary and secondary care databases and questionnaires quarterly up to 12 months post-recruitment. Cost analyses were compared using generalised linear models (GLM). Secondary outcomes assessed: access to care, patient satisfaction, headache burden and self-perceived quality of life using headache-specific (MIDAS, HIT-6) and a generic questionnaire (EQ-5D-5L).

Results. Mean (SD) cost up to 6 months post-recruitment 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 to 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.

The study was an independent single Trust site (at Guy's and St Thomas' NHS Foundation Trust) prospective, observational study. Patients were recruited either at the neurology department or the radiology department.

Data was collected by a research member at baseline and then quarterly up to 12 months following recruitment. Data collection was completed in February 2019. Data at baseline was collected before the participant’s initial appointment (either neurology appointment or MRI exam) at GSTT. Follow-up data was collected as per the participants’ preference, either via phone, email or post. The participants’ preference was established at baseline and recorded in the case report form. All data was collected using an electronic case report form (RedCap) and subsequently exported to Microsoft Excel 2013 and analysed using Stata 15.0.

Only data from participants that withdrew the informed consent was not considered in the analyses (intention to treat analysis). A very high degree of costing data completeness was expected given the comprehensive data collection methodology. However, where data for the estimate of the total healthcare costs was missing, mean values from the total sample were inputted.